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THE CLINICAL EXAMPLE 1

Patient S, 1936 of the river (i/b №14892-12) has addressed in surgical unit TSS and CHLH MGMSU of A.I.Evdokimova with complaints to aching pains in the field of the top jaw, a flow of pus from the small cavities of a remote teeth on the top jaw.

In the anamnesis at the patient of 40 courses of therapy bisfosfonatami on a basis zolendronovoj acids ("Zometa") in connection with presence of metastasises of a cancer of a prostate in pelvic bones and a backbone. Accompanying diseases - a hypertonia, a diabetes.

According to the patient, in 2011 in an out-patient department on a residence in connection with an exacerbation of a chronic periodontitis the exodontia 1 is spent and the demountable prosthesis on the top jaw is made. The beginnings right after of use of a prosthesis the patient has noted occurrence of morbidity and a tumescence in the field of a remote teeth, has addressed in an out-patient department on a residence, whence is referred to regional hospital where the biopsy in the field of the top jaw and twice - audit with a necretomy was spent. After interventions fistulous courses on a mucosa in postoperative area were generated, there was a flow of pus. The patient has addressed in TSS and CHLH MGMSU

External survey of the patient. The configuration of the person is not changed, mouth opening free, painless, regionarnye lymph nodes mobile, painless at a palpation.

In an oral cavity: the thickening of an alveolar process in the field of an absent teeth 1 Is defined, the mucosa is hydropic, is insignificant giperemirovana. On a crest of an alveolar process fistulous courses with poor quantity purulent separated are defined, at sounding on which - a rough osteal tissue. Mobile sequesters at sounding it is not taped (the Drawing 33).

The tooth formula:

0 0 0 0 0 0 0 0 0 TO 0 0 0
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
0 P P P TO TO TO TO TO TO TO 0 0 TO 0

Fig. 33а. A photo. Fistulous courses with purulent separated in the field of an absent teeth 1.1-1.3.

It is spent doobsledovanie - MSKT CHLO (the Drawing 33б).

Fig.

33б. MSKT. MPR in a curvilinear plane. At level of an absent teeth 1 the osteodestruction zone is defined. A thickening of a mucosa right verhnecheljustnogo a sine.

The diagnosis: Bisfosfonatnyj an osteonecrosis of the top jaw in the field of an absent teeth 1.1-1.5.

Treatment of the patient is spent according to the report of treatment of patients of 1 group: antiseptic processings of a zone of an osteonecrosis, courses of local ozonotherapy in the field of the osteonecrotic centre within 4 months. At the primary reference and in 3 months of treatment definition of indicators of local immunity in oral cavities (Table 16) by which results positive dynamics of immunologic indicators is taped is spent: normalisation of levels of immunoglobulins in a saliva, normalisation of subpopulation structure of neutrophils, interrelation restoration between cellular, secretory and humoral mechanisms of protection in an oral cavity.

At the next control survey signs of presence of the generated sequester - mobility have been taped at sounding, by results of MSKT - presence of a zone of demarcation (the Drawing 34).

Fig. 34. MSKT. An axial projection. The generated sequester in the field of the top jaw on the right.

Table 16

Dynamics of indicators of local immunity in an oral cavity at the patient

S against spent treatment

Indicator Units of measure Before the treatment beginning In 3 months of treatment Norm
S-IgA Mg of % 15,0 26,0 26,5 2,6
IgA Mg of % 14,0 11,0 10,2 1,0
IgG Mg of % 16,0 13,0 13,1 1,1
The general number of neutrophils in washout % 56,0 57,0 55,0 1,6
DRON % 38,0 33,0 32,5 1,7
EN-PO % 50,0 59,0 58,2 4,0
FI % 75,0 82,0 76,0 5,0
FCH - 8,0 8,0 8,1 0,6
S-IgA/IgG - 0,9 2,0 2,0 0,1
S-IgA/IgA - 1,1 2,4 2,6 0,2
EN -

PO/ДРОН

- 1,3 1,8 1,8 0,1
ДРОН/IgG - 2,4 2,3 2,5 0,2
IGG/ - 0,2 0,16 0,17 0,01
IGG/ - 2,0 1,6 1,6 0,1

In connection with presence of clinical and radiological signs of presence of the generated sequester, to the patient the sequestectomy under local anaesthesia in out-patient conditions has been spent. The operation course is presented in drawings 35-38. In the postoperative period control survey on 10е days (the Drawing 39), and also in 1 month (the Drawing 40).

Fig. 35. A photo. Infiltration anaesthesia carrying out.

Fig. 36. A photo. A sequestectomy. The sequester is taken by means of a clamp, without a trauma of an intact bone. As a result of a sequestectomy it is not received oroantralnogo or oronazalnogo reports. Internal walls of defect are covered granuljatsionnoj by a tissue.

Fig. 37. A photo. A remote sequester.

Fig. 38. A photo.

Postoperative defect.

Fig. 39. A photo. A kind

Postoperative defect in 10 days.

Fig. 40. A photo. A kind of postoperative area in 1 month.

The analysis of indicators of a painful syndrome before treatment of the patient is presented in table 17.

At control survey in 6 months after a sequestectomy of new sites of an osteonecrosis it has not been taped, to the patient the demountable prosthesis on the top jaw is made (the Drawing 41) By results of MSKT the expressed osteoreparation in the field of edges of postoperative defect (the Drawing 42) became perceptible.

Table 17

Dynamics of indicators of a pain of patient S.Po the Poppy-Gillovsky

To painful questionnaire

Before treatment After treatment
Sensory scale ICHVD 6 0
RIB 9 0
Affective scale ICHVD 3 0
RIB 8 0
Evaljuativnaja a scale 2 0

Fig. 41. A photo. The demountable prosthesis on the top jaw is made, the patient is completely rehabilitated.

Fig. 42. MSKT. An axial projection. A zone of an osteoreparation in the field of walls of postoperative defect.

3.4.

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Scientific source ZASLAVSKAYA NATALIA ALEKSANDROVNA. OPTIMIZATION of PREVENTIVE MAINTENANCE And TREATMENT BISFOSFONATNYH of OSTEONECROSES of JAWS At PATIENTS WITH MALIGNANT NEOPLASMS. The dissertation on competition of a scientific degree of the candidate of medical sciences. Moscow - 2014. 2014

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