Transplantation of teeth

The loss of a constant first large molar tooth on the lower jaw in children and adolescents results in significant deformations of the dental arch and, as a consequence, the entire dento-jaw system.

Loss of teeth in adults adversely affects the masticatory function and forces patients to resort to dental prosthetics, which does not always satisfy them in a functional and cosmetic relationship. In this regard, dentists have long and persistently developed various types of odontoplasty: auto-, allotransplantation and implantation of the roots of the teeth.

Autotransplantation of teeth

Autotransplantation of teeth is indicated in the following cases:

1. when removing the retinated tooth, the removal of which into the right bite using the methods of conservative orthodontics is impossible;
2. if necessary, replace the defect of the dentition if the conducted orthodontic treatment involves tooth extraction;
3. with complex anomalies of teething, when conservative-orthodontic treatment does not give the desired results;
4. if it is possible to remove the tooth of "wisdom" and use it to replace previously removed first or second large molars.

The questions of autotransplantation of teeth were elaborated in detail by NA Chudnovskaya (1964), VA Kozlov (1974), and others.

Autotransplantation of the tooth is contraindicated in general and local diseases that disrupt the process of bone regeneration (inflammatory processes in the jaws and mucous membrane of the oral cavity, tuberculosis, other chronic and acute infectious, endocrine, oncological diseases, etc.).

Transplant should be only uncut teeth, which are in the stage of complete formation of the crown, but with the roots unformed to the end (or at the beginning of their formation) with a bifurcation clearly outlined on the roentgenogram. The transplant is transplanted with a dental sac.

Wisdom tooth transplantation is performed simultaneously with the removal of the roots of the first lower major molar (in two separate stages).

I stage of the operation: removal of the roots of the first permanent lower major molar and the preparation of a sensory bed in its alveolus. Ultimately atraumatically remove the first lower large molar tooth or its roots, scraped from the granule alveoli, granuloma or cyst; if there is a gingival fistula, it is subjected to curettage by a small spoon. Inter-root septum partially resected. The wound is washed with a solution of an antibiotic and injected into it with a gauze swab moistened with an antibiotic, which is left until the transplantation of the transplanted rudiment of the wisdom tooth.

II stage of the operation:

• an unsharpened wisdom tooth with a dental sac is extracted by sawing the outer wall of the jaw into the depth of the bone plate within the wisdom tooth;
• the extracted tooth and its pouch are immediately placed in a pre-prepared bed, from which a tampon with an antibiotic is extracted;
• of fast-hardening plastic, a kappa bus is produced in the area of the graft and adjacent teeth, which is fixed when the patient's teeth are closed.

On the 25th day after surgery, the kappa splint is removed. Thanks to the technique of manufacturing the tire-kappa, the graft on the transplant from the very first minutes after the transplant has a physiological load, which has a beneficial effect on the process of bone regeneration around the transplanted tooth and its trophic.

On the X-ray patterns produced after the operation using this technique, gradual formation of bifurcation, formation of the root cavity of the tooth, root growth and transplant engraftment, mainly in the periodontal type, are noted. The contact surface of the crown of the transplanted tooth gradually reaches the level of the occlusal surface of adjacent teeth and contacts the antagonists.

After 2 months after the operation, the first signs of pulp reaction to the effect of the device for electrodontodiagnosis are detected. Gradually, the electrical excitability of the transplanted tooth approaches the parameters of the symmetrical tooth and becomes equal to them.

According to some authors, the sensitivity of the transplanted tooth is due not to the restoration of the pulp, but to the root of the tooth in the canal, and to the pulp chamber - connective tissue and bone containing nerve endings.

