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лава 4. икрохирургические вмешательства
в пародонтологии
ÑÊÂÈÏÒ ÅÂΘÂ
àëíéêàü ÇéèêéëÄ
ÇÔÂ‚˚ ËÒÔÓθÁÓ‚‡ÌË ÔÓÒÚ˚ı ÒÚÂÍÎflÌÌ˚ı ÎËÌÁ ‰Îfl
Û‚Â΢ÂÌËfl ËÁÓ·‡ÊÂÌËÈ ·˚ÎÓ ÓÔËÒ‡ÌÓ ‚ ‰‚Ì„ËÔÂÚÒÍËı Ô‡ÔËÛÒ‡ı, ̇ÔËÒ‡ÌÌ˚ı 2800 ÎÂÚ Ì‡Á‡‰. Ç 1694 „.
‡ÏÒÚÂ‰‡ÏÒÍËÈ ÍÛÔˆ ÄÌÚÓÌ ‚‡Ì ã‚ÂÌ„ÛÍ (Anton van
Leeuwenhook) ÒÓÁ‰‡Î ÔÂ‚˚È ÏËÍÓÒÍÓÔ ÒÓ ÒÎÓÊÌ˚Ï
Ó·˙ÂÍÚË‚ÓÏ. Ç Ï‰ˈËÌ ÔÂ‚˚ ÏËÍÓıËÛ„˘ÂÒÍËÂ
‚ϯ‡ÚÂθÒÚ‚‡ ·˚ÎË Ôӂ‰ÂÌ˚ ‚ ÍÓ̈ XIX ‚Â͇.
Ç 1921 „. ä‡Î çËÎÂÌ (Carl Nylen), Ò˜ËÚ‡˛˘ËÈÒfl ÓÚˆÓÏ
ÏËÍÓıËÛ„ËË, ÔÂ‚˚Ï ËÒÔÓθÁÓ‚‡Î ·ËÌÓÍÛÎflÌ˚È ÏËÍÓÒÍÓÔ ÔË ÓÔÂ‡ˆËË Ì‡ Ûı (Dohlman, 1969). é‰Ì‡ÍÓ
ÚÓθÍÓ ‚ 1960 „. ÑʇÍÓ·ÒÂÌ Ë ëÛ‡ÂÒ (Jacobsen Ë Suarez)
‡Á‡·ÓÚ‡ÎË Ë ÛÒÔ¯ÌÓ ÔËÏÂÌËÎË ÏÂÚÓ‰ËÍÛ Û¯Ë‚‡ÌËfl
ÍÓ‚ÂÌÓÒÌ˚ı ÒÓÒÛ‰Ó‚ ‰Ë‡ÏÂÚÓÏ 1 ÏÏ, Ë Ò ÚÂı ÔÓ ÓÔÂ‡ˆËÓÌÌ˚È ÏËÍÓÒÍÓÔ ÔÓ˜ÌÓ ‚Ó¯ÂÎ ‚ ωˈËÌÒÍÛ˛
Ô‡ÍÚËÍÛ (Barraquer, 1980).
Ç ÒÚÓχÚÓÎÓ„ËË ËÒÔÓθÁÓ‚‡ÌË ÏËÍÓÒÍÓÔ‡ Ô‰ÎÓÊËÎË
ÄÔÓÚÂÍÂ Ë Ü‡ÍÓ (Apotheker Ë Jako, 1981) ‚ 1978 „. ÇÔÓÒΉÒÚ‚ËË ‚ 1992 „. ä‡ (Carr) ÓÔÛ·ÎËÍÓ‚‡Î ÒÚ‡Ú¸˛ Ó
ÔËÏÂÌÂÌËË ÏËÍÓÒÍÓÔ‡ ÔË Ôӂ‰ÂÌËË ˝Ì‰Ó‰ÓÌÚ˘ÂÒÍÓ„Ó Î˜ÂÌËfl. Ç 1993 „. íË··ÂÚÚÒ Ë ò‡ÌÂÎÂÍ (Tibbetts Ë
Shanelec, 1998) ÔÓ‚ÂÎË ÍÛÒ ÔÓ ÏËÍÓıËÛ„˘ÂÒÍÓÈ Ô‡Ó‰ÓÌÚÓÎÓ„ËË Ì‡ ÂÊ„ӉÌÓÏ ÍÓÌ„ÂÒÒ ÄÏÂË͇ÌÒÍÓÈ
‡Í‡‰ÂÏËË Ô‡Ó‰ÓÌÚÓÎÓ„ËË, ˜ÚÓ ÔË‚ÂÎÓ Í Ó„‡ÌËÁ‡ˆËË
ÌÂÒÍÓθÍËı ˆÂÌÚÓ‚ Ó·Û˜ÂÌËfl Ô‡Ó‰ÓÌÚÓÎÓ„Ó‚ Ë ÒÚÓχÚÓÎÓ„Ó‚ ‰Û„Ëı ÒÔˆˇθÌÓÒÚÂÈ ÏËÍÓıËÛ„˘ÂÒÍËÏ
ÏÂÚÓ‰Ë͇Ï.
