Work with soft tissues: mucogingival operations. Area of ​​keratinized gingiva around implants

To eliminate various defects of the facial skeleton and soft tissues of the face, free tissue grafting is widely used in surgical dentistry. There are transplantation of a person's own tissues - autotransplantation; transplantation of tissues from another individual - allotransplantation; transplantation of tissues from a genetically identical person - ieotransplantation; transplantation of animal tissues to humans - xenotransplantation; implantation of artificial materials - metal, biomaterials, etc. - explantation; transplantation of a non-viable graft, which acts as a scaffold and stimulates the formation of new tissue - allostatic transplantation. In general surgery, there are other types of transplantation that are not used in facial reconstructive surgery.

Best by engraftment ability is considered autoplastic sky method. Its success is based on the fact that the fabric, separated from organism, never straightaway does not die and the well-known time keeps alive. Transferred to new soil, she not only remains alive, but also survives. However, the application of the method in the well-known degrees limited because reserves plastic material at autoplasty small. In addition, an additional patient injury when taking tissue from a donor site.

Very successful transplants of tissues taken from people who are genetically identical. For example, from an identical twin.

allogeneic plastic - it is the plasticity of tissues and organs from one organism to another the same kind. Unfortunately, despite many ways decrease in antigenic foreign tissue activity organ transplant attempts often end in failure

due to protein incompatibility of tissues. The best material is tissue taken from a corpse, and not from living organisms, since the antigenic properties of cadaveric tissues are less pronounced.

Xenogenic tissue transplantation - plastic tissue taken from an animal for humans, is not currently successful. It is used mainly to stimulate the regenerative abilities of the tissues surrounding the defect.

Currently, explantation has become widespread - the implantation of inanimate materials - plastics, metal, carbon composites, biomaterials, etc. Explants (implants from a biological point of view) can take root and get used.

Skin plastic. As tissues for transplantation, skin, subcutaneous tissue, fascia, ligaments, mucous membrane, muscle, cartilage, bone, nerve, vessel, combined tissue are used.

Free skin grafting is one of the promising methods of plastic surgery. Three types of skin grafting are currently known, depending on the thickness of the flap.

The first type - a thin skin flap (K. Thiersch) up to 0.5 mm thick - represents the epidermal layer and the upper layer of the skin itself - the growth layer. There are few elastic fibers. These flaps undergo wrinkling due to scarring of the underlying tissue.

The second type is a split skin flap with a thickness of 0.5 to 0.7 mm<рис. 195). В расщепленный лоскут включается еще и солидная часть эластических волокон сетчатого слоя кожи. Этот лоскут стали широко применять, когда появились специальные дер-матомы различной конструкции (Педжета, Колокольцева, Драже, НИИЭХАлИ с ручным приводом и т.д.) (рис. 196).

The third type is a thick flap with a thickness of over 0.8 mm, it includes all layers of the skin. Healing (epithelialization) of the donor site when taking a thin and split skin flap occurs due to the growth of the epithelium of skin derivatives (sebaceous and sweat glands, hair follicles). After borrowing a full-thickness skin flap, the donor site requires plastic replacement.

The use of various types of flap has its indications. During skin grafting, different viability of the flaps was noted depending on their thickness. Thus, a thin flap survives best and a thick one is worse.

In each case, surgeons must consider which method is more beneficial to apply. To close wounds of the face, a split skin flap is most often used; in the oral cavity - a thin flap.

Skin grafting can be primary, secondary, and in the form of skin grafting on granulations.

Primary skin grafting provides for free skin grafting on a fresh wound after an acute injury or on a postoperative wound accompanied by a large loss of skin. Primary free skin grafting is often an integral part of combined reconstructive surgeries. She is can be combined with all types of skin plastics.

In secondary free skin grafting, the skin is transplanted onto the wound surface formed after excision of various granulating wounds. Granulations must be completely removed. Free skin grafting is more often used in the treatment of burns. As a rule, skin is transplanted into the face and neck in the form of a single flap according to the shape and size of the defect.

Cartilage transplantation Cartilage is widely used in the practice of reconstructive surgery for the purpose of contouring or supporting plastics. Cartilage is a good plastic material, as it is easily processed with a knife and has special biological properties (it is an avascular tissue that feeds by diffusion of tissue juices) Metabolic processes in cartilage are inactive, and it sufficiently resistant to infection

Cartilage plasty is used to eliminate saddle nose deformity (Fig. 197, a, b, c, d), a defect in the lower edge of the orbit, for facial contouring, etc.

As a rule, costal cartilage is used, preferably from the 7th rib, since it is more accessible for taking and has a size of up to 8-12 cm. Cadaveric cartilage transplantation gives a good effect. It has a low antigenic property and therefore is rarely absorbed. Frozen and lyophilized (vacuum-dried) cartilage is absorbed more often

Bone grafting of the jaws, especially the lower one, presents certain difficulties. This is due to the following features: 1) the lower jaw is the most mobile bone, it has finely differentiated functions; it is involved in speaking, breathing, chewing, facial expressions; translational, 3) the jaws are carriers of teeth that are associated with them and with the external environment. Therefore, the development of pathological processes in their area aggravates the postoperative course

Most often, bone grafting of the lower jaw is performed. Depending on the timing of the procedure, primary and secondary bone grafting is distinguished.

By using primary bone grafting replace the defect immediately after injury or removal of a benign tumor of the lower jaw

Secondary bone grafting carried out after a certain period after the formation of a defect, usually not earlier than 6-8 months

In bone grafting, it is necessary to analyze the defect and clearly plan its elimination. After analyzing the defect, it is necessary to decide where the graft will be taken from and what size, what method of fixation will be used

The most important point in the success of bone grafting is the reliability of fixing the graft to the ends of the fragments of one's own jaw. For this, various “locks” are cut out at the ends of the fragments and in the graft. The graft can also be laid overlay, spread out, etc. Fragments are fixed, as a rule,

as well as isolating it from the oral cavity. The autograft should be taken according to the shape and size of the defect. It is considered to be the most appropriate two places for taking the graft: the rib (V, VI, VII) and the iliac crest. The rib is taken either in full thickness, or a split (lightweight) seedling. If you need a bend in the chin area, then it is better to take the iliac crest.