On the basis of observations, it has been established that the reason for non-immolation of the teeth, as a rule, is a significant excess of the volume of the newly created alveoli in comparison with the volume of the root of the tooth. This was the case, for example, when the retinas were located near the alveoli that occurred after the extraction of the second molar or its roots, as a result of which both cavities in the bone (in place of the second molar and the transplanted wisdom tooth) inevitably united into a single one, the size of which exceeded the volume of the root tooth. To avoid this, it is recommended that the extracted retested tooth be placed for 2 months in a preservative liquid (100 ml isotonic sodium chloride solution and 10 ml 96% ethyl alcohol) and stored in a refrigerator at a temperature of 4-6 ° C. After 2 months in the young bone tissue formed on the site of the former operation, form the cavity-alveolus and put a canned tooth in it. A year after autotransplantation, complete or complete restoration of bone tissue around the transplanted tooth is noted against the background of complete clinical well-being, and the periodontal gap line is preserved without any changes only in certain areas. In other places, the bone is snug against the root of the tooth.

In experiments with autologous transplantation of the mandibular tooth rudiments (by reversing the places of the same name among them), VN Zemchikov (1972) established that this operation is completed, as a rule, by their engraftment and development, although the surgical trauma applied to the rudiments upon allocation and transplantation to a new site distorts their morphogenesis and the course of mineral, protein metabolism in further development. To reduce the harmful effects of this injury, you should approximate the transplanted rudiment closer to the mandibular vascular-neural bundle, until it comes into contact with it.

In developing the technique of transplantation of impacted tooth in the dental arch next dental surgeons emphasized the importance of moving the teeth into the correct position without breaking the neurovascular bundle, it noted, however, that this is possible only provided that the tooth position allows to move only his crown and the root apex leave thus "in an initial position". The proposed operation involves the removal of only a layer of bone tissue between the compact bone and the root of the displaced tooth throughout its entire length, and then fixing the tire in its achieved position. On the edges of the alveoli around the tooth-graft sutures are applied. This delicate operation with preservation of the thinnest vessel can be performed only by a very experienced dental surgeon, specialized in transplantation of teeth.

It matters also where the dental autograft will interfere. When transplanted into the natural alveolus, it fuses more favorably - in a periodontal type, and in an artificial one - along an osteoid, i.e., less favorable type, in which the viability of transplanted teeth is reduced by 1-3 years; In addition, the use of such teeth (osteoid-like animals) under support for non-removable prostheses leads to progressive root resorption, while no similar changes are observed with periodontal type of fusion.

[1], [2]

Allothransplantation of teeth

Allografting of teeth is of great practical interest, and therefore has long attracted the attention of experimenters and clinicians.

Transplantation of dental rudiments is shown in the case of the appearance (or the presence from the moment of birth) of defects in the teeth of children, which violate the function of chewing and speech, which are not amenable to orthodontic treatment and which threaten the growth and development of alveolar processes, in particular:

• in the absence of a child with a removable or permanent bite of two or more adjacent teeth or their rudiments lost as a result of previous periodontitis or trauma, with the preserved alveolar process and the absence of pronounced destructive changes therein;
• in the absence of large molars of the lower jaw or their rudiments in young children (6-8 years), which leads to a rapid development of the deformity of the alveolar process, a lag in the development of the corresponding half of the jaw;
• with congenital adentia.

Based on the results of experimental studies carried out in this area by various authors (VA Kozlov, MM Maksudov, GE Dranovsky, and others), the following conclusions can be drawn:

1. the most favorable time for transplantation of dental rudiments is the period when they already have the basic structures without pronounced their differentiation and form-formation;
2. taking donor rudiments and transplanting them to the recipient should be carried out, strictly observing the requirements of asepsis and trying to minimize trauma of the transplant;
3. transplanted rudiments must be brought into contact with the tissues of the recipient on their entire surface, thus ensuring a firm fixation and feeding of the sac;
4. rudiments need to be isolated from oral infection by blind seams or glue for the entire period of their engraftment and development.

[3], [4], [5], [6], [7],

Implantation of the roots of teeth

There are 5 types of implants: subgingival, periostal, interdental, intraosseous, combined. G. K. N. Fallashussel (1986) considers subgingival implants as a special type and adds another group of transosseous implants, and R. Telsch (1984) considers it appropriate to differentiate closed and open implants: an implant is considered closed. Completely covered by a mesenchymal tissue (eg a magnet), and an open implant penetrating through the epithelium. In addition, JG Schwarz (1983) subdivides implants depending on the shape of the screw, needle-shaped, cylindrical, in the form of a root of the natural tooth, flat and combined intraosseous-subperiosteal.

