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9.2. An anatomic substantiation of a method dentalnoj implantations at treatment of patients with full loss of a teeth

Now for restoration of integrity of dentitions ventplants of various forms are used: screw, cylindrical, in the form of a natural root of a tooth, plastinochnye etc. Their length and diameter vary depending on firm of the manufacturer.

Various clinical situations demand the equipment dentalnyh implantatov taking into account quantity of an osteal tissue in a zone of a prospective operative measure.

N.K.nechaeva (2010) notices, that screw designs implantatov (in 44,8 % of cases) and lamellar implantaty - in 16,3 % of cases, implantaty with memory of the form - in 22,8 % most often now are used.

A.S.Ivanov (2011) is cited the data uniting to the indications for all screw designs according to which the width of an osteal tissue of an alveolar process in shchechnojazychnom a direction should be not less than 6 mm, by the minimum height of an alveolar process over the channel of a mandible and under a bottom of an alveolar bay of a genyantrum should be not less than 10 mm; meziodistalnoe distance between implantatami - 8 mm. Demands to a bone for the equipment plastinochnogo implantata: value of vertical height of a bone - more than 8 mm, a thickness of a bone (the shchechno-lingual size) - more than 3 mm.

Separate interest submit data, presented to V.J.Nikolsky's work from co-workers. (2011). On the basis of clinical experience they suggest to differentiate patients depending on degree and a kind of an atrophy of an alveolar process of the top and alveolar part of a body of the mandible after an exodontia and to develop for each situation a strategy variant dentalnoj implantations.

That fact is interesting, that in the accessible literature not enough attention is taken away to change of value of an angle of an inclination of a body of the mandible at loss of a teeth and the equipment dentalnyh implantatov taking into account these value. Only in
V.V. works Razdorsky from co-workers. (2010) there are statements, that the equipment plastinochnyh designs implantatov at use of a method of intraosteal implantation is impossible at value of an angle of an inclination of a body of the mandible more than 20 °, and at the equipment of cylindrical designs - more than 30 °. Here it is a question about implantatah with memory of the form which in spite of the fact that have appeared in stomatology enough recently, thanks to the merits find more and more a wide circulation. If to survey demands to their equipment they it is a little separated by that has been described above. So, the height of an osteal tissue in the field of a stabilising element of a design implantata with thermomechanical memory of the form should make not less than 10-12 mm, and the necessary thickness of a bone should make not less than 5 mm for lamellar designs and 8-10 mm - for cylindrical (Razdorsky V.V. from co-workers., 2010). In addition to it the distance to the bottom a nasal cavity and genyantrums should be not less than 1 mm.

Let's survey separately of feature of changes of an alveolar process top and bodies of the mandible at full absence of the teeth, the researches taped as a result of carried out us.

By us it is established, that the majority morfometricheskih parametres of an alveolar process of the top jaw essentially change at full absence of a teeth. So, there is an authentic reduction of its height at different levels: at level lateralnogo edges of a piriform opening, an infraorbital foramen and skuloverhnecheljustnogo a seam.

Average value of the given indicator in group with full absence of a teeth they make 8,8±0,7 mm, however at different levels neodinakovy. So, the greatest value of height of an alveolar process are observed in the field of lateral incisors and canines (at level lateralnogo piriform opening edges) - 12,4±1,2 mm, the least - at level of molar tooths (skuloverhnecheljustnogo a seam) - 7,0±0,9 mm.

Average value of a thickness of an alveolar process of the top jaw in group full absence of a teeth decrease in comparison with group with
Intact occlusion not so considerably as its height. If average value of a thickness of a bottom edge of an alveolar process in group with a full set of a teeth averaged 8,8±0,3 mm, and value of its maximum thickness 12,9±0,3 mm in group with full absence of a teeth of value of the given indicators have decreased accordingly to 7,3±0,6 mm and 8,3±0,7 mm.

Thus, on the top jaw at full absence of a teeth to limit the sizes applied implantatov there will be, first of all, a height of an alveolar process.

So, at full absence of a teeth average value of height of an alveolar process of the top jaw sufficient for the equipment dentalnyh implantatov are available only in forward department. In lateral departments the big influence on a choice of the size implantata plays affinity of a genyantrum. And, as shown in our research if in group with a full set of a teeth the share giperpnevmatizirovannyh sinuses makes 62,5 % in group with full absence of a teeth - 87 %.

Let's repeat, that, by results of the carried out research, in group with full absence of a teeth the average height of an alveolar process of the top jaw at level of an infraorbital foramen and skuloverhnecheljustnogo a seam has made 7,1±0,9 mm and 7,0±0,9 mm accordingly. Only in 35,4 % of cases value of the given indicator exceeded 9 mm, and in 64,6 % it varied from 3 to 9 mm, that, first of all, has been caused by a hyperpneumatization of genyantrums.