There are several methods of lower jaw autoplasty - according to Kabakov, Pavlov, Nikandrov, Vernadsky, etc.

After engraftment of the graft, biological restructuring and regenerative processes take place in it. The degree of the latter depends on the function of the graft. 15 days after transplantation, bone destruction begins, reaching its apogee by the end of the 2nd month, then regenerative processes begin to predominate. The bone graft is compacted and thickened.

Autotransplantation of bone has the following disadvantages: 1) it is not always possible to obtain a massive graft; 2) it is difficult to model a transplant of the desired shape; 3) additional trauma is applied to the patient.

Alloplasty of the lower jaw was developed in the most detail by N. A. Plotnikov. He proposed two options for alloplasty: one-stage resection and osteoplasty and secondary bone grafting. As a material, lyophilized grafts are used - the lower jaw or femur, taken from a corpse, frozen to -70 ° C and dried in vacuum at a temperature of -20 ° C. Cold significantly removes antigenic

transplant properties. Bone in ampoules can be stored at room temperature for a long time.

Cadaverous bone preserved with 0.5% formalin solution is also successfully used. Various methods of cadaveric bone preservation make it possible to use orthotopic grafts, i.e. parts of the bone that are identical in anatomical structure to the missing ones. Orthotopic grafts taken from the temporomandibular joint are also used, which allow not only to restore the lower jaw, but also the joint at the same time. Thus, it is possible to achieve an aesthetic and functional effect with end defects of the lower jaw (N. A. Plotnikov and A. A. Nikitin).

In recent years, many surgeons have begun to refuse alloplasty of the lower jaw with lyophilized bone due to the development of complications (graft resorption without replacement of the newly formed bone, inflammation, false joint formation). This has led to more frequent requests for autoplasty or explantation.

Free grafting of fascia is used as an integral part of the operation for paralysis of mimic muscles (myoplasty, combined myoplasty and fascioplasty, with dynamic and static suspension methods). In these cases, an autofragment of the anterior fascia of the thigh is more often used. Canned fascia can be used for contour plastics in case of facial hemiarthrosis.

Free transplantation of the mucous membrane is used to replace defects and deformities of the eyelids and oral cavity. The mucous membrane is borrowed from the cheek or lower lip.

Free transplantation of adipose tissue is used very rarely, since after transplantation this tissue is significantly reduced in size and often cicatricial processes develop.

Free nerve transplantation has been successfully used for paralysis of mimic muscles (A. I. Nerobeev).

Free transplantation of combined grafts. Combined grafts are called grafts consisting of heterogeneous tissues transplanted in a single block. An example of such a transplant is the plasty of a defect in the nose with a part of the auricle.

In recent years, methods of transplantation of combined grafts (including skin, subcutaneous tissue, muscles, and, if necessary, bone tissue) using microvascular anastomoses have been introduced into reconstructive surgery (A. I. Nerobeev, McKeep). For contour plastics, fascial-fat and skin-fat flaps are used. Complex musculoskeletal and skin-fat grafts using microvascular surgery are used even in jaw plastic surgery.

In various parts of the face and jaws, defects and deformities,

very different in origin, but similar in form, are eliminated in ways based on fundamental os"- new plasty: local tissues, pedicled flaps, Filatov stem and free tissue grafting.

It was first described by Björn in 1963, and systematized by Sullivan and Atkins (1968), remaining the most relevant at that time.

This procedure consists in replacing the non-keratinizing movable mucosa or increasing the size of the gums due to the keratinizing mucosa, which is most often taken from the surface of the sky. Recession zones are not closed. Sometimes the gum edge spontaneously shifts closer to the crown, then it is impossible to predict such a result. This is a common intervention for severe periodontal disease, which is widely used by dentistry in Simferopol, which has extensive experience in the treatment of oral diseases.

Indications for gingival flap transplantation

To stop local gingival recession, it is often enough to correct hygiene and eliminate traumatic factors, such as occlusal trauma. If gingival recession continues, then surgical intervention is indicated - expansion of the attached gum. An operation is also necessary if the gingival recession extends beyond the transitional fold, i hygiene is difficult, especially in the places where the bridles are attached. In such cases, inflammation develops, which is difficult to treat. The gingival margin is constantly shifting and exposed to injury from a toothbrush. In such a situation, interruption of the recession by transplanting a free gingival flap becomes the method of choice. With generalized gingival recession, such treatment is possible, but difficult, since it is not always possible to obtain the necessary amount of material for transplantation.

In generalized recession, transplantation of perforated flaps has been successfully used.

Contraindications

SDL transplantation is not indicated in areas of stabilized recession available for cleansing, in the absence of inflammation or obvious aesthetic disturbances. The operation is also not performed when there are direct indications for the closure of defects.

Principles of SDL transplantation

SDL is most often taken from the surface of the sky. The keratinized mucosa retains a whitish tint even after transplantation. In the area of ​​the upper incisors and canines, this shade may be noticeable, which should be taken into account at the planning stage.

The procedure is performed under conduction anesthesia. The operating field is additionally infiltrated with an anesthetic.

The first surgical step is to prepare the recipient field located in the apical direction from the recession zone. A horizontal incision is made along the transitional fold. If there is no gingival attachment, the incision is made 1 mm from the gingival margin. The incision penetrates through the mucous membrane into the submucosal layer without reaching the periosteum. The mucous membrane, submucosal connective tissue and muscles are carefully separated from the periosteum. A recipient field is formed, covered with periosteum, for transplanting a free gingival flap. It is possible to successfully transplant SDL onto a bleeding bone surface that is not covered by the periosteum.

The second surgical stage is the sampling of a flap approximately 1 mm thick from the surface of the palate.

The third surgical stage consists in adapting the SDL to the recipient field and fixing it with suture material.

Video:

Healthy:

Related articles:

1. Advantages of the SDL (gingival flap) transplantation technique for periodontitis: Stopping the process of gum recession. Deepening of the vestibule of the mouth....
2. In recent years, indications for plastic (mucogingival) operations in dentistry have expanded....

