CC BY
22
УДК 616.31
http://dx.doi.org/10.26787/nydha-2686-6838-2019-21-10-77-82
ПРИМЕНЕНИЕ НЕСЪЕМНЫХ ИНДИВИДУАЛЬНЫХ ОРТОДОНТИЧЕСКИХ АППАРАТОВ С ОПОРОЙ НА МИКРОИМПЛАНТАТАХ У ДЕТЕЙ С ДВУСТОРОННЕЙ РАСЩЕЛИНОЙ ГУБЫ И НЕБА
Дудник О.В., Мамедов Ад.А., Зубков А.В.
ФГАОУ ВО Первый МГМУ им. И.М. Сеченова Минздрава России, (Сеченовский Университет),
г. Москва, Российская Федерация
USE OF FIXED INDIVIDUAL MICRO-IMPLANT SUPPORTED ORTHODONTIC APPLIANCE IN CHILDREN WITH BILATERAL CLEFT LIP AND PALATE
Dudnik O. V., Mamedov Ad.A., Zubkov A. V.
I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
Аннотация: Врожденные пороки развития че-люстно-лицевой области являются актуальной и, не до конца решенной, медицинской и социальной проблемой. Данные литературы последних лет отмечают тенденцию к их росту, что характеризует неблагополучие в состоянии здоровья населения. Целью исследования являлось повышение эффективности лечения детей с двусторонней расщелиной губы и неба за счет ранней ортодонтическо-хирургической подготовки. Под наблюдением находились 80 детей с расщелиной губы и неба. Из них 56 детей с двусторонней расщелиной верхней губы и неба с периода новорожденности до 3 лет. Из них 28 пациентов составили первую группу, которым проводилось лечение по стандартному протоколу, 28 пациентов составили вторую группу подготовленных к операции по разработанной методике. Применение разработанной орто-донтической конструкции с активными элементами и миниимплантами в 96,4% случаев позволяет сократить предхирургическую ортодон-тическую подготовку, нормализовать положение межчелюстной кости и форму верхней челюсти с последующим проведением первичной
Annotation: Congenital malformations of the maxillofacial region are a pressing and not fully resolved medical and social problem. The literature data of recent years have noted a tendency for their growth, which characterizes the disadvantage in the state of public health. The aim of the study was to increase the effectiveness of treatment of children with bilateral cleft lip and palate due to early orthodontic-surgical training. 80 children with cleft lip and palate were under observation. Of these, 56 children with bilateral cleft lip and palate from the neonatal period to 3 years. Of these, 28 patients made up the first group that received treatment according to the standard protocol, 28 patients made up the second group prepared for the operation according to the developed methodology. The use of the developed orthodontic structure with active elements and mini-implants in 96.4% of cases allows reducing pre-surgical orthodontic training, normalizing the position of the maxillary bone and upper jaw shape, followed by primary cheloro-plasty and, further, uranoplasty, as well as reducing the time requiredfor rehabilitation of patients with bilateral cleft lip and palate, thereby achieving a stable aesthetic and functional result.
хейлоринопластики и, в дальнейшем, уранопластики, а также, сократить сроки реабилитации пациентов с двусторонней расщелиной губы и неба, достигнув тем самым стабильного эстетического и функционального результата.
Ключевые слова: расщелина губы, расщелина неба, микроимплантаты, хейлопластика, орто-донтическое лечение.
БИБЛИОГРАФИЧЕСКИЙ СПИСОК
[1] Арсенина О.И., Малашенкова Е.И., Пащенко С.А. Алгоритм ортодонтического лечения пациентов с врожденной расщелиной губы, неба и альвеолярного отростка до и после костной аутопластики// СТОМАТОЛОГИЯ 5, 2017 [с.62-65].
[2] Alzain I. et all. Presurgical cleft lip and palate orthopedics: an overview//Clinical, Cosmetic and Investigational Dentistry 2017:9 [p.53-59]
[3] Eriguchi M. et all. Growth of Palate in Unilateral Cleft Lip and Palate Patients Undergoing Two-stage Palatoplasty and Orthodontic Treatment/Bull Tokyo Dent Coll (2018) 59(3): [p. 183—191]
[4] Pet M. A. et al. The Furlow palatoplasty for velopharyngeal dysfunction: Velopharyngeal changes, speech improvements, and where they intersect //The Cleft Palate-Craniofacial Journal. - 2015. - Т. 52. - №. 1. - [p.12-22].