Ç 2001 „. ·˚Î ÓÔÛ·ÎËÍÓ‚‡Ì ·Óθ¯ÓÈ Ó·ÁÓ, ÔÓÒ‚fl˘ÂÌÌ˚È
ÔÂËÏÛ˘ÂÒÚ‚‡Ï Ë ‚ÓÁÏÓÊÌÓÒÚflÏ ÓÔÂ‡ˆËÓÌÌÓ„Ó ÏËÍÓÒÍÓÔ‡ ‚ Ô‡Ó‰ÓÌÚÓÎÓ„ËË (Belcher). é‰Ì‡ÍÓ ÌÂÒÏÓÚfl ̇
ÚÓ ˜ÚÓ ÏÌÓ„Ë ‡‚ÚÓ˚ Ò˜ËÚ‡˛Ú ÏËÍÓÒÍÓÔ ÌÂÓˆÂÌËÏ˚Ï
ËÌÒÚÛÏÂÌÚÓÏ ‚ ‡·ÓÚ ԇÓ‰ÓÌÚÓÎÓ„Ó‚, ‚ ˆÂÎÓÏ Â„Ó ËÒÔÓθÁÓ‚‡ÌË ‚ Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍÓÈ ÒÔˆˇθÌÓÒÚË ÌÂ
Ó˜Â̸ ‡ÒÔÓÒÚ‡ÌÂÌÓ.
èêàåÖçÖçàÖ åÖíéÑéÇ åàäêéïàêìêÉàà
Ç èÄêéÑéçíéãéÉàà
Ç Ô‡Ó‰ÓÌÚÓÎÓ„ËË ÓÔÂ‡ˆËÓÌÌ˚È ÏËÍÓÒÍÓÔ Ó·ÂÒÔ˜˂‡ÂÚ ‰ÓÔÓÎÌËÚÂθÌÓ ÓÒ‚Â˘ÂÌËÂ Ë Á̇˜ËÚÂθÌÓ ۂÂ΢ÂÌËÂ. äÓÏ·Ë̇ˆËfl ˝ÚËı Ô‡‡ÏÂÚÓ‚ ÔË‚Ó‰ËÚ Í ÔÓ‚˚¯ÂÌ˲ ÚÓ˜ÌÓÒÚË ıËÛ„˘ÂÒÍËı χÌËÔÛÎflˆËÈ (Belcher,
2001). é·˚˜ÌÓ ÔÂ˜ËÒÎÂÌÌ˚ ÔÂËÏÛ˘ÂÒÚ‚‡ ̇Á˚‚‡˛Ú
ÏËÍÓıËÛ„˘ÂÒÍÓÈ Úˇ‰ÓÈ (ËÒ. 4.1).
