Defects and deformities of the palate: causes, symptoms, diagnosis, treatment

Defects of the palate can occur as a result of gunshot and non-fire damage, inflammatory processes, as well as as a result of surgical removal of the palate tumor, previously produced unsuccessful uranostafiloplasty, etc.

According to available data, postoperative defects and deformities of the palate remain in 1.8-75% of patients operated on congenital non-races of the palate.

[1]

What causes defects and deformations of the sky?

Among the inflammatory processes most often the causes of acquired deformities of the palate are syphilis, odontogenic osteomyelitis, and also necrosis of the palate due to the erroneous administration of a solution possessing the properties of protoplasmic poison (alcohol, formalin, hydrogen peroxide, etc.).

Deficiency of the solid palate can also arise as a result of its irritation with a suction prosthesis, causing the appearance of a hematoma with subsequent inflammation of the mucous membrane, periosteum and bone with its sequestration.

In peacetime, the dentist often has to deal with postoperative defects. So, in each maxillofacial clinic, still a significant part of patients are persons with defects and deformities that have arisen due to uranostafiloplasty.

The reasons for such a frequent occurrence of postoperative end-to-end defects are, in our opinion, the following factors:

• stereotyped use of the same method of surgery for various forms of palate non-healing;
• non-compliance with rational operation techniques;
• injuries with tweezers of flaps exfoliated from the solid palate;
• too frequent stitching in the sky;
• lack of plastic material for very wide and atypical non-growth;
• bleeding after surgery and the associated tamponade of bleeding wound sites;
• insufficient retrotransposition and mesopharyngoconstriction (as a consequence of the inhibitory effect of the vascular-neural bundles even if they are removed from the bone bed according to the method of PP Lvov);
• application of a single-row seam with insufficiently free approach of the edges of a crooked defect, etc.

Causes of cicatricial deformation and shortening of the newly created soft palate after uranostaphyloplasty is the formation of coarse scars on the surface of the soft palate facing the nasal part of the pharynx in the peripheral niches and interplastic spaces (after interlaminar osteotomy).

The medial plate of the pterygoid process returns to its original position under the action of the scars and thrust of the inner part of the medial pterygoid muscle attached to this split plate.

To a large extent, the formation of scar tissue in the peripheral niches and interplastic spaces is facilitated by a tight tamponade with their iodoform-gauze strips.

Symptoms of defects and deformities of the sky

Symptoms of end-to-end palate defects largely depend on their location, dimensions and the presence of concomitant defects (lips, cheeks, nose, teeth, alveolar processes).

With isolated defects of the hard palate, patients complain of ingestion (especially liquid) in the nose. The larger the defect of the palate, the worse pronunciation. Some patients cover defects with wax, plasticine, cotton wool, gauze, etc., to get rid of these painful symptoms.

If the defect of the solid palate is combined with a defect in the alveolar process and the lip, complaints are added to the disfigurement of the face, difficulty in grasping and holding food in the mouth.

In the absence of a sufficient number of supporting teeth, patients complain of poor fixation of the upper removable prosthesis; complete removable dentures are not held at all on the upper jaw.

Large through defects of the soft palate and in the region of its border with the hard palate always affect the clarity of speech and lead to the ingestion of food masses in the nose of the pharynx, causing chronic inflammation of the mucous membrane there.

Small (spot or slit) defects of the soft palate may not be accompanied by subjective disorders, but the food through them still seeps into the nasal part of the pharynx, as in the case of narrow, sagged defects of the hard palate.

It is noted that patients with deformation of the dento-jaw system are 2-3 times more likely to get caries.

Cicatricial deformations and shortening of the soft palate are accompanied by pronounced speech disorders (open nasal), which can not be eliminated by any conservative means.

Change in the profile of the patient's face most often occurs as a result of the predominance of the lower lip over the upper. This deviation is most pronounced in individuals previously operated on for the through forms of non-spreading of the palate.

The main type of deformation of the upper dental arch is its narrowing, especially in the region of small molars, and underdevelopment of the sagittal. Most dramatically, these changes are expressed in operated patients with continuous forms of palate neuralgia and a permanent bite. Deformed bite deformities are observed in patients with end-to-end palate non-palpation, previously undergoing surgery in the sky. They have false frontal prognosis, which resulted from the development of the maxillary jaw over the sagittal, and a one- or two-sided cross bite as a result of its narrowing.