31.5. FREE TISSUE TRANSFER

♦ Free skin graft

Free skin graft method in reconstructive surgery of the maxillofacial region began to be used since 1823 when Bunger Ch.H. transplanted a piece of skin taken from the thigh into its entire layer on the nose. In 1869 French surgeon Reverdin J.L. proposed to cut off the surface layers of small pieces of skin and transplant them onto a granulating wound. Wolfe J.R. (1875) developed the technique of free full-thickness skin grafting and indications for its use. Thiersh K. (1886) proposed a method for transplanting thin skin flaps in order to epithelialize large areas. In the development of the method of free skin grafting, an outstanding role belongs to Russian surgeons - Pyasetsky P.Ya. (1870), Yanovich-Chayinsky SM. (1871), Yatsenko A.S. (1871), Fomin I.Ya. (1890) and other scientists.

The schematic structure of the human skin is shown in fig.31.5.1. In the figure, curly brackets and a dotted line indicate the thickness of various skin seedlings used for transplants in the maxillofacial region. The thickness of the skin of the maxillofacial region is on average 1 mm, but it varies in different parts of the face and neck. The thickness of the skin depends on age, gender, as well as the individual characteristics of the organism (place of residence, working conditions, etc.).

Rice. 31.5.1. Schematic structure of the skin

man (Mukhin M.V., 1962). Curly brackets and dotted lines show the thickness

various skin seedlings used for transplantation.

1 - epidermis;

3 - subcutaneous fatty tissue;

4- fascia;

a - a thin flap according to Thiersch; b - split flap; c - flap in the entire thickness of the skin;

d - skin flap with subcutaneous adipose tissue.

The most suitable donor sites for skin grafting on the face are the following areas of the human body - behind the ear, the inner surface of the shoulder and thighs. These areas are devoid of hair and are closer in color to the skin of the maxillofacial region.

Currently, depending on the thickness of the skin taken, the following types of skin flaps are used: split(thin, medium, thick) and full-thickness flaps in the entire thickness of the skin (without subcutaneous fat and with a thin layer of it).

Thickness thin split skin graft is on average 0.2-0.3 mm (thin flap according to Thiersch), middle- 0.5 mm and thick- about 0.8 mm. Different sizes of split skin graft can be obtained using the dermatome, which was first proposed by Padgett E.C. in 1939.

Indications for free skin grafting:

To replace defects and eliminate cicatricial deformities of the mucous membranes of the mouth and nose after surgery and non-gunshot injuries, burns, inflammatory processes;

To deepen the vestibule of the oral cavity with complete or partial atrophy of the alveolar process of the jaw;

In order to form a bed for an ocular prosthesis;

To eliminate post-burn cicatricial deformities of the face and contractures;

In case of soft tissue injury, accompanied by a defect in the skin;

After removal of keloid scars;

With cicatricial deformities and eversion of the eyelids and lips;

To close granulating wounds and cavities formed after the removal of extensive capillary hemangiomas, pigmented nevi, malignant tumors, etc.;

At the stages of treatment of thermal lesions or purulent wounds.

Thin split skin flaps(flaps according to Thiersch) consist of: epidermis and papillary dermis. They are widely used to replace defects in the mucous membranes of the oral cavity and nose, eye sockets. In these cases, skin grafting is carried out on rigid stencil liners or soft iodoform gauze liners. The thermoplastic mass (wall) is preheated in hot water and, at moderate pressure, the wound (cavity) is filled with it, pressed against the wound walls. After the wall hardens, on its surface facing the walls of the wound, a skin flap is applied with the epithelium to the stencil and attached to it. The skin flap should fit snugly against the wound surface. The liner is fixed in a stationary state and removed only after 8-10 days.

With a smooth course of the postoperative period, thin skin flaps take root in 7-8 days. Initially, the flap has a pale, dry, parchment-like appearance. In the future, the seedling gradually becomes more pink and thickens, and the edges of the flap passing to the surrounding tissue are smoothed out. The disadvantage of using a thin flap is that over time, these flaps tend to wrinkle, which occurs as a result of scarring of the underlying tissue. Pain and tactile sensitivity in the graft begins to recover after 1-2 months (first along the edges, and then in the center) and usually ends its recovery after 5-6 months (depending on the size of the flap). Under the influence of pressure, trauma or temperature effects, the flaps can crack and ulcerate, and later become infected and melt.

Medium to thick split skin flaps are used to replace defects in the mucous membranes of the mouth and nose, the skin of the eyelids, with scalped wounds, as well as for the temporary closure of extensive infected wounds in seriously ill patients or in the presence of granulating wounds (on the face, head and neck). In the latter cases, the two-stage (delayed) skin grafting. First, the wound is prepared for skin grafting: antiseptic treatment of the wound surface, ointment dressings, dressings with hypertonic sodium chloride solution, excess granulations are cauterized with 25% silver nitrate solution. After the wound is covered with fine granulations, it is closed with a free skin graft. Seedlings are sutured to the edges of the wound or to the underlying tissues.

Transplanted skin flaps always undergo contraction, which causes secondary deformities. Donor wounds are covered with a layer of dry gauze, a fibrin film and are not bandaged until it is completely healed under a bandage.

Full thickness skin graft most fully replaces the missing skin. The transplanted flap retains its normal color and mobility, the function of the sebaceous and sweat glands, as well as hair growth, is restored on the flap. The author of full-thickness skin transplantation is A.S. Yatsenko, who described this method in 1871. A full-layer skin seedling is most sensitive to adverse conditions that may occur during its transplantation. Full-thickness flaps take root well on loose connective tissue, fascia and muscles, and on adipose tissue, periosteum, bone and granulation tissue, these seedlings often do not take root.

Rice. 31.5.2. Appearance of a patient with cicatricial eversion of the lower eyelid before surgery and 7 days after free skin grafting (b).