G. Strub (1983) identifies 4 different types of connection of tissue bones and implants depending on the materials:

1. bone connection (bioglass, glass-ceramics);
2. bone contact (titanium, carbon, ceramics based on aluminum oxide);
3. covering with connective tissue (polymers, acrylates);
4. combination (all non-bioactive materials).

By diligence to the anatomical structures distinguish between intraosseous and subperiosteal implants.

Intraosseous - directly fixed in the bone, and the subperiosteal lie on the bone (resting on it), the size and structure of the bones determine the shape and size of the implant. Intraosseous implants are most often shaped like a screw, cylinder, staple or sheet.

Subperiosteal implants, which repeat the shape of the alveolar process of the jaw, on which they are laid, are made from the impression obtained during the first surgical intervention, but are laid during the second operation. The implant consists of an internal (fixing) part and an outer (supporting) part.

By the nature of the performed function, the implants can be divided into retaining and supporting ones, intended for fixing both removable and non-removable prosthesis structures.

Implants, implanted in the frontal part of the lower jaw, are intended solely for the stabilization of removable dentures in the case of complete absence of teeth. Most often for these purposes use screw-like and cramp-shaped implants.

To create a distal support at the end defects of the dentition, leaf structures are most suitable, which can be applied on both jaws without risk of damage to important anatomical formations. Their incorporation is technically simple, and the implants themselves, with proper placement, evenly distribute mechanical loads to the jawbone. The manufacture of such implants is possible by milling of titanium, in part - with a coating of titanium powder.

Based on clinical and experimental data, V. Los (1985) identifies general and local indications and contraindications for the use of intraosseous implants. Implantation can be carried out by persons who, according to the conclusion of an internist consultant, do not have systemic diseases that cause lax wound healing.

Contraindicated implantation in periodontitis, blood diseases, endocrine diseases, allergic conditions, various types of tumor or tumor-like formations.

Local indications: the presence of a pronounced alveolar crest in the area of the removed teeth, when the mandibular canal and airways are at a distance that allows placing the intraosseous implant. Any implantation should be performed with the patient's obligatory consent. It can be carried out to people of all age groups. Patients with a labile nervous system for 2-3 days before surgery are assigned sedatives.

Preparing for dental implantation

According to the diagnostic models compared in the bite, it is possible to place the prosthesis with support on the implant and natural teeth. If necessary, the occlusal plane is aligned. Contact intraoral X-ray photographs give an idea of the condition of the tissue at the site of implantation, the location of the mandibular canal and the maxillary sinus.

The technique of implantation according to VV Losyu

Under local anesthesia, the incision is made along the center of the alveolar crest to the bone with an eye scalpel. Its length is 1-1.5 cm, which slightly exceeds the size of the implant. Bluntly, the edges of the wound are dilated until the alveolar ridge is exposed. Then the implant is tapped in the wound to prevent errors in determining the direction and length of the planned implant in the bone. The size of the implant is made by cutting the bone. To do this, use carbide or special burs, whose diameter is less than the transverse dimension of the implant by 0.1-0.2 mm.

In the melodistal angles of the wound perpendicular to the crest of the alveolar process and parallel to the existing teeth that limit the defect, create perforations with a depth of 5-7 mm. By connecting 3-4 holes, lying on one line, we get a ready-made implant bed. Its depth is controlled by a special probe. The elimination of bone overheating is achieved by working at low velocities and by constant irrigation of the bone wound with a cold physiological solution.

In order to prevent metallurgy, the wound is rinsed, the injured bone is scraped off and the bone sawdust is extracted from it with a stream of saline. Then the implant is put into the groove as far as it will go and wedges it into the bone with light blows of the surgical hammer through the mandrel. The correctness of the operation is indicated by:

1. The implant is immovably stabilized in the bone.
2. Intraosseous part of it is submerged under the cortical plate.
3. The cervix is at the level of the periosteum.
4. The supporting element of the implant is located parallel to the supporting teeth.
5. Between the supporting part and the antagonizing teeth there is a gap of 2-3 mm.
6. Between the mandibular canal and the implant or the airway sinus and implant, a distance of 5-7 mm is maintained.