The teleradiography data confirm that the basal part of the upper jaw is underdeveloped in patients with continuous forms of palate incisions. The cause of underdevelopment of the upper dental arch along the sagittal is the pressure of the cicatrized upper lip and, possibly, interlaminar osteotomy, which is produced in the wing-maxillary maxillary growth zone of the sagittal.

Patients with traumatic palate defects suffering from speech disturbance are depressed by the fact that people around them suspect a defect of syphilitic origin. This is one of the factors driving the treatment.

To characterize acquired palate defects, largely reflected in these classifications, it should be added that the tissues around them are affected by scars, which are especially pronounced in syphilis and often lead to scar deformation of the entire soft palate. In some cases, there is a complete or partial fusion of the soft palate with the posterior and lateral walls of the pharynx nose, in which patients complain of nasal, nasal breathing and the accumulation of nasal mucus that can neither be removed nor drawn into the esophagus.

Classification of defects and deformations of the sky

Defects and deformations of the palate, remaining after uranoplasty, EN Samar classifies as follows.

By localization:

I. Solid palate:

1. anterior section (including alveolar process);
2. middle department;
3. back department;
4. lateral departments.

II. Boundary of hard and soft palate:

1. on the middle line;
2. away from the middle line.

III.Soft palate:

1. defects (1 - along the middle line, 2 - away from the middle line, 3 - tongue);
2. deformation (1 - shortening, 2 - cicatricial-altered palate).

IV. Combined.

In size:

1. Small (up to 1 cm).
2. Medium (up to 2 cm).
3. Large (over 2 cm).

According to the form:

1. Round.
2. Oval.
3. Slit.
4. Wrong form.

We divide the end-to-end defects by shape into crooked, round, oval and irregular shapes; in size - small (up to 1 cm in diameter or along the length, if the defect is crooked), medium (from 1 to 2 cm) and large (over 2 cm in diameter or along the length).

A detailed classification of palate defects that occur after gunshot wounds, inflammation and oncology operations, was developed by EA Kolesnikov.

By localization, he distinguishes between defects in the anterior, posterior, and border regions of the hard and soft palate; they can be one- and two-sided.

According to the condition of the alveolar process and the localization of the defect in it:

1. without a defect of the alveolar process;
2. with a process defect (through or through);
3. with a process defect in the anterior part;
4. with a process defect in the lateral section.

Depending on the safety of supporting teeth on the upper jaw:

1. defects in the presence of teeth (on one side, on both sides, in different sections of 1-2 teeth);
2. defects in the complete absence of teeth.

On the condition of surrounding tissues:

1. without scar changes of soft tissues near the defect;
2. with cicatricial changes (mucous membrane of the palate, with defects of soft tissues of the circumoral area).

According to the size of the defect:

1. small (up to 1 cm);
2. medium (from 1 to 2 cm);
3. Large (from 2 cm or more).

According to the form:

1. oval;
2. rounded;
3. undetermined defects.

All the extensive gunshot defects of the hard palate, which can not be closed by local tissues, VI Zausaev divides into three groups:

1. defects of the solid palate and alveolar process with dimensions not exceeding 3.5x5 cm;
2. more extensive defects of the solid palate and alveolar process;
3. defects of the solid palate and the alveolar process, combined with a defect in the upper lip or cheek.

With regard to defects of traumatic origin, we adhere to the above classification VI Zausaev.

[2], [3], [4]

Complications of defects and deformations of the sky

During operations in the region of the anterior and posterior parts of the hard palate, intense bleeding from the large palatine artery may occur . You can stop it by temporarily pressing or inserting into the bone orifice the end of the closed hemostatic clamp, and then - a piece of the spongy part of allogeneity, catgut.

With rough cutting of the mucosa-periosteal flaps, rupture of the mucous membrane of the nasal cavity and opening of the previously eliminated non-healing of the hard palate may occur .

If the operation is performed under local anesthesia, aspiration of blood clots is possible . To prevent such complications, you must carefully suck the contents of the mouth with an electric pump.