The disadvantage of the method of transplanting seedlings in the entire thickness of the skin is that the wound at the donor site after excision of the flap does not independently epithelialize, but must be sutured. Technically, the excision of a full-thickness skin flap consists in the fact that a sample of a seedling is cut out of a washed x-ray film and placed on a donor site. Excision of the skin is carried out with a scalpel. The skin is dissected along the contour of the template to the subcutaneous fatty tissue. With the help of tweezers, the lower edge or corner of the flap is raised and the skin is cut off from the underlying fatty tissue with sawing movements of the scalpel. The graft transferred to the receiving bed is straightened and fixed first with guiding sutures, and then final interrupted sutures are applied, with the help of which the edges of the wound and the seedling are tightly compared. The operation ends with the application of a moderately pressing aseptic bandage. The first dressing is carried out no earlier than 7-8 days after the operation. When transplanting the flap to granulating wounds, on the 3rd-5th day after the operation, the state of the graft should be checked. In the presence of a hematoma or purulent exudate (purulent hematoma), the seedling is perforated to evacuate the contents, treated with antiseptics and bandaged again (Fig. 31.5.2).

F. Burian (1959) believes that the transplanted skin during the first 24 hours or more takes nutrients from its own base. After 24-48 hours, thin blood vessels of the bed begin to germinate to the vessels of the transplanted graft. The transplanted skin flap should be in a new place in a state of a certain tension, the value of which should be equal to the skin tension at the original site of the graft, because. when the flap is reduced, the gaps of the crossed vessels are reduced or closed.

Conditions necessary for successful free skin grafting:

Asepticity of the place of plastic surgery and the donor site;

Careful preparation of the bed (complete hemostasis, excision of scars to the full depth, there should be no irregularities, etc.);

Proper formation of the skin sapling (one should take into account the possibility of its subsequent reduction, respect for the graft, the correct selection of the donor site, etc.);

Proper placement of the skin seedling on the receptive bed (careful contact between the edges of the graft and the wound, moderate and uniform stretching of the seedling);

Ensuring rest and tight contact of the skin graft with the wound surface of the receiving bed during the entire period of engraftment of the seedling by applying a bandage.

Free skin grafting on the face and neck requires careful planning and adherence to the rules of surgical technique. Abundant blood supply to the soft tissues of the maxillofacial region, on the one hand, can ensure good engraftment of the graft, and on the other hand, contribute to the development of a hematoma located under the seedling and impairing its nutrition. There is a possibility of infection due to the proximity of the mouth and nose. The mobility of the facial tissues, as a result of the contraction of the masticatory and facial muscles (eating, breathing, speech, facial expressions), requires the provision of rest and close contact of the seedling with the wound surface of the bed during the entire period of engraftment of the skin graft.

♦ cartilage transplant

In reconstructive surgery of the face, due to its biological properties, it is widely used cartilage. Cartilage does not have blood vessels, it consists of a strong and elastic tissue. In 1899, N. Mangoldt was the first to make a free transplant of costal cartilage to replace a tracheal defect. The cartilage is easily formed and acquires the necessary shape, takes root almost without undergoing changes. Cartilage has great viability and high resistance to infection, easily survives even in unfavorable conditions (under thinned skin). It does not always die even with the development of suppuration in the area of ​​the postoperative wound. Cartilage does not undergo resorption and does not regenerate, which is of great value in plastic surgery. After transplantation and engraftment, the cartilage does not change its shape and size.

Rice. 31.5.3. Appearance of a patient with unilateral underdevelopment of the body of the lower jaw before (a) and after chondroplasty (b).

Rice. 31.5.4. Appearance of a patient with unilateral underdevelopment of the body of the lower jaw before (a) and after chondroplasty (b).

Rice. 31.5.5. Appearance of a patient with underdevelopment of the chin part of the lower jaw before (a) and after chondroplasty (b).

Uneven pressure on the cartilage in a new place can cause its curvature, and also the curvature occurs when the perichondrium (connective tissue membrane) is preserved in the graft, which shrinks over time and leads to this undesirable complication. According to A.M. Solntseva (1964) proved that the transplanted cartilage, regardless of its type and age of the patient, most often does not undergo resorption. Cartilage has low antigenic properties. In a new place, he ages faster (F. Burian, 1959).

Used for transplant own (autocartilage) costal cartilage (usually from the 7th rib), cadaveric cartilage (the first information about transplantation of cadaveric cartilage to eliminate nasal deformity belongs to N.M. Michelson and was published in 1931), frozen and freeze-dried(frozen, followed by drying in vacuum) allocartilage.

Chondroplasty is used to eliminate saddle-shaped deformity of the back of the nose or deformity of the ala of the nose, with defects and deformities of the lower orbital edge of the maxillary and zygomatic bones or the lower jaw, with plastic surgery of the auricle, chin and lower eyelid, congenital and acquired deformities of the facial skeleton, as well as to eliminate secondary and residual deformities of the face after surgical treatment of congenital nonunions of the lip and palate (Fig. 30.6.10, 30.6.11, 31.5.3-31.5.5).

♦ bone graft

The first free bone graft to replace the anterior mandible was performed by V.M. Zykov in 1900. A 4 cm graft was taken from the anterior part of the unchanged part of the lower jaw and transplanted into the defect area. The ends of the graft were placed in recesses made in the fragments of the lower jaw. There are the following types of tissue transplantation:

autotransplantation- transplantation of own bone tissue;

allotransplantation- transplantation of bone from one person to another;

implantation- implantation into tissues of materials alien to the body (plastics, biologically inactive metals, etc.).

Allocate primary bone grafting(the defect is replaced immediately after injury, removal of a tumor or other tumor-like formation of the lower jaw) and secondary bone grafting(osteoplasty is performed after a certain period of time after the formation of the defect).

D
For autoosteoplasty, a rib (V, VI, VII, preferably on the right, i.e. not from the side of the heart, so that postoperative pain does not simulate heart pain) or an iliac crest is taken, and in some cases it is also performed with a piece (section) of the body lower jaw (races 28.1.10, 31.5.6). Rib can be used as in its entire thickness, and split. For alloosteoplasty, a canned (formalized) or lyophilized (frozen and vacuum-dried) lower jaw, iliac crest, rib, femur, or tibia is used.

