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INSTALLING BASAL IMPLANTS


TRANSINUSAL METHOD


The installation of basal implants by the transinusal method on the upper jaw is an alternative to sinus lift.


Rybak V.A., Pavlenko M.A., Klimentyev V.G.
Institute of Dentistry NMAPE them. P.L. Shupika
Summary. In this paper, we propose a method of using basal implants in a transinusal way — as an alternative solution to the problem, which allows you to achieve the optimal therapeutic effect with minimal surgical trauma, without the use of sinus lifting.
Key words: sinus lifting, allografts, autogenous plasma.
Statistics show that bone tissue is the most frequently transplanted material in modern medicine, lagging behind the number of transplants only from blood products (D.J. Trantolo, D.L. Wise, K Lewandrowski, J.D. Gresser, 2000). So Boyne (1973) developed and formulated a set of fundamental scientific installations, according to which an ideal osteoplastic material should:
— be available in the required quantity;
— have a high potency for bone formation;
— promote revascularization of the defect zone;
— have a high osteoinductive potential;
— provide regeneration of supporting tissues of the tooth with its mobility;
— possess osteoconductive properties;
— contribute to the formation of a new connective tissue attachment in the area of periodontal defects.
The most widely used clinical practice today is frozen allografts, lyophilized, demineralized lyophilized and irradiated allografts (A. Garg, 2004). Untreated allografts have pronounced antigenic properties, while existing treatment methods can significantly reduce them. antigenicity, while maintaining the properties of the grafts for a sufficiently long period of time.
The formation of toxic peroxide compounds, primarily OH-hydroxyl radical, as a result of lipid peroxidation, induces damage to cell structures, primarily membranes. This process is carried out in the presence of free H2O. In this regard, the basis of all modern methods aimed at the long-term preservation of allogeneic bone tissue is the complex process of extracting water from the transplant to the lowest possible level. The next variety of transplants are xenogenic bone materials. Xenogenous donors (from the Greek xeno-alien, unusual and genesis — origin) of bone materials are representatives of animals other than the recipient of the species. Assessing the results, we can conclude that, even transplanting bone material from donors who have a very high structural similarity with humans, such as primates, the outcome of the operation remains unpredictable and often ends with premature resorption or rejection of the graft.
Today, the use of allogeneic bone material is possible due to additional plasma treatment enriched with growth factors (PRGF-Endoret).
PRGF-Endoret — is the first 100% autologous platelet-rich plasma. PRGF®-Endoret® contains a mixture of autologous growth factors that are derived from both plasma and platelets. Platelets have a complex storage system in the form of intracellular granules, which allows them to transport a large number of biologically active molecules. According to some authors, the list of proteins and peptides includes nearly 500 kinds of molecules. Alpha granules are the most common, as there are between 40 and 80 alpha granules per platelet, but they also have the greatest degree of retention. In addition, they contain a number of antibacterial proteins, which are generally called thrombocidins and are lethal factors for a wide variety of bacterial species.
However, it is important to remember that plasma contains important growth factors, and the combination of plasma and platelet factors is a key element in the biological effect of PRGF-Endoret.
The PRGF-Endoret technology is based on the preparation of 100% autogenous platelet-rich plasma, the application of which to damaged areas increases the regeneration rate in most types of tissues without any side effects. The biological activity of the composition obtained using PRGF-Endoret technology is based on two fundamental things. On the one hand, the plasma contents and, specifically, platelet growth factors, the action of which regulates the main processes involved in tissue regeneration.
On the other hand, a fibrin matrix, which is used as a temporary structure for organizing cells and controlling the release of energy from the growth factors present in PRGF-Endoret. PRGF-Endoret biological mediators stimulate and support important processes such as cell proliferation and migration, chemotaxis (or a signal to cells at a distance to get into the location of damage), inflammation and auto / paracrine synthesis of new biologically active molecules.
Studies have shown that when using allogeneic bone material + PRGF-Endoret as a result gives 30% of the newly formed bone. If you use autologous bone material + PRGF-Endoret, the result is 43% of the newly formed bone.
It has been established that the mucous membrane grows much faster than the bone, forming, sometimes, huge defects in the maxillary sinus, which, subsequently, have to be eliminated with the help of serious surgical intervention of the maxillofacial surgeon. Intervention of the maxillofacial surgeon.
 