After surgery, there is sometimes some difficulty in breathing due to changes in breathing conditions, swelling of the nasal mucosa, pharynx nose, throat and trachea (if the operation was performed under an eshterhoeal anesthesia), and also due to the displacement of the tampon from under the plate. There may be bleeding from the side wounds, which is associated with the lysis of blood clots in the vessels damaged during the operation.

If the method of operation is unsuccessfully chosen, there may be divergence of the seams, especially after operations using the methods of Axhausen, VA Aronson, NM Mikhelson. In such cases, as a rule, a repeated operation is unavoidable, if the defect in the sky does not cover the formed scars.

Outcomes and long-term results

Outcomes and long-term results depend on the location and magnitude of the defect, postoperative care, speech therapy, palate massage, etc. If speech disturbance was associated only with the penetration of air through the defect and it was managed to be eliminated in an operative way, the speech normalization occurs in a few days after the removal of sutures and the disappearance of edema. In this respect, the most probable are the accidentally arising traumatic defects of the hard palate in adults. The situation is worse for defects and deformations of the soft palate that have arisen in a child after uranostaphyloplasty: the normalization of speech is slower, speech therapy, palate massage, and exercise therapy are required. Electrostimulation, etc.

Adverse outcomes are noted in many patients after operations on Schenborn-Rosental (lengthening of the soft palate due to a pharyngeal flap on the foot): the wrinkling of the flap occurs, as a result of which the speech remains a nasal matter. This method should be used only in cases when no other method can be used, including stitching of the palatine pharyngeal arches (according to AE Rauer), after which the results are much better than after the operation of Schenborn-Rosental.

[5], [6], [7], [8]

Treatment of defects and deformations of the sky

Treatment of acquired defects and deformities of the palate, surgical or orthopedic. Indications for only orthopedic treatment are only the poor state of health and a difficult general condition of the patient, which does not allow the operation, especially multi-stage and complex.

If the general condition of the patient with a deformed (after uranoplasty) upper jaw is satisfactory, it is possible to apply the surgical-orthopedic method developed by ED Babov (1992) for the treatment of narrowing of the upper jaw: after osteotomy of the maxillary conformation, the middle part of the face is expanded with the help of the orthodontic device, imposed on the day of the operation. Osteotomy of zygomatic arches is performed by the author according to the method of GI Semenchenko et al. (1987), consisting of a transverse osteotomy of the zygomatic arches in the region of the temporal-zygomatic sutures.

Defect of the palate should be sought to close by a one-stage local plastic surgery. Only in case of impossibility of elimination of a defect in this way it is necessary to use plastic with Filatov's stalk.

The tactics of the doctor when eliminating defects and deformations that remain after an unsuccessful urano-staphyloplasty depends on the location, size, shape of the defect, the condition and the number of surrounding tissues.

The standard method for eliminating all defects does not exist, if only because the condition of surrounding tissues, even around the defect of the same localization in different patients, may not be the same. For example, even the tissues of different parts of the palate, unchanged by the scars, are very different in one and the same patient. Thus, in the anterior part of the hard palate there is absolutely no submucosa; on average, it is only about the alveolar processes, but in a small amount; the border of the hard and soft palate is characterized by a pronounced tension of the soft tissues. Defects of the soft palate can be combined with his scar scar, and sometimes with the absence of the palatine tongue or with a twist in the nose of the pharynx.

In connection with this, 7 departments are distinguished in the sky: the anterior one is limited by a line from 31 to 13 teeth; two side - about 543 | and | 345 teeth; middle (4) - between the side, front and back, bounded in front by a line between 6 | and | 6 teeth, and behind - a broken line at an obtuse angle from 8 | up to 8 teeth; "Borderline" - between this broken line and the line connecting the middle of the crowns of 8_18 teeth; soft sky.

Methods of elimination of defects in the anterior part of the hard palate and alveolar process, as well as soft palate deficiency

With residual non-growth of the alveolar process, if there is a clearance of 1-3 mm between the edges of the non-affection, it is recommended to apply the method of PP Lvov, which is as follows. Along the edges of non-infirmity, mucus-periosteal gingival grafts (on the stem) are formed, cut off and sewed together along the lower edge, and then hemmed to the soft tissues of the hard palate and the vestibule of the mouth.

If the edges of the gingival defect of the gum tightly adjoin one another, they should be de-epithelialized with fissure boron and, by mobilizing the tissues with cuts near the edges of the defect, sew, as in the case of primary uranoplasty.