Rice. 31.5.6. The use of autobones (the lower edge of the body of the lower jaw) for bone grafting of an ununited fracture.

In maxillofacial surgery, flat bones are used for transplantation (hip, rib, lower jaw), i.e. bones are formed by two plates of compact substance, between which there is a thin layer of spongy substance. The ribs have thin outer compact plates, and their main part is spongy bone. Bone grafts should be transplanted only on a healthy bone, fastening the ends of the fragments (healthy bone and seedling) with various metal fasteners or forming “locks” to connect the ends of the fragments (Fig. 28.1.10, 31.5.6). The transplanted bone graft causes irritation of the tissues of the bed and these cells rush to it as if it were a foreign body (15 days after bone transplantation, the destruction of the graft begins, which reaches its maximum by the end of the second month). At the same time, the cells that create new bone, which originate from the very base of the graft, begin to activate. Bone regeneration occurs (after about 6 months), the graft thickens and thickens. If bone grafts are transplanted into soft tissues, for example, into subcutaneous adipose tissue, then the seedling undergoes resorption.

Restorative and reconstructive osteoplastic operations on the lower jaw and temporomandibular joint using bone allografts, according to N.A. Plotnikova (1986) are shown in the following injuries and their consequences.

I. Arthroplasty of the temporomandibular joint orthotopicallo-transplantation(graft transplanted to the site of the removed part of the jaw)with mandibular head, with restoration of joint elements(articular capsule and lateral pterygoid muscle) shown at:

Condylectomy (for post-traumatic arthrosis or fracture of the condylar process);

Comminuted fracture of the head of the lower jaw;

Fracture of the condylar process (intra-articular, high, oblique and old-scrap) with dislocation of the head.

II. Arthroplasty of the temporomandibular joint during the removal of altered condylar processes due to ankylosis is indicated for:

Fibrous ankylosis (transplantation of a half-joint - the lower floor of the joint);

Bone ankylosis (transplantation of a complete allogeneic joint).

III. Primary one-stage bone alloplasty shown at:

Comminuted fracture of the lower jaw with a defect in bone tissue;

Fracture passing in the area of ​​the cyst;

Improperly fused fracture of the lower jaw;

Removal of an extensive sequester in post-traumatic osteomyelitis.

IV. Secondary bone grafting shown at:

Ununited fractures (false joints);

Defects of the lower jaw with a length of not more than 5 cm in the absence of pronounced cicatricial changes in the soft tissues of the perceiving bone bed.

V. Combined plastic(orthotopic allograft combined with cancellous autograft) or autoplasty shown:

With defects ranging from 5 cm to total.

Contraindications to conduct osteoplasty of the lower jaw in case of traumatic injuries, according to NA Plotnikov (1986), are associated with a violation of the general condition of the patient, as well as with the nature of the bone bed (lack of soft tissues to cover the graft, an unfinished inflammatory process in the area of ​​the defect) or the state of the surrounding tissues ( pustular diseases of the skin of the face). According to long-term observations of N.A. Plotnikova (1979, 1986) proved that arthroosteoplasty should not be performed for defects in the branches of the lower jaw and the condylar process in childhood, because this causes a slowdown in the growth of the jaw (on the side of the operation) and leads to its deformation. Children with such injuries should be treated by an orthopedist, and bone grafting should be postponed for several years.

Rice. 31.5.7. Appearance of a patient with a defect in the tip of the nose before (a, b) and on the 7th day after transplantation of the combined graft taken from the auricle (c).

In recent years, non-biological materials (implants) have been increasingly used for bone grafting, from which endoprostheses of the lower jaw and condylar process are made: sapphire (V.I. Kutsevlyak, E.N. Ryabokon, 1995), glass-ceramic material "Biositall" (E.U. Makhkamov et al., 1995), kergap (A.A. Timofeev, 1998), pure titanium and titanium coated with aluminum oxide (A.A. Timofeev et al., 1997, 1998), porous titanium nickelide ( Yu.A. Medvedev, 1995), biocompatible osteoconductive polymers (A.I. Nerobeev et al., 1995) and others. (Fig. 28.1.13- 28.1.14).

♦ Transplantation of combined grafts

Combined called such transplants, which consist of heterogeneous tissues and are transplanted as a single block. For the first time, a free transplantation of a combined graft was performed by K.P. Suslov in 1898. He successfully repaired a defect in the alar of the nose after an injury by free transplantation of part of the auricle. Operation K.P. Suslov is called in some textbooks by the name of König F., who described a similar surgical intervention, but only in 1902.

Operation K.P. Suslov, is performed to eliminate defects in the wing or tip of the nose. The scalpel refreshes the edges of the defect, which usually has a triangular or oval shape. Measure the size of the defect and transfer them with brilliant green to the washed x-ray film. A graft is cut out from the upper middle part of the auricle in its entire thickness and placed in the defect of the nose so that the edge of the cartilage enters between the outer and inner layers of the wound. The back surface of the auricle should always be turned outward, and the front - inward. The graft is carefully fixed with sutures made of a thin polyamide thread. (fig.31.5.7-31.5.11).

Rice. 31.5.8. Appearance of a patient with a defect in the ala of the nose before surgery (a) and 2 weeks after free transplantation of part of the auricle (b).

G.V. Kruchinsky (1978) developed a method for transplanting complex grafts to eliminate nasal defects of various shapes. The place for taking the graft is the inner edge of the auricle. According to the author, it is in this area that large grafts can be obtained, while maintaining the size and shape of the donor auricle.

Rice. 31.5.9. Appearance of a patient with a nasal alar defect before (a) and one month after free transplantation of a combined graft taken from the auricle (b, c).

Rice. 31.5.10. Appearance of a patient with a nasal tip defect before surgery (a) and six months after free transplantation of a part of the right auricle (b).

Rice. 31.5.11. Appearance of a patient with a defect in the ala of the nose before (a) and one year after free transplantation of a combined graft taken from the auricle (b).

Free tissue grafting has a prominent place in plastic surgery. In plastic surgery, they resort to tissue transplants of the most diverse in their anatomical and histological structure and morphological origin.

