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surgical ways of modelling marginal parodonta

To eliminate superfluous visualisation of a gum it is possible by means of orthognathic surgery, orthodontic treatment or parodontologicheskih surgical interventions [88, 107, 108].

In the early eighties have been offered surgical techniques of correction of not aesthetic contour of a gum, in particular, elongation of a clinical crown of a tooth with excising of soft tissues and bones [78], operations on augmentation of volume of an osteal crest [109, 113].

Optimisation of a bed for the equipment osteointegrated implantatov, etc. [45, 48].

Now perfection of methods of an osteal plasty for closing of the isolated aesthetic defects proceeds. These procedures can be very effective for creation of a harmonious smile. Stomatologists
Should be informed on various variants of treatment and refer patients to experts of corresponding qualification [110].

Now in stomatology there is a separate direction plastic parodontologii, referred on elimination of the congenital or got anatomic defects parodontalnogo a complex [62].

As it became perceptible earlier, the most correct criterion of definition of level of edge of a gum is position of cutting edges of incisors of the top jaw [57].

At orthopedic treatment health of soft tissues has huge value irrespective of type of restorations. Gum damage leads to adverse result of therapy in any case. However even healthy, soft tissues are not always aesthetic enough [12].

In a beautiful smile all should be attractive: a teeth and a regional gum should be not only aesthetic enough in itself, but also be in harmony among themselves.

Asymmetry of a gum in an aesthetic zone can be eliminated by means of limited parodontologicheskih operations. The treatment purpose consists in achievement of symmetry of a forward segment of a dentition, especially in the field of the central incisors. Symmetry disturbance is especially appreciable at a gum denudation at a smile (desnevaja a smile). In spite of the fact that elimination of excessive visualisation of a gum can seem simple procedure, she demands careful planning and thorough understanding. Before a surgical intervention it is necessary to estimate a considerable quantity of factors: position of cutting edge, initial length of crowns of a teeth, a parity of length
Root and a crown, position of an osteal crest, a teeth and an inclination of roots, position of cemently-enamel bond.

desnevogo edges usually eliminate asymmetry by means of elongation of clinical crowns of a teeth or the interventions referred on elimination of recession of a gum. Orthodontic promotion or intruzija teeth is besides, used.

At operation carrying out «elongation of a clinical crown» is necessary to frame sufficient space for restoration of adequate biological width. In this case it is necessary to spend an ostectomy for creation of the optimum form of a crest. The surgical technique consists in a resection of an osteal tissue for a thinning of edge of an alveolar crest and creation of conditions for formation of adequate biological width. As in norm desnevoj the edge usually follows a contour subject an osteal crest, the ostectomy is necessary for spending taking into account demanded architecture of a free part of a gum. The edge of an interdental septum should be always located on 3-4 mm more okkljuzionno, than a contour of a bone from the vestibular party of a tooth for papilla maintenance.

Surgical elongation of a clinical crown demands reconstruction of a bone with the help of borons and gouges and formations of a full-layer flap. The fact of the surgical trauma bound with otkidyvaniem of a flap and an ostectomy, leads irreversible rezorbtsii a blanket of an alveolar crest approximately on 0,63 mm [99].

This phenomenon is necessary for considering at planning and correction carrying out, especially in the presence of a thin biotype of a gum. In one of
Clinical researches it has been noticed, that after the spent surgical elongation of a clinical crown not always it is possible to reach biological width of 3 mm as a result of an insufficient denudation of a surface of a crown and a root of a tooth [64].

Gistometrichesky research of an experimental material at monkeys has shown, that at neogenesis after surgical elongation of a clinical crown with an ostectomy there is an apical moving of the attached epithelium to apical border of delection of a surface of a root [97].

Putting off of tooth adjournment and polishing of a surface of a root during elongation of a clinical crown is necessary for reliable formation of a soedinitelno-WOVEN attachment. In spite of the fact that the primary wound repair occurs within 10 days, and for final formation of position regional parodonta it is necessary nearby 6мес, stabilisation of position of fabric structures is formed in 6 weeks after a surgical intervention. Competent carrying out of plastic operations and noninvasive work with tissues allow to reduce neogenesis and formation terms desnevogo edges.

Loss keratinizirovannoj the attached gum worsens aesthetic result. To keep keratinizirovannuju the attached gum at carrying out of augmentation of a clinical crown of a tooth probably by means of formation of a level-by-level connective tissue flap and its apical moving. Long-term stability regional parodonta after augmentation of a clinical crown is possible under condition of absence

Destructions of biological width. For connective tissue and epithelial bond it is necessary about 2 mm, and with the account desnevoj sulcuses - 3 mm. Otherwise the result of aesthetic aftertreatment will be

The unsatisfactory.

Gum recession.

Very often chronic trauma owing to aggressive cleaning of a teeth, or an inflammation parodonta as a result of scurf influence are principal causes of recession of soft tissues [74, 80].

Besides, recession occurrence provokes a misplaced of a teeth [71], shchelevidnye defects of a vestibular cortical plate of an alveolar crest [82], high fastening of a bridle [91], and even iatrogenic factors.

Elimination of the given factors is necessary for treatment and recession preventive maintenance. Sullivan and Atkins (Sullivan and Atkins) have offered known classification of recession, which has in two basic groups on a vertical (superficial and deep) and subgroups on a horizontal component (narrow and wide) [118].

The given classification was applied widely enough till 1985 when Miller (Miller) has developed advanced classification which has allowed to prognosticate probability of elimination of recession [88].

Recession elimination in full it is possible to expect, if it corresponds I or to II class. At recession of III class degree of its elimination can be defined, having placed parodontologichesky a probe horizontally on the imagined line bridging free edge of a gum on an average line
The next teeth. Miller's classification is the most widespread and can be used at treatment planning, allowing the doctor and the patient to receive more prognosticated expectations concerning results of treatment.