Restrictions on a thickness of an alveolar process for screw implantatov are available in the field of incisors and canines where average value of its thickness make 6,1±0,4 the mm, however the given value do not interfere with the equipment plastinochnyh implantatov. In the field of premolar tooths and molar tooths application cylindrical implantatov with memory of the form for which the thickness of a bone in the field of a stabilising part of a design should be a little more than for usual implantatov in connection with features of their structure is limited.

Thus most often (in 52,1 % of cases) in group of skulls with full absence of a teeth on the top jaw IV class arhitektoniki an osteal tissue on U was observed. Lekholm and G. Zarb (1985) at which the thin compact layer surrounds a spongiform layer with small density trabekul. I.G.Makarevsky from co-workers. (2009) notice, that similar quality of a bone dictates necessity of use implantatov the big sizes as only then the perception of a masticatory stress will be high-grade, however in lateral departments of jaws in connection with a hyperpneumatization of genyantrums it is impossible.

If under such circumstances to use small on diameter and length implantaty at the further prosthetics there is variety of difficulties which finally can lead to adverse result. Accordingly application of the techniques calculated on the equipment implantatov in boundary with a genyantrum sites of a bone and use of a total osteal plasty for escalating of height of an osteal tissue is anatomically proved.

As to a mandible value of a thickness and height of its body are also statistically authentically more expressed in group with a full set of a teeth in comparison with group with their full absence.

So, there is an authentic reduction of height of a body of the mandible at different levels: at level of a mandibular symphysis, the middle of a premental segment, the middle of a postmental segment, at mental foramen level. On the average, the height of a body of the mandible at full loss of a teeth decreases on 9,6±0,8 mm and in 25,5 % of cases makes only 10-15 mm. The least value of height of a body of the mandible at full loss of a teeth are observed in the field of molar tooths (the middle of a postmental segment) - 16,1±1,7 mm, the greatest - in the field of incisors (in area

Mandibular symphysis) - 23,4±1,8 mm. In spite of the fact that at first sight, the residual height of a bone is sufficient for the equipment of any implantatov, calculation of its value taking into account topography of the channel of a mandible testifies to the return. It is necessary to consider, that at the equipment dentalnyh
implantatov the true height of a body of the mandible, and distance from an upper edge of its alveolar part to the mandible channel is important not.

According to E. Oliver (1928), position of the given channel can be a miscellaneous, and it qualify as high, low and intermediate. The average distance from the bottom part of the channel to edge of the basis of a mandible makes 5,9±2,2 mm, and its lowermost point is at the first molar tooth (Ulm C. et al., 1989). According to T.G.Robustovoj (2003), the mandible channel has diameter of 2-2,4 mm, and distance between it and implantatom should be not less than 1 mm.

It turns out, that at the equipment implantatov in the absence of a teeth in the field of molar tooths there are the appreciable difficulties bound to shortage of height of a body of the mandible and augmentation of risk of damage of the bottom alveolar nerve at non-observance of topography of the channel.

At the analysis of the results received by us, it is obvious, that least problems arises at the equipment implantatov on a forward site of a mandible as, average value of height of a body of the mandible in the given area even at loss of a teeth make 20,8±0,8 mm. It also coincides with opinion of other authors (Burns D. et al., 1995; Bijlani M., Lozada J., 1996). However, as note M. Arzoumann et al. (1993), the raised care is demanded thus by implantation on sites where premolar tooths are located, to front from a mental foramen as the mental nerve leaving it can have a loop which is settling down on 3 mm to front.

Limiting factor at the equipment dentalnyh implantatov in the given area the thickness of a body of the mandible and value of an angle of its inclination in a preddverno-LINGUAL direction can be only. Here again on the first place leave plastinochnye implantaty as in the spent research, especially at level of forward group of a teeth, value of a thickness of an upper edge of the body of the mandible, defining diameter used implantata, have made less than 8 mm, and the equipment of screw designs demands great values of the size of a bone in a shchechno-LINGUAL direction.

A little bit other picture is observed in the field of premolar tooths and molar tooths (at level of a mental foramen and the middle of a postmental segment). At the given levels of value of a thickness of an upper edge of a body of the mandible in group with full ostutstviem teeth make 7,0±0,8 and 7,3±0,8 mm accordingly, that, basically is sufficient for the equipment screw implantatov small diameter though and not quite corresponds to demands for implantatov with memory of the form. However value of the maximum thickness of a bone at the given levels testify that in the field of a stabilising element of a design implantata there will be an optimum quantity of an osteal tissue.