If the techniques of patchwork plastics were discussed above, where the skin of the operated person was taken as the basis and transplanted to a new place, remaining partially connected with the mother soil, then in this section we will talk about the free separation of pieces of tissue and transplanting them to a new place. Tissues can be used not only from the operated person or another person, but also from various animals, and sometimes can be used as a support material and inorganic substances.

The most widely used in reconstructive and plastic ENT operations is autoplastic material, i.e. tissues of the same person who is operated on: skin comes first, then cartilage, bone, and less often fat.

Transplantation of tissues from a corpse or from one person to another - homoplasty, is used very rarely, since experience has shown that engraftment of such material, due to the difference in the biogenetic properties of tissues and the body as a whole, almost never happens.

As for heteroplasty - the use of material from animals, it is almost never practiced in restorative ENT operations.

Alloplasty has a much greater use, when various substances are used as a reference material: paraffin, horn, metal plates, silver, gold, ivory, etc.

Free tissue transplantation is based on the ability of various living tissues to continue their life even if they are separated from the body.

Experimental data have shown that different tissues in their isolated state can maintain their life differently. So, for example, the nervous tissue is the least resistant and the skin is the most viable, then the mucous membrane, periosteum, cartilage and bone.

It is known that Busse saw the movement of ciliated hairs of the nasal mucosa on the 18th day after the operation.

Grohe transplanted the periosteum and observed engraftment and bone formation in the transplanted flap after 96 hours, and Morpurg observed the same even after 192 hours.

If measles is transplanted along with the periosteum, then, by taking root, it causes by its presence the activation of the growth of the surrounding connective tissue.

During transplantation, Academician Petrov attaches great importance to the periosteum, through which communication and blood supply with the surrounding tissues are restored much faster. According to Petrov and his students, it is known that “during bone transplantation, all elements of the grafts undergo gradual degeneration and death, and at the same time regeneration and restructuring takes place, carried out mainly due to the embryonic elements of the surrounding extraosseous connective tissue, the fibroblasts of which grow on the graft, grow into into its Haversian canals and metaplase into osteoblasts and cells." The fact that the cells of the surrounding tissue are involved in the creation of the regenerate is said by Petrov, Bashkirtsev, Leriche, Beer, Martin, and others.

During reconstructive ENT operations, cartilage is often used as a support. When transplanting costal cartilage, it was experimentally found that he. can remain for a number of years without visible changes.

The integumentary epithelium of the skin is distinguished by its great viability, which, with skillful storage, can maintain its viability for a long time. According to Ventscher, the skin epithelium can be viable for up to 22 days, according to Lungren, this period is extended to 30 days. It all depends on the conditions in which the transplant is located.

The main condition for the viability of the graft is the asepsis of the operation, its sterility; the presence of infection and microorganisms has a detrimental effect on it. The ambient temperature is equally important. At high temperatures, physicochemical processes proceed most rapidly and vigorously. Therefore, some recommend to produce artificial warming of the flap in the postoperative period.

Experimental data have established that at low temperatures, grafts last longer and are more viable. This is explained “by the fact that at low temperatures, biochemical processes in tissues, the growth and development of microorganisms slow down. As long as the flap has not engrafted, as long as it does not receive nutritional material from the body, at low temperatures it will spend much less of its nutritional resources for the life of the cells. slower ingrowth of vessels, which are so necessary for the graft to provide it with nutrients and its viability.

Postoperative care for a free graft should be more thorough than for a pedicled flap.

With a freely transplanted graft, sometimes the first, ineptly performed, dressings can lead to its complete death.

A more detailed indication of graft care will be made in the descriptions of individual tissue grafts.

The history of the development of the issue of free tissue transplantation is completely connected with operations on the ENT organs.

At the beginning of the 19th century, Bünger “successfully transplanted a flap of skin from the thigh to the place of the destroyed nose,” writes Pokotilo in his work.

Czerny in 1871 took a piece of the mucous membrane from a small tongue and transplanted it onto a granulating surface; the mucosa adhered and gave a real integumentary epithelium.

A piece of costal cartilage was transplanted for the first time in 1890 to replace the trachea by Mangoldt.

In 1896, Koenig used a piece of thyroid cartilage as a free graft to replace the tracheal wall.

In the same year, for the first time, Israel performed a free bone graft from the lower leg to create the bridge of the nose.

All these historical dates are associated with the development of reconstructive ENT surgery - a specialty that belonged at that time not to laryngologists, but to surgeons.

Transplantation of free tissues in plastic and reconstructive ENT surgery is performed differently.

It is possible to transfer the graft to the defect, covering the wound surfaces, non-healing ulcers with the skin; the graft can also be transferred into the tissue, under the skin.

During rhinoplasty, otoplasty and when restoring the walls of the larynx, it is necessary to use most of the supporting material - cartilage, bone or any prosthetic substance.

Superficial skin transplantation is rarely used in plastic ENT surgery; it has to be used for facial plastic surgery, for closing large granulating surfaces, for removing birthmarks, scarring after burns of the face or body.

Reverden in 1869 reported to the Society of Surgeons in Paris about his method of skin grafting, after which this method was widely used.

The following suggestions are only modifications of Reverden's basic method.

For the first time such a proposal was made in 1871 by Yatsenko. Twenty-two years later, Krause makes the same proposal and at the same time proposes to take a skin-thick flap of Hirshberg, with the only difference being that the latter used a flap with a subcutaneous fat layer, while Krause took a skin flap. without subcutaneous fat.

Davis (1914) suggests the use of small pieces of skin taken from its entire thickness.

Next comes a group of authors who propose to increase large pieces of skin by further notching and stretching it in all directions. These authors include Douglas (1930), who proposes to form a lattice "flap-sieve"; he cut circles on the skin flap with a steel punch, which were left in place of the removed flap for the subsequent healing of the newly formed defect after cutting out the flap-sieve.

Subsequent authors Dregstedt and Wilson modify this technique in that they do not use a punch, but limit themselves to notching the flap and stretching it. The flap was taken in its entire thickness, but without the subcutaneous fat layer. Schneider (1938) developed and improved this technique, thereby achieving closure of skin defects of 400 - 500 square meters. cm.