Besides adverse aesthetic result gum recession associates with rising of sensitivity and high probability of development of caries on the bared surface of a root. Variety of surgical methods which can be carried to four basic categories has been developed for recession elimination:

- Grafts on a leg;

- Techniques koronalnogo and lateralnogo [59] movings desnevyh grafts on a leg are applied to elimination small recessions (1 class on Miller) in the presence of a zone keratinizirovannoj the attached gum in width of 3 mm [46].

Updating koronalno the displaced flap has been offered Tarnou (Tarnow) - semilunar koronalno the displaced flap [120]. The technique allows to receive very good result and to provide close conformity of colour of a gum at elimination of recession of I class. Possibility of performance and the favorable forecast of a technique are limited by height and thickness of a site of an epithelium of the gum located more apically of recession.

Technique lateralno the displaced graft on the leg, which else name rotirovannym a flap, has some updatings, however a major principle, consists in nakryvanii the bared surface of a root of a tooth a gum site sideways from recession. Advantage of grafts on
To leg consists in formation of good blood supply and fine conformity of colours of area of operation and the next sites of a gum. It is possible to consider as a disadvantage of the specified methods necessity of presence of a wide zone keratinizirovannoj the attached gum in donor area and enough a deep vestibule, and also impossibility of elimination plural recessions. Thus, koronalno and lateralno the displaced grafts on a leg are recommended for elimination only single to recession in the presence of an adequate zone keratinizirovanngo the attached epithelium of a gum in the next sites to recession.

- Free graft of soft tissues.

Free desnevoj [90] and subepithelial connective tissue [77] grafts are successfully used for recession elimination. Free desnevoj a graft apply to zone augmentation keratinizirovannoj the attached gum round a teeth and implantatov, and also for closing of the bared surface of a root. Such grafts usually receive in the sky where the thickness of soft tissues makes 1,5-2 mm. After healing sites of transplantation are a little bit more light a surrounding gum. By means of this technique of recession it is possible to eliminate on the average on 75 %, and full elimination of recession manages to achieve in 50 % of cases [53]. Subepithelial connective tissue grafts also often enough use for closing of the bared surface of a root. Advantage of the given technique consists in maintenance of the best blood supply of a graft (from an accepting bed and a flap blocking a graft). Besides, use of a subepithelial graft
Allows to reach the best conformity of colour of a site of transplantation and adjoining areas, process remodelirovanija usually comes to the end within one year. The basic contraindication to carrying out of the given manipulation is absence of a sufficient thickness mucous in donor area (more often in the sky). Average and full closing of the bared surface of a root at recession I and II class makes 91 and 68 % accordingly [53].

- The combined techniques.

Combined are the techniques consisting of more than one way of elimination of recession, consisting of one or several surgical interventions. As an indicative example transplantation free desnevogo a graft and koronalnogo flap shifts can serve. Thus podsadka transplantation of a free connective tissue graft with simultaneous overlapping koronalno the displaced flap or transplantation of a free graft with the subsequent koronalnym shift on the given site of a gum. And as as an example transplantation of a subepithelial connective tissue graft and formation of a double papillary flap for closing of area of transplantation can serve. Other combined techniques, have not received a wide circulation.

Transplantation of a subepithelial connective tissue graft (especially thick) allows to restore effectively a papilla at the minimum loss of an interdental osteal septum. Adequate blood supply is provided with the help minimum travmatichnogo the report and conservation of an intact periosteum.

The referred fabric neogenesis

The technique referred fabric neogeneses (scientific and technological revolution) is based on maintenance of sufficient space for occurrence of a bloody clot with the subsequent formation of new cement of a root and a new connective tissue attachment, and as new bone. Results of a scientific and technological revolution with use rezorbiruemyh and nerezorbiruemyh membranes for recession elimination are comparable to application of a subepithelial connective tissue graft [105]

The scientific and technological revolution can be applied to elimination extensive (5 mm and more) recessions. A clear advantage of a technique of a scientific and technological revolution for recession elimination is absence of discomfort and complications from a donor site and optimum conformity of colour in the field of an intervention and adjoining departments regional parodonta. The main disadvantage is restriction of carrying out of operation only one tooth. To apply the given technique expediently to elimination of recession in the absence of an adequate donor site.

Restoration of the lost interdental papillas is one of the most important and challenges in modern parodontologicheskoj plastic surgery. Besides occurrence of "black triangles» face-to-face group of a teeth of the top jaw, absence of papillas leads to fixation of nutrition and occurrence of phonetic problems. As it became perceptible above, presence and the form of an interdental papilla directly depend on the size and the form of interdental contact, a crest of an alveolar bone and the form of interdental surfaces of a teeth [73]. The design of the lost soft tissues in interdental areas demands restoration of conditions for existence of papillas.

Orthopedic and other nonsurgical methods allow to change contact point, structure lateralnyh surfaces and an inclination of a teeth, that in itself can lead to restoration of the lost papilla. Performance of the surgical interventions referred on augmentation of volume of soft tissues and a bone in the field of interdental intervals, is usually complicated owing to anatomic restrictions and complexity of maintenance of adequate blood supply. Despite working out of various surgical methods for papilla reconstruction (including with use of grafts) [47, 63]. The given ways do not allow to restore interdental papillas.

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Scientific source Grivkov Alexey Sergeevich. the CLINICO-FUNCTIONAL SUBSTANTIATION of the METHOD of CREATION And REALIZATION THREE-DIMENSIONAL DESIGN of the PROJECT REGIONAL PARODONTA AT AESTHETIC PROSTHETICS. The DISSERTATION on competition of a scientific degree of the candidate of medical sciences. Great Novgorod - 2014. 2014

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