In places where the flaps are most stretched, the wound is sewn with a polyamide thread. The operation lasts 30-40 minutes.

Patients are recommended hygienic care for the oral cavity: irrigation with decoction of chamomile with a small amount of hydrogen peroxide, a solution of furacilin, citral, artificial lysozyme (from the protein of a chicken egg). After the operation, an analgesic is prescribed internally.

A week after the operation, the stitches are removed, and the control radiography is performed.

On the upper jaw, the operation is easier: there is less dense bone tissue. Otherwise, surgical interventions on the upper and lower jaws have no noticeable differences.

Postoperative radiographic inspection after 5-7 days allows to judge the correctness of the implant position, its relationship with the anatomical formations, gives an idea of bone resorption and apposition. Normalization of the density of the bone pattern around the implant indicates the completion of the process of incorporation of the structure. The study of the mucosa in the implantation area makes it possible to judge the presence or absence of inflammatory phenomena.

In the overwhelming majority of cases, the surgical wound heals with primary tension, but in the oral cavity there is always the danger of infection. To prevent this, special attention is paid to hygienic care of the oral cavity.

Two months after the operation, a denture defect, limited on one side by an implant, is prosthetically applied. Immutable implant and absence of inflammatory phenomena of the mucous membrane around it serve as indispensable conditions for this.

Natural supporting teeth that limit the defect (preferably two adjacent ones) are treated according to the usual method. To obtain impressions, use silicone impression media.

V. In Los prefers solid-cast prosthesis designs, because they, in his opinion, have higher medical and biological properties. In order to reduce the load on the supporting elements in modeling the intermediate part of the bridge, it reduces by 1/3 the area of its chewing surface. The intermediate part should not exceed three teeth in length. After checking the design, the bridge is fixed on the supporting elements with cement.

After a certain period of adaptation (for 1-2 weeks exceeding the usual time), such a prosthesis, fixed on the implant and teeth, gives a completely satisfactory functional effect.

In the Ukrainian National Medical University, a new method of surgical implantation of intra-inoculated cylindrical implants "Method for the restoration of frontal dental flaw defects" was developed by a group of authors. This operation is carried out in two stages: the first - the formation of an artificial hole in the alveolar process of the jaw, the second - the introduction and wedging of the intraosseous cylindrical implant.

To prevent excessive bone trauma and possible complications resulting from overheating during drilling, as well as to expand indications for implantation in cases of narrow alveolar process (occurs in 49.1% of cases), surgical preparation is carried out as follows: under local anesthesia for center of the alveolar process with a perforator in the mucosa make a circular hole 2.5-3.0 mm in diameter, which is 0.5 mm smaller than the diameter of the neck of the implant. This leads to the fact that after implant implantation, the mucous membrane tightly surrounds its neck and forms an epithelial "cuff" around it, as a result of which there is no need to dissect soft tissues, superimpose, and then remove stitches. Then, by means of bone piercers, a channel is formed in sequence, by compacting the spongy substance of the bone, in which the expanding pin is jammed. Two weeks later, the second stage is carried out: the extraction pin is extracted, corresponding to the size of bone punching, the intraosseous canal is formed according to the size of the implant, in which it is jammed.

To address the choice of implant design, it is necessary to take into account the morpho-functional structure of the alveolar process. For this Yu.V. Vovk, P.J. Gal'kevich, I.O. Kobilnik, I.Ya. Voloshin (1998) before the operation with the help of clinical instrumental-x-ray methods determine the features of the structure of the alveolar process along the vertical; However, GG Kryklyas, VA Lubenets, and OI Sennikova (1998) established 7 variants of the horizontal relief of the toothless alveolar processes exposed by the surgeon, and therefore they consider that the surgeon can decide the choice of the implant structure only after will expose the crest of the alveolar process and study its relief.

The use of intraosseous implants opens wide opportunities for prosthetics of teeth with non-removable bridges that can serve for a long time, preventing the development of secondary deformations in both the jaws and in the dentition.