In reconstructive ENT surgery, it is more often necessary to use another method of tissue transplantation - implantation inside under the skin, made for the first time by Czerny in 1896, who transplanted fat. In the same year, it was proposed by Mangoldg to transplant costal cartilage as a supporting material for rhinoplasty. In the same year, Israel proposed to transplant the bone, which turned out to be a less convenient material during plastic surgery.

A part of the thyroid cartilage was transplanted by Koenig in the same year. Much later, in 1934, it was proposed by Proskuryakov for rhinoplasty to use cartilage taken from the auricle to correct minor defects. In 1935, Michelson proposed the use of cadaveric cartilage. Many different grafts are used subcutaneously as a support material, but we will focus only on those that are most necessary in the plastic surgery of the face and ENT organs.

Transplantation of mucous membranes, fat and fascia

During reconstructive operations on ENT organs, one always has to deal with organs where one wall is covered with skin, and the second is lined with mucous membrane.

Restoration of a thin wall with a supporting skeleton and coating it with a diverse material is an extremely complex and in some cases even unsolvable task. In rhinoplasty, the restoration of the mucous membranes is rare, they are usually replaced by skin, which in no way can replace the mucous membrane. The nasal mucosa is too specific and diverse in its physiological purpose.

The surgeon has one task - to restore the patency of the nose and create a lumen. In this case, only part of the physiological role of the nose is allowed.

There are completely unresolved issues such as the restoration of the physiological usefulness of the nose and its mucous membranes, both olfactory and respiratory zones.

Attempts to transplant the mucous membrane took place as early as 1871.

Czerny was the first to take a piece of mucous membrane from a small uvula and transplanted it onto a granulating surface, where it took root and gave rise to a true integumentary epithelium.

Despite this, nevertheless, free transplantation of mucous membranes has not yet received wide application and distribution. The main reason is the limited usability.

The mucosa is mostly used from the lips or cheeks in the form of a flap on the leg.

In laryngology, mucosal transplantation is rare, more often it is used in eye practice.

According to Sapezhko, when transplanting the mucous membrane, the flap is cut out into “this thickness without fat, it is sharply reduced and it has to be sutured to the wound from the edges.

After transplantation, the mucosal flap acquires a "deadly pale" color, cyanotic spots appear in the places of its contact with the underlying tissue, which gradually expand and after 12-24 hours the entire flap acquires a cyanotic color with swelling and swelling. Cyanosis should be considered as a favorable factor; it usually lasts from a day to several days, and then passes.

The epithelium dies on the third or fourth day, which obscures the picture of the blood supply to the flap, since the graft surface becomes cloudy.

The process of engraftment of flaps proceeds as well as engraftment of the skin, which is proved by microscopic studies.

Dyachenko, on the basis of studying the issue of mucosal transplantation, establishes the following conditions:

The transplanted flap should fly closely to the underlying tissues; bleeding must be stopped, blood clots removed. The flap should be washed in warm physiological saline solution, where it can remain without harm for up to 1.5 hours. Adipose tissue on the lower surface of the flap should be removed with scissors, but the entire submucosal layer should not be removed. Neither the flap nor the surface of the defect should be exposed to strong antiseptic solutions; transplantation should be done aseptically as possible. The flap should cover the entire defect, as scars form at the free spaces. The transplanted flap must be protected from drying out. To replace the mucous membrane in practice, transplantation of thin layers of skin according to the Thiersch method or thick-skin submerged flaps according to our method is used. The skin surface changes under changed physical conditions from the side of the environment, it loses its usual appearance, a thick stratum corneum is not formed, in an altered form it even fits the general appearance of the mucosa - moist, whitish.

But microscopically, the skin will always remain skin with its inherent elements: sweat glands, sebaceous glands and hairs. Transplanted thin grafts in most cases prevent the formation of scars, strictures, and atresia. Therefore, there is no reason to completely refuse to replace the mucous membrane with skin grafts, especially since the method of mucosal transplantation in ENT practice has not yet completely entered life.

Free fat and fascia grafting

In reconstructive and plastic ENT surgery, fat is used quite rarely. Adipose tissue can only be used as a lining for leveling depressions on the face after gunshot wounds, excision of scars, when restoring lost parts of the face, such as the chin area, cheeks, etc.

Fat, as a material for plastic surgery, is inconvenient, first of all, it is very unstable to infection, it can very easily serve as a source of suppuration, does not tolerate injury, is not very viable; in the process of engraftment, it can undergo extremely undesirable changes, such as transformation into scar tissue, wrinkling and changes in its volume

Adipose tissue is sometimes used in surgery for arthroplasty as a lining in the formation of a joint, in stopping bleeding from parenchymal organs, etc.

For the first time, fat was transplanted to Czerny in 1896 to restore a difficult gland after its removal.

In the process of fat transplantation, it is necessary to observe the strictest asepsis and care in handling the graft - do not injure it, do not squeeze it, do not take it with your hands to avoid unnecessary infection, do not grind the piece, but transplant it in a whole layer or piece with the underlying fascia, very thin.

The most suitable place to take large pieces of fat is the abdomen and thigh, which are especially rich in this material in women.

After a wide skin incision, they begin to cut out a piece of fat, it is better to cut it off with scissors. A thin layer of fascia is taken to hold the lobules of fat together, otherwise they easily disintegrate.

A pocket or tunnel is prepared in advance, into which the fat graft is placed; sometimes it’s more comfortable to take it on a provisional thread and drag it into a prepared pocket. Good hemostasis must be maintained.

In our practice, this type of plastic is rarely used due to the fact that fat is a very capricious and unstable material. With great success, plastic surgery is carried out using fat not in the form of a free graft, but with its movement on a wide leg, like an apron, wrapped in the direction of the defect and cut out somewhere in the vicinity of the existing defect.

This type of plasty is preferred by us, since with it the fat flap is more viable and more resistant to infection. Such techniques have to be resorted to when correcting sharp depressions after excision of scars.