ñÂÎ˚È fl‰ ·‡ÁÓ‚˚ı ÔË̈ËÔÓ‚ ıËÛ„ËË ËÏÂÂÚ ÌÂÔÓÒ‰ÒÚ‚ÂÌÌÓ ÓÚÌÓ¯ÂÌËÂ Í Ô‡Ó‰ÓÌÚÓÎÓ„ËË. ìÒÚ‡ÌÂÌËÂ
«ÏÂÚ‚˚ı» ÔÓÒÚ‡ÌÒÚ‚, ÓÒÚÓÓÊ̇fl ‡·ÓÚ‡ Ò Ú͇ÌflÏË,
ËÒÒ˜ÂÌË ÌÂÍÓÚËÁËÓ‚‡ÌÌ˚ı Ú͇ÌÂÈ, Û‰‡ÎÂÌË ËÌÓÓ‰Ì˚ı ÚÂÎ, ̇‰ÂÊÌÓ ۯ˂‡ÌË ·ÂÁ ̇ÚflÊÂÌËfl, ËÏÏÓ·ËÎËÁ‡ˆËfl ÎÓÒÍÛÚÓ‚ Ë„‡˛Ú Ó„ÓÏÌÛ˛ Óθ ÔË ‚˚ÔÓÎÌÂÌËË
Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍËı ÓÔÂ‡ˆËÈ (ÛÍÓ‚Ó‰ÒÚ‚Ó ÍÓÏÔ‡ÌËË
ÑÊÓÌÒÓÌ Ë ÑÊÓÌÒÓÌ, 1994, Ò. 9). éÔÂ‡ˆËÓÌÌ˚È ÏËÍÓÒÍÓÔ Ë ‡‰ÂÍ‚‡ÚÌ˚È ÏËÍÓıËÛ„˘ÂÒÍËÈ ÔÓÚÓÍÓÎ ÒÔÓÒÓ·ÒÚ‚Û˛Ú ÔÓ„ÌÓÁËÛÂÏÓÏÛ ‰ÓÒÚËÊÂÌ˲ ÔÓÒÚ‡‚ÎÂÌÌ˚ı
ˆÂÎÂÈ.
Ç Ô‡Ó‰ÓÌÚÓÎÓ„ËË ıËÛ„˘ÂÒÍËÈ ÓÔÂ‡ˆËÓÌÌ˚È ÏËÍÓÒÍÓÔ ÏÓÊÂÚ ·˚Ú¸ ÔÓÎÂÁÂÌ ÔË Ôӂ‰ÂÌËË ‡ÁÌ˚ı
‚ϯ‡ÚÂθÒÚ‚, ‚ ˜‡ÒÚÌÓÒÚË, ÔË ‚˚ÔÓÎÌÂÌËË ÍÓÒÏÂÚ˘ÂÒÍËı ÓÔÂ‡ˆËÈ Ì‡ Ïfl„ÍËı Ú͇Ìflı, Ó·‡·ÓÚÍ ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl Ë Û‰ÎËÌÂÌËË ÍÎËÌ˘ÂÒÍÓÈ ÍÓÓÌÍË ÁÛ·‡.
èË ‚˚ÔÓÎÌÂÌËË Ô·ÒÚ˘ÂÒÍËı ÓÔÂ‡ˆËÈ Ì‡ Ô‡Ó‰ÓÌÚÂ
·Óθ¯Ó ۂÂ΢ÂÌË ÔÓÁ‚ÓÎflÂÚ ËÒÔÓθÁÓ‚‡Ú¸ Ó˜Â̸
ÚÓÌÍË ¯Ó‚Ì˚ χÚÂˇÎ˚ Ò ÚÓ̘‡È¯ËÏË Ë„Î‡ÏË Ë Ï‡ÎÂ̸ÍË ËÌÒÚÛÏÂÌÚ˚, ËÁ·Âʇڸ ÙÓÏËÓ‚‡ÌËfl «ÏÂÚ‚Ó„Ó» ÔÓÒÚ‡ÌÒÚ‚‡, ‡ Ú‡ÍÊ χÍÒËχθÌÓ ÚÓ˜ÌÓ ÔÓÁˈËÓÌËÓ‚‡Ú¸ Ë ÒÚ‡·ËÎËÁËÓ‚‡Ú¸ Ú͇ÌË.
í˘‡ÚÂθ̇fl Ó·‡·ÓÚ͇ ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl ËÏÂÂÚ ·Óθ¯Ó Á̇˜ÂÌË ‰Îfl ËÒıÓ‰‡ Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍÓ„Ó Î˜ÂÌËfl. Lindhe Ë Nyman (1984) ÛÒÚ‡ÌÓ‚ËÎË ÌÂÔÓÒ‰ÒÚ‚ÂÌ-
икрохирургическая триада
вет
Увеличение
овершенные
хирургические навыки
ис. 4.1. икрохирургическая триада
17
ÌÛ˛ Ò‚flÁ¸ ÏÂÊ‰Û Í‡˜ÂÒÚ‚ÓÏ Ó·‡·ÓÚÍË ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl Ë ÛÒÔÂıÓÏ Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍÓÈ ÚÂ‡ÔËË. ç‡Î˘ËÂ
‡‰ÂÍ‚‡ÚÌÓ„Ó ‰ÓÒÚÛÔ‡ Ë ‚ËÁÛ‡ÎËÁ‡ˆËË ‚ Á̇˜ËÚÂθÌÓÈ ÒÚÂÔÂÌË ÔÓ‚˚¯‡ÂÚ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ÒÌflÚËfl ÓÚÎÓÊÂÌËÈ (Cobb,
1996), Ú‡Í ÊÂ, Í‡Í ‰ÓÔÓÎÌËÚÂθÌÓ ÓÒ‚Â˘ÂÌË ‡·Ó˜Â„Ó
ÔÓÎfl (Reinhardt et al., 1985).