The method of DI Zimont

If the defect of the anterior part of the palate is small or medium in size, especially if it is a slit-shaped one, then it is best to apply DI Zimont's method (Figure 169). The edges of the defect are excised with a narrow and sharp scalpel, making an arcuate incision to the bone near the papillae of 4321 | 1234 teeth and separating the muco-periosteal flap with the base facing the middle part of the palate. Catgut sutures the edges of the defect from the side of the nose, put the flap in its place and sew the edges of the wound from the side of the palate mucosa. Given that the method does not provide for the creation of a nasal epithelial lining, EN Samar proposed to create it through a split autologous transplant, which is sewn to the edges of the periosteal defect by 4 sutures with catgut.

Methods EN Samara

1. With defects in the anterior part of the palate, combined with the absence of incisors or the intermaxillary bone, an M-shaped incision is made in the Langenbeck section to form a wide flap of the mucous membrane and periosteum of the entire anterior part of the palate with a pedicle in the middle section (Figure 170) it is turned downwards and its ends are stitched together; cut from the lip and alveolar process flap (with a pedicle at the anterior edge of the defect) is tipped with the epithelial surface to the defect and hemmed to the wound surface of the turned M-shaped mucosal-periosteal flap. The formed duplicate is laid on the defect of the hard palate and fixed with sutures. The wound is sewn on the lip. Cut out the flap in the mucosa-submucosa layer; in those cases where there is a toothless alveolar process, the continuation of the graft flap is its mucosa and periosteum.

To create a duplicate without tension in the seams, the length of this flap should exceed the defect length by 1.5-2 cm.

2. With defects of the anterior section of the solid palate, combined with two defects of the alveolar process (along the sides of the premaxillary bone) on the intermaxillary bone, a T-shaped incision is made, which is turned with the base toward the teeth; They cut off two triangular mucosal-periosteal flaps and tilt them 180 ° to form an inner lining. Langenbeck incisions (up to 6 | 6 teeth) are made and connect them at the lower edge of the defects. The severed mucosal-periosteal palatine flap is laid on truncated triangular flaps and fixed by their sutures.

When creating a palatine patch for Langenbeck, you need to carefully cut it off in the middle part so that you do not open the bone-mucosal defect that was previously eliminated by the surgeon (during uranoplasty).

Methods for elimination of defects in the front and middle parts of the palate

Method Spanier-Kriemer-PH Chekhovsky

The method of Spanier-Kriemer-PH of Chekhovsky is applicable in those cases when the through defect of the solid palate has an oval shape and does not exceed 1x0.5 cm. At the same time, if a stock of tissues allows, on one side of the defect, the mucous- periosteal flap so that after cutting, tearing and tilting through 180 ° it could cover the defect with an excess of 3-4 mm around the perimeter. This peripheral strip of the flap is de-epithelialized by means of a milling cutter; only a part remains that is notepithelialized, capable of repeating the shape and size of the defect, closing its entire lumen after tilting the flap 180 °.

On the opposite side, as well as above and below the defect, form an interstitial niche by stratifying the soft tissues horizontally. The depth of the niche should be 4-5 mm.

Then they cut out the muco-periosteal flap, separate it from the bone base, capsize it with epithelium into the nasal cavity, and inject the de-epithelial margin of the flap into the interstitial niche and fix it with several U-shaped seams made of polyamide thread that are tied near the base of the alveolar process. In case of insufficiently tight fit of the edge of the interstitial niche (from the oral cavity) to the wound surface of the overturned flap, they should be brought together by applying 1-2 knotty catgut sutures.

If the defect of the hard palate is small (no more than 1 cm in diameter or along the length), the operation ends on this. The wound is closed with an iodine-shaped swab, which is strengthened by a protective palatine plate prepared before the operation. After 3-4 days, the tampon and the plate are removed, the wound is irrigated with a solution of hydrogen peroxide and is further conducted by an open method. U-shaped sutures are removed on the 9th-10th day. The wound surface of a flap 180 ° tilted is epithelialized from the edges.

If the size of the through defect of the solid palate exceeds 1 cm, during the operation, another split skin flap is placed on the wound surface of the flap, which is turned into the oral cavity, which is usually harvested on the anterior abdominal wall.