[5] Tsichlaki A. et all. A scoping review of outcomes related to orthodontic treatment measured in cleft lip and palate//Orthod Craniofac Res. 2017;20: [p.55-64].
Keywords: cleft lip, cleft palate, microimplants, cheiloplasty, orthodontic treatment.
REFERENCES
[1] Arsenina O.I., Malashenkova E.I., Paschenko S.A. Algorithm orthodontic treatment of patients with congenital cleft lip and alveolar bone before and after bone autoplasty// Stomatologia 5, 2017 [p.62-65].
[2] Alzain I. et all. Presurgical cleft lip and palate orthopedics: an overview//Clinical, Cosmetic and Investigational Dentistry 2017:9 [p.53-59]
[3] Eriguchi M. et all. Growth of Palate in Unilateral Cleft Lip and Palate Patients Undergoing Two-stage Palatoplasty and Orthodontic Treat-ment//Bull Tokyo Dent Coll (2018) 59(3): [p. 183-191]
[4] Pet M. A. et al. The Furlow palatoplasty for velopharyngeal dysfunction: Velopharyngeal changes, speech improvements, and where they intersect //The Cleft Palate-Craniofacial Journal. - 2015. - T. 52. - №. 1. - [p.12-22].
[5] Tsichlaki A. et all. A scoping review of outcomes related to orthodontic treatment measured in cleft lip and palate//Orthod Craniofac Res. 2017;20: [p.55-64].
Cleft lip and palate is one of the most common malformations of the maxillofacial region, occupying the 3-4th place in the structure of congenital anomalies. Among them, the most severe form is bilateral cleft lip and palate, which is relatively rarer (15-25%) than other forms [1].
In the complex treatment of children with cleft lip and palate, the use of early orthodontic methods of treatment is important in order to prepare such patients for primary surgical intervention. For the treatment of children with this pathology, removable orthodontic appliances are most often used. To eliminate diastasis between the alveolar processes and correct anomalies in the form of the maxillary arch with bilateral cleft of the upper lip and palate, modified forming apparatuses are used [1,3]. In these cases, the treatment is characterized by long periods and depends on many factors: the value of diastasis, the timing of the start of treatment, the child's getting used to the device. The
disadvantages of these devices are poor fixation in the conditions of a toothless jaw, the need for frequent visits to the doctor and the need for repeated replacement of devices [2,5].
One of the urgent problems of modern dentistry, pediatric maxillofacial surgery, orthodontics is the development and improvement of methods for early rehabilitation of children with pathology of the maxillofacial region, as a congenital malformation leads to deformation of the middle third of the face, disharmony of the development of the facial skeleton, grossly violates the functions of vital important organs and systems, facial aesthetics and negatively affects the formation of the child's psychoemotional status [3,5].
An analysis of the results of the orthodontic removal of dentoalveolar deformities in patients with bilateral cleft lip and palate shows that a special approach to their treatment is necessary. Individual planning of orthodontic preparation, the choice of rational methods and means of orthodontic treatment depending on the age of the patient, the method of planned cheilo - and uranoplasty, the condition of the teeth, the type and type of cleft, the severity of dentoalveolar deformities [2,4]. The aim of the study was to increase the effectiveness of treatment of children with bilateral cleft lip and palate due to early orthodontic-surgical preparation.
Materials and methods. For the period from 2011 to 2019, at the Department of Pediatric Dentistry and Orthodontics of the First MGMU named after THEM. Sechenov under supervision were 80 children with cleft lip and palate. Of these, 56 children with bilateral cleft of the upper lip and palate from the neonatal period to 3 years. Of these, 28 patients made up the first group, which was treated according to the standard protocol with preliminary orthodontic preparation on removable devices, 28 patients made up the second group, which underwent partial opener osteotomy and fixed fixed orthodontic apparatus with minisynthes and intermaxillary rods.