çÂÒÏÓÚfl ̇ ÚÓ ˜ÚÓ ·Óθ¯ËÌÒÚ‚Ó ÒÚ‡ÚÂÈ, ÔÓÒ‚fl˘ÂÌÌ˚ı
ÓÔËÒ‡Ì˲ ÔÂËÏÛ˘ÂÒÚ‚ ËÒÔÓθÁÓ‚‡ÌËfl ÒËÒÚÂÏ Û‚Â΢ÂÌËfl ‚ ÒÚÓχÚÓÎÓ„ËË, ÓÔË‡ÂÚÒfl ̇ ÌÂÔÓ‰Ú‚ÂʉÂÌÌ˚Â
‰‡ÌÌ˚ (Campbell, 1989), ‚ ‰‚Ûı ÒÚ‡Ú¸flı ·˚ÎË ÔÓ‰ÂÏÓÌÒÚËÓ‚‡Ì˚ ‡θÌ˚ ÍÎËÌ˘ÂÒÍË ÔÂËÏÛ˘ÂÒÚ‚‡ Û‚Â΢ÂÌËfl. Leknius Ë Geissberger (1995) ÔÓ͇Á‡ÎË ÔflÏÛ˛
Á‡‚ËÒËÏÓÒÚ¸ ÏÂÊ‰Û Û‚Â΢ÂÌËÂÏ Ë Í‡˜ÂÒÚ‚ÓÏ ÓÚÓÔ‰˘ÂÒÍËı χÌËÔÛÎflˆËÈ.
֢ ‚ Ó‰ÌÓÈ ËÁ ‡·ÓÚ ‡‚ÚÓ˚ Ô˯ÎË Í ‚˚‚Ó‰Û, ˜ÚÓ ÔË
ÛÒÚ‡ÌÂÌËË ˆÂÒÒËÈ Ò ÔÓÏÓ˘¸˛ ÔÂÂÒ‡‰ÍË ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌ˚ı Ú‡ÌÒÔ·ÌÚ‡ÚÓ‚ ËÒÔÓθÁÓ‚‡ÌË ÏËÍÓıËÛ„˘ÂÒÍÓÈ ÚÂıÌËÍË Ó·ÂÒÔ˜˂‡ÂÚ ·Óθ¯Û˛ ÔÎÓ˘‡‰¸
Á‡Í˚ÚËfl ˆÂÒÒËË (Burdhardt Ë Land, 2005). ä ÒÓʇÎÂÌ˲,
‚ ÒÚÓχÚÓÎÓ„ËË Ì‰ÓÒÚ‡ÚÓ˜ÌÓ ËÒÒΉӂ‡ÌËÈ, ÔÓÒ‚fl˘ÂÌÌ˚ı ÓˆÂÌÍ ˝ÙÙÂÍÚË‚ÌÓÒÚË ÏËÍÓıËÛ„ËË ÔË Û‰ÎËÌÂÌËË ÍÎËÌ˘ÂÒÍÓÈ ÍÓÓÌÍË ÁÛ·‡ ÔÓ Ò‡‚ÌÂÌ˲ Ò Ú‡‰ËˆËÓÌÌ˚ÏË ÏÂÚÓ‰Ë͇ÏË. é‰Ì‡ÍÓ Îӄ˘ÌÓ Ô‰ÔÓÎÓÊËÚ¸, ˜ÚÓ
ÔËÏÂÌÂÌË ÏËÍÓÒÍÓÔ‡ ÔÓÁ‚ÓÎËÚ ÔÓÎÛ˜ËÚ¸ ÎÛ˜¯Ë ÂÁÛθڇÚ˚ ÔË Û‰ÎËÌÂÌËË ÍÎËÌ˘ÂÒÍÓÈ ÍÓÓÌÍË, Ó·‡·ÓÚÍÂ
ÍÓÌfl Ë ‰Û„Ëı Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚‡ı.