After that, the area of operation in the sky is closed with a foam plate, impregnated with deoxycorticosterone acetate, and 2-3 layers of iodine gauze and a protective plate are applied over it.

The first dressing and removal of the sutures are performed on the 10th day, when the wound surface is already covered with islets of the epithelium. The split flap itself, which served as a source of epithelialization, never fully survives. Unextended edges of it should be carefully cut off and removed. By this time, the marginal epithelization of the wound surface is also noticeable. In the future, the wound is opened.

If the defect of the solid palate is triangular and so large that it is impossible to cover it with one flap, a two-fold method should be used - tipping and stitching of two flaps cut at the edges of the defect. The part of the edges of such flaps, which are turned over by the epithelium into the nasal cavity, must inevitably fall into the interstitial niches (above and below the place where the flaps are cut out). Therefore, the section of free overlapping of the two flaps (ie, mutual overlapping of each), as well as the edges to be inserted in interstitial niches, must be de-epithelialized by a milling cutter. Nondepithelialized areas on both flaps should, when folded, correspond to the area of the through defect. After scraping, cutting off the bone and tilting 180 °, the flaps are sewn together with U-shaped seams. The same seams fix the edges of the flaps inserted into interstitial niches. For a more reliable and rapid epithelialization, the wound surface of the overturned flaps can be covered with a split skin flap.

With the aim of eliminating the extensive end-to-end defects of the anterior section of the hard palate that remain after surgery for bilateral non-eruption of the palate and alveolar process, RN Chekhovsky also recommends using the above method of tipping two flaps from the sides of the defect. But for their overlapping, the author uses a slimy-periosteal flap, cut out on the vomer and intermaxillary bone; his leg is facing forward - to the incisal opening on the intermaxillary bone. The flap is lifted from its base and laid on the side flaps overturned and sewn together.

To eliminate residual defects in the anterior part of the hard palate, E. N. Samar recommends the use of the method of DI Zimont. To eliminate small and medium defects in the area of the hard palate, E.N. Samar, as well as Burian, use two flaps: one is tilted to the nose (with a foot at the edge of the defect), and the second is shifted from the adjacent area of the palate (on the stem facing the vascular bundle ). The first flap is formed on one side of the defect, the second on the opposite side.

The application of this method is due to the assumption that the tissues bordering the defect are in a state of chronic inflammation and therefore their regenerative abilities are reduced. We do not share these fears; the experience of our clinic testifies to the high viability of the flaps cut at the edge of the defect and tilted 180 ° epithelium into the nasal cavity, which is also confirmed by experimental studies.

The method of Yu. I. Vernadsky

To eliminate a large defect of the solid palate of a polygonal shape, it is possible to recommend a local-plastic technique for its closure, conventionally called "multifilament", which avoids the use of multi-stage plastics by the Filatov stalk. Accordingly, each facet of the defect is cut out and tipped (on the leg facing the edge of the defect) de - epithelialized mucosal-periosteal flap. As a result of mutual overlapping of several (3-4-5) flaps, the entire defect is completely closed. To increase the viability of the flaps, the probability of "sticking" them together and "survival", we recommend that the patient carry out finger massage of the edges of the defect within 2-3 preoperative days.

If the defect of the hard palate is very large, then it is not always possible to achieve its elimination from the very first time, even with the application of a multibeam method. In such cases, it is necessary to repeat the operation by the same procedure every 2-3 months, achieving each time a gradual reduction in the size of the defect, until it is completely eliminated. Experience shows that a 2-3-fold operation is tolerated by patients much more easily than multi-stage plastic with the use of Filatov's stem.

A.E. Rauer's method

To eliminate postoperative through and combined defects of the soft palate, shortening (scarcity) and cicatricial scar deformity, many surgeons resort to repeated radical uranostafiloplasty.

With cicatricial changes in the anterior sections of the hard palate and shortening of the soft palate up to 2 cm, EN Samar recommends the operation of AE Rauer - stitching of the palatine pharyngeal arch. In our clinic this operation is very rarely used.

As for the operation Schenborn-Rosental (plastic soft palate flap on the leg from the back wall of the pharynx), then we do not use it at all, considering non-physiological (creating unavoidable conditions for closed nasal), and for the consequences - unhygienic due to a permanent disruption of normal ventilation of the nose of the pharynx .