 


Clinical case No. 1


Patient Y born in 1960 (53 years old) was admitted to the European Dental Center for Maxillofacial Surgery KOKB September 26, 2013 with a preliminary diagnosis of Odontogenic left-sided sinusitis. The patient complained of nasal discharge, nasal congestion. Pain in the left infraorbital region, shortness of breath, purulent discharge through the left nasal passage.
Anamnes morbi
He complained of nasal discharge, nasal congestion, pain in the left infraorbital region, shortness of breath, purulent discharge through the left nasal passage. In 2010, bilateral sinus lift was performed.
Status localis:
The face is symmetrical. The skin is flesh-colored without pathological changes. Breathing through the left nasal passage is difficult. The mucous membrane of the oral cavity in the area of ​​23-27 teeth is weakly hyperemic, as a result of cicatricial changes. Palpation: in the region of the maxillary sinus, slight pain is noted on the left. Slight serous discharge is observed from the left nasal opening. The mucous membrane of the oral cavity is pale pink. In the area of ​​23-27 teeth there is hyperemia and edema of the mucosa. Complete atrophy of the alveolar bone in the area of ​​24-26 teeth is noted. On 23 and 27 teeth, a movable cermet structure is fixed. The opening of the mouth is free.
On cone beam computed tomography, the presence of a defect in the alveolar process of the upper jaw on the left at the level of missing 24-26 teeth with transition to the anterior maxillary sinus and the cheek-alveolar ridge is determined. The sinus is made of homogeneous contents. (Fig. 1,2,3).
Figure  1

Panoramic radiography of patient Y before starting treatment.


 
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Figure  2

Panoramic radiography of patient Y before starting treatment.


 
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Figure  3

Volumetric modeling based on computed tomography of patient Y before surgery


 
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The data of the laboratory data of the patient upon admission, without features.
09/27/2013 Operation:
Fence of cortical plate and spongy autograft from the crest of the right ilium.
Operation progress:
After antiseptic treatment of the skin under anesthesia, an incision was made in the skin, subcutaneous tissue 4.0 cm long from the upper anterior spine parallel to the anteroposterior area of ​​the iliac crest. Acutely stupidly passed to the inner surface of the ridge (Figure 4). Splits were formed with a chisel, a cortical-spongy block was taken from the internal surface of the ilium. The spongy bone material was taken (Figure 5).
The cortical-spongy plate is placed in a solution of 0.9% NaCl. After the installation of the tape drainage, the sutures are made of silk, a / c bandage, spirit lamp.
Figure  4

Photograph of the operation. Passage to the inner surface of the iliac crest


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Figure  5

Photograph of the operation. Fence of the cortical-spongy block from the inner surface of the ilium


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09/27/2013 Operation:
Augmentation of the left upper jaw with an autograft from the iliac crest
After treatment of the skin and oral cavity with an antiseptic under general anesthesia + Sol. Ultracaini 4% — 4 ml. removed the bridge and roots of 23.24 teeth. An incision of the mucous membrane was made according to Neyman-Zaslavsky in the region of the transitional fold on the upper jaw. The mucosal-periosteal flap, maxillary sinus curettage is exfoliated (Figure 6). Cortical spongy autograft fitting, fixation with titanium screws (Figure 7). After immobilization of the mucosal-periosteal flap-sutures with silk, hemostasis during the operation (Figure 8)
Figure  6

Photograph of the operation. Exfoliation of the mucoperiosteal flap. Curettage of the maxillary sinus.


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Figure  7

Photograph of the operation. Cortical sponge autograft fitting, fixation with titanium screws.


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Figure  8

Photograph of the operation. Suturing of the surgical wound.


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Drug therapy in the postoperative period:
Dopamine 600 2 times a day
Ketanov 1.0 m for pain
Dalacin c 300 1 cap. 2 times a day
Lasix V.M. 1 r.d.
The operation was performed by the head of the center of maxillofacial surgery and dentistry of the Kiev regional clinical hospital Rybak V.A.
The patient was discharged in satisfactory condition for further dynamic outpatient observation.
Figure  9

Postoperative panoramic radiography of patient Y


 
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Clinical case No. 2


Figure 10

Preoperative panoramic radiography of patient X


 
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Patient X used the bicortical technique for installing basal implants in the tubercle-pterygoid suture, on the left side, through the maxillary sinus. Thanks to the polished surface of the implant, one can forget about such a negative postoperative complication as sinusitis, even despite the fact that part of the structure is located directly in the maxillary sinus. The operation is carried out according to the immediate download protocol. Temporary crowns are installed on the third day after surgery (Figure 11). After half a year, a permanent metal-ceramic construction was established.
The operation was performed by the head physician of the European Dental Center Klimentyev V.G.
Figure  11

Photograph of erected temporary bridges. 3rd day after surgery


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Figure 12

Panoramic radiography of patient X 6 months after surgery


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Figure  13

Photograph of established permanent ceramic-metal bridges. 6 months after surgery.


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Conclusions:


When using an alternative technique for installing basal implants in a transinusal way, we can talk about a 97% survival rate, an indicator that is important, first of all, for specialists. Also, it should be noted that when using this technique, as an alternative to sinus lifting, we can talk about a significant improvement in the results for the patient:
— significantly reduced rehabilitation period;
-the indications for the use of this technique are expanding;
— lack of pain and comfort;
— lack of risks associated with the sinus lift technique;
Analysis of clinical examples showed that rehabilitation of patients with indications for sinus lift surgery is possible in the shortest possible time using our methods.