ис. 4.3. Острое рассечение лоскута внутрибороздковым
доступом с помощью ложковидного скальпеля
ÌÓ ‡Á‰ÂÎËÚ¸ ̇ ÓÒÌÓ‚Ì˚ „ÛÔÔ˚ ÔÓ Ô‰̇Á̇˜ÂÌ˲:
Ò͇θÔÂÎË, ÂÚ‡ÍÚÓ˚, ÌÓÊÌˈ˚, Ë„ÎÓ‰ÂʇÚÂÎË, ÔË̈ÂÚ˚ Ë ‰.
èÄêéÑéçíéãéÉàóÖëäàÖ àçëíêìåÖçíõ
Ç Ô‡Ó‰ÓÌÚÓÎÓ„ËË ÔË Ôӂ‰ÂÌËË ÏËÍÓıËÛ„˘ÂÒÍËı
‚ϯ‡ÚÂθÒÚ‚ ̇˷ÓΠ˜‡ÒÚÓ ËÒÔÓθÁÛ˛Ú Ú Ê Ò͇θÔÂÎË, ˜ÚÓ Ë ‚ ÓÙڇθÏÓÎÓ„ËË: ÛÌË‚Â҇θÌ˚È, ÒÂÔӂˉÌ˚È, ÏËÌË-ÒÂÔӂˉÌ˚È, ÎÓÊÍӂˉÌ˚È, ˜Â¯Û‚ˉÌ˚È,
‰Îfl ÒÍÎÂ (ËÒ. 4.2). ä ÓÒÌÓ‚Ì˚Ï ı‡‡ÍÚÂËÒÚËÍ‡Ï ˝ÚËı
Ò͇θÔÂÎÂÈ ÓÚÌÓÒflÚÒfl ËÒÍβ˜ËÚÂθ̇fl ÓÒÚÓÚ‡ Ë Ï‡ÎÂ̸ÍË ‡ÁÏÂ˚, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ÔÓËÁ‚Ó‰ËÚ¸ ˉ‡θÌÓ
ÚÓ˜Ì˚ ‡ÁÂÁ˚ Ë ‚˚ÔÓÎÌflÚ¸ ÒÎÓÊÌ˚ χÌËÔÛÎflˆËË Ì‡
Ó„‡Ì˘ÂÌÌÓÏ ÔÓÒÚ‡ÌÒÚ‚Â (ËÒ. 4.3).
àÒÔÓθÁÓ‚‡ÌË ·Óθ¯Ó„Ó Û‚Â΢ÂÌËfl ÔÓÁ‚ÓÎflÂÚ ÒÚÓχÚÓÎÓ„‡Ï ÔËÏÂÌflÚ¸ Ó˜Â̸ Ì·Óθ¯ËÂ Ë ‚˚ÒÓÍÓÚÓ˜Ì˚Â
ËÌÒÚÛÏÂÌÚ˚. çÂÒÏÓÚfl ̇ Ó„ÓÏÌÓ ˜ËÒÎÓ ‚‡ˇÌÚÓ‚
‡Á΢Ì˚ı ÏËÍÓıËÛ„˘ÂÒÍËı ËÌÒÚÛÏÂÌÚÓ‚, Ëı ÏÓÊ-
ìÌË‚Â҇θÌ˚È Ò͇θÔÂθ ËÏÂÂÚ ÛÍÓflÚÍÛ, ‚ ÍÓÚÓÛ˛
ÏÓÊÌÓ ÛÒÚ‡ÌÓ‚ËÚ¸ ÎÂÁ‚Ë ÓÙڇθÏÓÎӄ˘ÂÒÍÓ„Ó Ò͇θÔÂÎfl ÔÓ‰ β·˚Ï Û„ÎÓÏ. ó‡˘Â ‚ÒÂ„Ó ËÒÔÓθÁÛ˛Ú ÎÂÁ‚ËÂ
‹15.