Fascial plasty is almost never used in ENT surgery. For the first time the fascia was transplanted in 1909 by Kirchner. Fascia found great use in surgery, it was successfully used to reinforce sutures, hernia gates, muscle and tendon defects and the sphincter in case of rectal prolapse.

Fascia for plastic surgery is most often taken from the thigh, here it is more accessible. The wide fascia of the thigh is an excellent material for a number of appointments in plastic surgery; First of all, she is very strong.

A strip 3 cm wide can withstand a load of more than 2 pounds, it is extremely viable. Based on the experiments of Kirchner and Kenag, the fascia, after being stored for 35 days in a sterile solution at t ° 0 degrees, does not lose the ability to engraft well. (Korpev, dissertation "On the free transplantation of fascia", 1913). After 3-4 days, she can take root (Meyer). Fascia is able to rebuild and adapt to new conditions.

In some cases, the fascia can affect the regeneration of adjacent tissues to which it is adjacent. According to Barfurt, this is the trophic influence of functional irritation.

We successfully used the wide fascia of the thigh during the Thiersch-Brun operation in 1924, where the fascia took on the role of a sphincter in rectal prolapse. The operation was performed for the first time by academician, professor V. M. Mysh.

In ENT surgery, fascia is used to restore the shape of the face after facial paralysis; here the lowered muscles of the cheek, eyelid, corner of the mouth are pulled up. In our clinic, in such cases, preference is given to myoplasty - the most effective and persistent method for this suffering.

Popular treatment for periodontitis

Transplantation of connective tissue in the oral cavity is a common periodontal surgery. The purpose of this surgical intervention is to solve the problem of gum recession. Recession is the process of reducing gum tissue in one or a number of teeth. There are several reasons for this condition. Recession is often observed in periodontitis, when, as a result of inflammation, bone tissue is destroyed, exposing the root of the tooth. This is facilitated by insufficient oral hygiene, chronic diseases, malocclusion, the presence of bands and frenulums, smoking and gum injuries due to improper brushing.

Gingival recession is not only a functional problem, but also an aesthetic one. Exposing the neck and root of the tooth in the smile area looks unattractive and requires correction. French Dental Clinic dentists offer an effective and gentle way to eliminate recession - gum transplantation.

How does a gum transplant work?

If there is a shortage of soft tissues, they can be transplanted from another part of the oral cavity. A gum transplant from the palate is usually practiced. According to histological parameters, the mucosa of the hard palate is considered identical to the gum at the neck of the tooth. Therefore, the transplant transferred by the doctor is implanted without unnecessary difficulties and stops the recession.

This procedure is performed surgically. Before the intervention, the doctor eliminates the carious lesion at the site of exposure and cures the foci of inflammation. Transplantation is painless for the patient, it is performed under local anesthesia. For transplantation, the surgeon peels off several flaps of tissue in the mouth. One flap is cut out directly at the tooth. The doctor cleans the space under it, removes inflammatory processes, food debris, refreshes the root cement.

If necessary, the surgeon will take care of the restoration of bone tissue. This is especially true if gum transplantation is carried out during implantation. After the cleaning, the flap returns to its place and is covered with a flap from the sky. Then the transplanted tissue is fixed with sutures, a bandage is applied.

Postoperative care

After a connective tissue transplant, the FDC patient receives detailed oral care recommendations from the surgeon. At first, redness, swelling of the tissues and sensitivity of the teeth at the site of intervention may be observed. The patient needs to rinse his mouth with antiseptic solutions, brush his teeth with great care during the recovery period and eat soft foods. The surgeons of the clinic will monitor the healing process and make sure that the recovery goes smoothly. Sutures are removed after 10-12 days.

Without treatment, the recession can progress, leading to tooth loss. Solving the problem of reducing gum tissue will take less time and effort than prosthetics in case of their loss. Come to us for treatment, and the doctors of the French Dental Clinic will do their best to keep your teeth and gums healthy!

Professional approach

Experienced French specialists are engaged in dental treatment. The treatment style is individual and collegiate. This means that a team of highly qualified specialists will work on your problem, complementing each other with their knowledge and experience. The doctors in our clinic are specialists from France, who brought to our country, in addition to their knowledge and skills, also the European quality of service. In addition to a speedy recovery, we can offer you coziness and comfort, a friendly attitude, and pain-free dental treatment.

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Comprehensive dental treatment in Russia according to European standards

Philosophy of the clinic:

The peculiarity of their work lies in a comprehensive and collegial approach to treatment, for the discussion of which both doctors and dental technicians are involved. First of all, it is necessary to find out the wishes of the patient and, for our part, offer all possible options for making the only right decision. During the consultation, several treatment plans are discussed, the number of which may vary depending on the chosen method.

To date, all diseases of the teeth and oral cavity are well studied, only the methods of their treatment are changing. They improve from year to year, becoming better, more gentle, effective and painless. We follow all the innovations in the field of dentistry and apply them in our practice, sparing neither time nor money.

We have the opportunity to work on the equipment and materials of the latest generation, which allows us to produce high-precision diagnostics and high-quality treatment! FDC has 5 high-comfort rooms, where staying even for a long time is not burdensome for either the patient or the doctor, which has a very positive effect on the effectiveness of treatment.

First of all, the patient must feel that we are not indifferent to his condition, we know that this fear can itself cause serious ailments from the nervous and cardiovascular systems. Doctors of the Clinic will carefully listen to you at the first appointment and prepare an individual program of special preparation for the next visit.

For cash, credit card (Visa, MasterCard, American Express). It is possible to pay by transferring money to the account of the Clinic, which can be carried out both by the patient himself and by a third interested party, for example, an insurance company or an organization in which he works.

Useful information

Treatment of periodontitis

Treatment of all forms of periodontitis, including chronic, generalized and severe stages. Moscow clinic of advanced French dentistry. Modern methods of treatment of periodontitis and elimination of its symptoms and consequences: laser, splinting.

How often should you visit the dentist?

Dental health is essential to the health of every person. Untreated chronic infection or roots not removed in time can lead to heart disease, kidney disease and other vital organs. Bad teeth are a ticking time bomb that can explode at any moment. Therefore, a visit to the dentist is an important condition for a healthy and long life.