As it was spoken earlier, whether that will define sufficient quantity of an osteal tissue to be in an apical part implantata for its bracing it is necessary to consider not only shirotnye characteristics of a body of the mandible, but also value of an angle of an inclination of a body of the mandible in preddvernoyojazychnom a direction. If to establish dentalnye implantaty (especially with thermomechanical memory of the form) without a natural inclination of a body of the mandible, there is a risk of that the quantity of the osteal tissue surrounding a root part implantata will be insufficient, and, hence, distribution of a load to it irregular.

In the spent research it is established, that value of an angle of an inclination of a body of the mandible in a preddverno-LINGUAL direction are maximum in the field of molar tooths and average 24,0±1,6 °, that limits application on the given sites of lamellar designs implantatov a little.

Features arhitektoniki an osteal tissue of a body of the mandible at loss of a teeth as a whole are similar to those on the top jaw. Most often (in 53,4 % of cases) in group of skulls with full absence of a teeth on a mandible there is such type of an osteal tissue at which the thin compact layer surrounds an advanced spongiform layer (III class arhitektoniki an osteal tissue on U. Lekholm and G. Zarb (1985)). The basic disadvantage of such quality of an osteal tissue is reduction of the area of their contact zone with a bone.

I.G.Makarevsky from co-workers. (2009) notice, that similar quality of a bone dictates necessity of use implantatov the big sizes as only then the perception of a masticatory stress will be high-grade. However, as well as in a case with the top jaw, the appreciable atrophy of a body of the mandible at loss of a teeth, both at width, and in height not always allows to spend the equipment optimum on length and diameter implantatov without preliminary operational preparation.

To additional operative measures before the equipment dentalnyh implantatov on the top and bottom jaws carry, in particular, operation augmetatsii an osteal tissue in the field of a bottom of a genyantrum - a sine-lifting, a transposition of the bottom alveolar nerve or augmentation of height and volume of an alveolar process by means of osteal auto - and allotransplants equipment techniques dentalnyh implantatov in boundary regions (for example, in the field of a hillock of the top jaw) etc. are separately surveyed.

Speaking about carrying out of such operations as a sine-lifting or a transposition of the bottom alveolar nerve, it is necessary to notice, that they considerably extend the general terms of treatment (Komarnitsky Island V, 2012). Thus the given techniques are not deprived disadvantages, such as development intraoperatsionnyh and complications arising in the postoperative period (Ardekian L. et al., 2006; Aghaloo T.L., Moy P.K., 2007). At carrying out of operation a sine-lifting it: punching of a mucosa of a sinus (Raghoebar G. et al., 1996), a bleeding, chronic pains, a becoming infected of sinuses with development of a serous or purulent sinusitis (Doud Galli S.K. et al., 2001) etc. At a transposition of the bottom alveolar nerve the short-term or long parasthesia or anastezija (Buser D can develop. et al., 1996). Even at sparing preparing of a nerve and for lack of its traumatic changes neurosensory disturbances (Misch C.E are not excluded., Crawford E., 1990).

Alternative exit from the given situation is use of immediate implantation - the equipments implantata in the alveolar small cavity
Single-step with an odontectomy. About primary use implantatov with memory of the form it is spoken in works of many authors (Jaremenko A.I. from co-workers., 2011) in particular, at immediate implantation they will have conclusive advantage before traditional screw designs as are capable to be built in more effectively the cone-shaped small cavity of a tooth, and intraosteal "legs" dispersing at a body temperature implantata, similar to roots of a multirooted tooth, resist raznonapravlennym to the loads arising at chewing much more effectively.

Thus, the kind and size choice dentalnyh implantatov at full absence of a teeth will differ considerably depending on site topography where the operative measure is spent. Thus optimum conditions are available in forward department both top, and bottom jaws; in the field of lateral departments at an appreciable atrophy the risk of damage of a mucosa of a bottom of a genyantrum or the mandible channel is enlarged. As prevalence of the given complications makes 8,7 % and 3,4 % accordingly, wider use of a method of immediate implantation with the help implantatov with memory of the form, and also the additional operative measures considering changes of all morfometricheskih of characteristics of the top and bottom jaws at loss of teeth is expedient.

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Scientific source GAJVORONSKAYA Maria Georgievna. ANATOMO-CLINICAL SUBSTANTIATIONS of TREATMENT of the OKKLJUZIONNO-CAUSED DISEASES of the CHEWING APPARATUS. The dissertation on competition of a scientific degree of the doctor of medical sciences. St.-Petersburg - 2014. 2014

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