ëÂÔӂˉÌ˚È Ò͇θÔÂθ ÔËÏÂÌfl˛Ú ‰Îfl ÔÓËÁ‚‰ÂÌËfl
‚ÌÛÚË·ÓÓÁ‰ÍÓ‚˚ı ‡ÁÂÁÓ‚. í‡ÍÓÈ Ò͇θÔÂθ Ô‰ÒÚ‡‚ÎflÂÚ Â‰ËÌÓ ˆÂÎÓ ËÎË ÛÍÓflÚÍÛ ÒÓ ÒÏÂÌÌ˚ÏË ÎÂÁ‚ËflÏË. ëÂÔӂˉÌ˚È Ò͇θÔÂθ ËÒÔÓθÁÛ˛Ú ‰Îfl ÔÓÎÛ˜ÂÌËfl ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡, ÒÓÁ‰‡ÌËfl
ÚÓÌÌÂÎfl ‚ Ïfl„ÍËı Ú͇Ìflı Ë ÔÓ‰„ÓÚÓ‚ÍË ÔËÌËχ˛˘Â„Ó
ÎÓʇ.
ãÓÊÍӂˉÌ˚È Ò͇θÔÂθ ÒÍÓ¯ÂÌ Ò Ó‰ÌÓÈ ÒÚÓÓÌ˚, ˜ÚÓ
ÔÓÁ‚ÓÎflÂÚ ‡·ÓÚ‡Ú¸ ‚ ÒÎÓ Ïfl„ÍËı Ú͇ÌÂÈ, ÌÂÔÓÒ‰ÒÚ‚ÂÌÌÓ ÔË΄‡˛˘ÂÏ Í ÍÓÒÚË. чÌÌ˚È ËÌÒÚÛÏÂÌÚ ˜‡ÒÚÓ ÔËÏÂÌfl˛Ú ‰Îfl ÔÓ‰„ÓÚÓ‚ÍË ÎÓʇ ‰Îfl ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡.
ис. 4.2. ародонтологические скальпели для микрохирургии: 1 –
скальпель для использования сломанного лезвия; 2 – серповидный;
3 – мини-серповидный; 4 – ложковидный 260°; 5 – чешуевидный;
6 – глазной
18
åËÍÓıËÛ„˘ÂÒÍË ˄ÎÓ‰ÂʇÚÂÎË, ÂÚ‡ÍÚÓ˚ Ë
˝Î‚‡ÚÓ˚ ̇ÏÌÓ„Ó ÏÂ̸¯Â Òڇ̉‡ÚÌ˚ı. åËÍÓıËÛ„˘ÂÒÍË ÌÓÊÌˈ˚ ËÒÔÓθÁÛ˛Ú ‰Îfl ËÒÒ˜ÂÌËfl χÎÂ̸ÍËı ÍÛÒÓ˜ÍÓ‚ Ú͇ÌÂÈ. èË Ì‡ÎÓÊÂÌËË ¯‚Ó‚ ‚ ÒÚÓχÚÓÎÓ-
„ËË ‚ÓÓ·˘Â Ë ÏËÍÓıËÛ„˘ÂÒÍÓÈ Ô‡Ó‰ÓÌÚÓÎÓ„ËË, ‚
˜‡ÒÚÌÓÒÚË, ¯ËÓÍÓ ÔËÏÂÌfl˛ÚÒfl ÔË̈ÂÚ˚, ÍÓÚÓ˚ ·˚‚‡˛Ú ‰‚Ûı ÓÒÌÓ‚Ì˚ı ÚËÔÓ‚: Ò Ô·ÚÙÓÏÓÈ Ë ·ÂÁ ÌÂÂ.
äÓÏ ÚÓ„Ó, ÒÛ˘ÂÒÚ‚ÛÂÚ ·Óθ¯Ó ˜ËÒÎÓ ÏÓ‰ËÙË͇ˆËÈ
ÔË̈ÂÚÓ‚ Í‡Ê‰Ó„Ó ÚËÔ‡.
åËÍÓıËÛ„˘ÂÒÍË ËÌÒÚÛÏÂÌÚ˚ ÏÓ„ÛÚ ·˚Ú¸ ËÁ„ÓÚÓ‚ÎÂÌ˚ ËÁ ÚËڇ̇ ËÎË ıËÛ„˘ÂÒÍÓÈ ÌÂʇ‚²˘ÂÈ ÒÚ‡ÎË.