Prior to surgery, all children with bilateral cleft of the upper lip and palate underwent a routine clinical and laboratory examination (clinical blood and urine tests, biochemical blood tests, chest x-ray, ultrasound of the abdominal cavity, ECG, etc.). In addition, patients were examined by a neona-tologist, pediatrician and ENT doctor, since one of the leading places among concomitant pathology in children with cleft lip and palate was occupied by the pathology of ENT organs. It should be noted that the pathology of ENT organs does not appear immediately, but at an age closer to one year.
When examining the patient and preparing for surgery, his general condition, the presence of other congenital malformations, height and weight were evaluated. Together with specialists, they interpreted the results of clinical and laboratory analyzes and functional studies. After the conclusion of the pediatrician about the general condition of the child and the possibility of surgical treatment, an anesthesiologist was consulted with a view to the possibility of general anesthesia.
From the pathology of the maxillofacial area, dental surgeons and orthodontists were interested in the following indicators: the condition of the oral mucosa; degree of protrusion of the intermaxillary bone; intermaxillary bone size; the degree of mobility of the jawbone; the angle of deviation of the jawbone from the midline of the face; the shape of the lateral fragments of the alveolar process of the upper jaw; the distance between the anterior points of the lateral fragments of the alveolar processes.
After taking the diagnostic impressions, the marker contoured the borders of the lateral fragments of the alveolar bone and the middle intermaxillary bone with the vomer.
Then, models were photographed in a standard position and photos were transferred to a computer. Using the AUTOCAD program, the graphical shape of the crests of the lateral fragments of the alveolar processes, intermaxillary bone and the vomer was obtained, where reference points were applied in the program, between which linear and angular measurements were performed.
In connection with the need to manufacture a fixed orthodontic apparatus for the choice of design, we were interested in the following parameters: the severity of protrusion of the jawbone, the angle of deviation of the jawbone from the midline of the face, the distance between the anterior points of the alveolar processes of the lateral fragments of the upper jaw. Micro implants (Absoan-chor, Korea), designed specifically for use in orthodontics, were used as a support for the fixing elements of fixed orthodontic appliances with intraosseous fixation.
Elastic chains, nickel-titanium springs (Fig. 1) were used as rods between the device and microscrews fixed on the maxillary bone.
Fig. 1. Fixations of the maxillary expanding apparatus, microimplants, rubber rods on the
fragments of the upper jaw.
The fixed apparatus was fixed using microimplants used in orthodontics under general anesthesia. To do this, on fixed fragments (two lateral and intermaxillary bones), holes were prepared in advance in a projection at an angle of 45 degrees to the top of the crest of the alveolar process. The design of the apparatus also included a screw to expand the lateral fragments of the upper jaw, eliminating the narrowing of the upper jaw.
After adapting to the apparatus, the screw was activated by 0.5 mm once every two days with simultaneous activation of elastic traction for one link in three days. Given the further growth of the intermaxillary alveolar process of the upper jaw in length after cheiloplasty, it is necessary not to completely close the fragments of the cleft of the upper jaw, but also to leave diastasis between them to the width of the temporary tooth. The duration of the active period ranged from 20 to 25 days. One of the important stages is the retention period, which ranged from 15 to 30 days. One month after reaching a favorable fragment ratio, simultaneous bilateral cheiloplasty was performed.
Thus, the use of a maxillary orthodontic plate with a screw, microimplants in preoperative preparation plays an important role in surgical rehabilitation and allows surgeons to perform primary surgery without any difficulties, which positively affects the healing of lip tissue.
In all 56 children with bilateral cleft lip and palate, 56 control and diagnostic models were studied before and after the pre-surgical orthodontic preparation. Of these, 28 control and diagnostic models using conventional removable devices, 28 control and diagnostic models using fixed devices, fixed by microscrews, proposed by the developed technique. In the study of diagnostic models of the
jaw, attention was paid to the linear dimensions of the jawbone, the angle of deviation of the jawbone from the midline of the face, the angle of inclination of the lateral fragments of the alveolar process of the upper jaw.