The method of GV Kruchinsky

Of great practical interest is the proposal to remove defects in the area of the hard palate (including those that extend to the alveolar process) or the boundaries of the hard and soft palate due to a flap on the stem from the tongue of Vuerrero-Santos. GV Kruchinsky perfected this method and considers it suitable for the elimination of defects in the size from 1x1.5 to 1.5x2 cm. The operation by the method of GV Kruchinsky is performed under intratracheal anesthesia. The lining from the side of the nasal cavity is restored by tilting the mucosal-periosteal flaps from the edges of the defect. Then we cut out the flap in the area of the tongue back, beginning anterior to the blind hole; its nutritional leg should be located in the tip of the tongue. The mucosal flap along with the layer of longitudinal muscles of the tongue is separated almost to the tip of the tongue; gradually sewing the edges of the wound, the flap is turned into a tube. The flap formed in this way is a continuation of the tongue and has a powerful nourishing stem.

At the end of the operation, the tongue is fixed with two mattress sutures (on rubber tubes) to the small molars of the upper jaw. The flap is sutured to the edges of the wound in the area of the palate defect. The tongue is tightened and fixed, tying up previously prepared mattress sutures from both sides.

After 14-16 days, the stalk leg is cut off from the tongue, finally spread out on the palate wound, and part of the stem is returned to its original position. The author believes that the nourishing leg can be formed not only on the tip, but also at the root of the tongue or its lateral surface.

Concluding the consideration of the plastic issue with residual defects of the hard palate after the previous uranoplasty, it should be noted that a lyophilized dura mater is successfully used to replace the defect of the bone tissue, which turned out to be a promising plastic material.

Surgical restoration of the function of palate-pharyngeal pulp in patients previously exposed to uranophiloplasty

Methods EN Samara and NA Miroshnichenko

Using X-ray tomography and spectral methods of speech analysis of patients before and after uranostafiloplasty, developed by E.N. Samar (1986), NA Miroshnichenko (1991) established in 120 patients the need for correction of palate-pharyngeal pulp.

If this was due to a pronounced atrophy of the nephro-pharyngeal muscles and the upper throat compressor, a correction was applied according to the following procedure (E.N. Samar, NA Miroshnichenko, 1984, AS No. 1524876): from the incisions along the wing jaw folds on both sides were distinguished by the lower sections of the medial pterygoid muscles on the inner surface of the lower jaw, after which the medial bundles of these muscles with a width of up to 2.0 cm cut off the lower edge of the corners of the lower jaw. The bunched muscle bundles were introduced into the region of the lower part of the soft palate and stitched together on the median line with catgut.

The results of functional studies of palate-pharyngeal beet pulp showed that there are prerequisites for reconstructing palate-pharyngeal pulp after primary palate plasty not by retrotransposition of the soft palate, but by approaching the muscles of the upper throat compressor. In total, 54 patients underwent surgery. Of them, between the ages of 5 and 9, 20 people; at the age of 10 to 13 years - 19 people; aged over 13 years - 16 people; Before the operation, an x-ray tomographic examination of palate-pharyngeal pulp was performed.

In patients with submucous non-growth of the palate on X-ray tomograms, there was a lack of palate-pharyngeal closure; their surgical treatment was performed with the obligatory retrotransposition of the soft palate or with the reconstruction of the palate-pharyngeal pulp. Therefore, 11 patients with a submucosal palate defect underwent an operation on Voe Kilner, and 4 patients - according to the methods of these authors: when the mucosal-periosteal flaps were cut out on a solid sky, a vascular bundle on one side up to the middle section was vascularized, after which the anterior third of the flap the arterial leg was moved to a diamond-shaped defect of the nasal mucosa at the border of the hard and soft palate, made for retrotransposition.

The rest of the nasal mucosa remained intact. After this, the muscles of the soft palate, mucous membranes and muco-periosteal flaps were layer-by-layer. In all 15 patients, the anatomical result of the operation was positive, while the functional result was good for 9 people; the other 6 speech improved, but did not reach the norm. The authors note that even with complete restoration of the palate tissues, the functional activity of palate-pharyngeal pulp is not always noted.