The results were subjected to statistical processing and entered into a specially designed table. In all the studies performed, the arithmetic mean (M), the standard deviation (delta), the mean square error (m) were calculated, and the correlation coefficient was determined. The significance of differences in the mean absolute and relative values was calculated using Student's criteria (t). Results and discussion. Preoperative orthodontic preparation of 28 children with bilateral cleft lip and palate in the first group, the patients of which used removable orthodontic appliances, showed that in 22 patients (78.6%) they could not fully achieve the end contact between the maxillary bone and fragments of the alveolar process of the maxilla. In addition, during the treatment process it was necessary to manufacture several removable devices and the average treatment period was 7 months. Due to the insufficient fixation of devices on fragments of the alveolar processes, damage to the oral mucosa was observed, requiring treatment and correction of the devices. The use of extraoral elastic traction did not allow to eliminate the medial displacement of the side fragments, required frequent replacement, and also caused irritation of the delicate skin of infants. With a low active ability, the children were restless, parents often refused further treatment with removable devices. In this regard, the further implementation of the surgical stage of treatment was difficult, requiring repeated corrections and a long postoperative healing period.
In the second group of patients, whose preoperative orthodontic preparation was carried out using fixed devices fixed on mini implants, the ratio of the maxillary bone and lateral fragments was normalized in 27 patients (96.4%). In 1 patient (3.6%), it was not possible to achieve the desired result due to individual non-engraftment of mini implants.
It should be noted that the use of the developed non-removable devices made it possible to eliminate the narrowing of the lateral fragments of the alveolar process of the upper jaw, due to the expansion screw built into the design. Which, in turn, was a favorable factor for the further formation of the jaws. After orthodontic preparation of the upper jaw on a non-removable device, it was possible to surgically achieve the formation of the integrity of the alveolar arch, eliminate protrusion of the intermaxillary bone, narrowing (expansion) of the lateral fragments of the alveolar process of the upperjaw.
To comparatively characterize the results of preoperative orthodontic preparation of children with bilateral cleft lip and palate using removable and fixed orthodontic structures, we performed an anthropometric study of diagnostic models of the jaw (Table 1).
Table 1
Anthropometric data of models of the jaws of children with bilateral full cleft lip and palate prepared for surgery by various orthodontic appliances.
Preliminary orthodontic preparation, using a removable maxillary apparatus
Preliminary orthodontic preparation, using a fixed maxillary expanding apparatus and microimplants
On the displacement side of the intermaxillary bone On the side of the displacement intermaxillary bone All On the displacement side of the intermaxillary bone On the side of the displacement intermaxillary bone All
1 8,5±0, 52 10,9± 0,42 19,4±0,47 8,4±0,92 11,6±0, 87 20,0±0,71
3 9,4±0, 95 12,1± 0,62 21,5±,81* 8,3±0,93 11,5±0, 86 20,3±0,89
6 9,8±0, 92 12,7± 0,74 22,5±,83* 1,2±0,27 1,4±0,3 2 2,6±0,29*
12 8,1±0, 84 10,7± 0,88 18,8±0,86 0,9±0,17 1,1±0,1 8 1,0±0,18*
In patients of the first group, as a child grows with a bilateral cleft lip and palate, defects (diastasis) between the intermaxillary bone and lateral fragments of the upper jaw increase and reaches its maximum by 6 months. After cheiloplasty performed at this age, a statistically unreliable decrease in bone defect is noted. In patients of the second group, after preoperative preparation using fixed maxillary devices fixed with mini implants, full face contact between the maxillary bone and fragments of the upper jaw was achieved, which confirms the static processing of the results in the compared groups (P<0.05).
Conclusion. The use of the developed orthodontic design with active elements and mini implants in 96.4% of cases allows to reduce pre-surgical orthodontic preparation, normalize the position of the maxillary bone and the shape of the upper jaw, followed by primary chelorinoplasty and, in the future, uranoplasty, as well as reduce the rehabilitation time for patients with bilateral cleft lip and palate, thereby achieving a stable aesthetic and functional result.
After preoperative preparation using non-removable maxillary devices fixed with microimplants, a full face contact between the maxillary bone and fragments of the upper jaw is achieved, which is confirmed by static processing of the material (P <0.05).
Conflict of interest:The authors of this article confirmed the lack of conflict of interest and financial support, which should be reported.