å‡ÒÒ‡ ÚËÚ‡ÌÓ‚˚ı ËÌÒÚÛÏÂÌÚÓ‚ ̇ÏÌÓ„Ó ÏÂ̸¯Â, ÌÓ
ÓÌË „Ó‡Á‰Ó ΄˜Â ‰ÂÙÓÏËÛ˛ÚÒfl Ë Ó·˚˜ÌÓ Ì‡ÏÌÓ„Ó
‰ÓÓÊÂ, ˜ÂÏ ÒڇθÌ˚Â. äÓÏ ÚÓ„Ó, ËÌÒÚÛÏÂÌÚ˚ ËÁ ÒÚ‡ÎË Ì‡Ï‡„Ì˘˂‡˛ÚÒfl. ëΉÛÂÚ ÓÚÏÂÚËÚ¸, ˜ÚÓ ‡ÒÒÓÚËÏÂÌÚ ÒڇθÌ˚ı ËÌÒÚÛÏÂÌÚÓ‚ ̇ÏÌÓ„Ó ‡ÁÌÓÓ·‡ÁÌÂÂ.
(a)
à„Î˚ Ë ¯Ó‚Ì˚ χÚÂˇÎ˚
ä‡Í ·˚ÎÓ Ò͇Á‡ÌÓ ‚˚¯Â, ‰Îfl ÔÓÙË·ÍÚËÍË Ó·‡ÁÓ‚‡ÌËfl
«ÏÂÚ‚˚ı» ÔÓÒÚ‡ÌÒÚ‚ ÌÂÓ·ıÓ‰ËÏÓ ‡‰ÂÍ‚‡ÚÌÓ ۯ˂‡ÌË ‡Ì˚ Ò Ó·ÂÒÔ˜ÂÌËÂÏ ‰ÓÒÚ‡ÚÓ˜ÌÓÈ ËÏÏÓ·ËÎËÁ‡ˆËË
(b)
ис. 4.5: а– пересадка соединительнотканного трансплантата
с помощью тоннельной методики; b – заживление после
трансплантации
ÎÓÒÍÛÚ‡ Ë ÓÚÒÛÚÒÚ‚ËÂÏ Ì‡ÚflÊÂÌËfl. è‡‚ËθÌ˚È ‚˚·Ó
¯Ó‚ÌÓ„Ó Ï‡ÚÂˇ· ‚Ó ÏÌÓ„ÓÏ ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ‰ÓÒÚËÊÂÌ˲ ˝ÚÓÈ ˆÂÎË.
(a)
Ç ÒÚÓχÚÓÎÓ„ËË Ó·˚˜ÌÓ ËÒÔÓθÁÛ˛Ú Ë„Î˚ Ò ËÁ„Ë·ÓÏ 3/4
(‰ÎË̇ 10 ÏÏ) ËÎË 1/2 (‰ÎË̇ 12,7 ÏÏ), Ô˘ÂÏ ÔÓÒΉÌËÈ ‚‡ˇÌÚ Ë„Î˚ ÔËÏÂÌflÂÚÒfl ̇˷ÓΠ˜‡ÒÚÓ (ËÒ.
4.4‡). é‰Ì‡ÍÓ ÌÂ‰ÍÓ ÒÚÓχÚÓÎÓ„Ë Ô‰ÔÓ˜ËÚ‡˛Ú ·ÓÎÂÂ
ÍÛÔÌ˚ ˄Î˚ ‰ÎËÌÓÈ 16–19 ÏÏ. í‡ÍË ˄Î˚ ‚ÔÓÎÌ ÔÓ‰ıÓ‰flÚ ‰Îfl fl‰‡ ıËÛ„˘ÂÒÍËı χÌËÔÛÎflˆËÈ, ̇ÔËÏÂ
ۯ˂‡ÌËfl Ïfl„ÍËı Ú͇ÌÂÈ ÔÓÒΠ˝ÍÒÚ‡ÍˆËË ÁÛ·Ó‚, ÏÂÎÍË ˄Î˚ Ó·ÂÒÔ˜˂‡˛Ú ·ÓΠ‚˚ÒÓÍÛ˛ ÚÓ˜ÌÓÒÚ¸ ̇ÎÓÊÂÌËfl ¯‚Ó‚ ÔË Ôӂ‰ÂÌËË Ô·ÒÚ˘ÂÒÍËı ÓÔÂ‡ˆËÈ.
(b)
ис. 4.4: а – изогнутые иглы с окружностью 1/2 и 3/8; b –
шпателевидная игла (6,6 мм) по сравнению с кожной иглой FS-2
длиной 19 мм
òÔ‡ÚÂ΂ˉ̇fl ˄· ˜‡ÒÚÓ Û‰Ó·Ì‡ ‚ ÏËÍÓıËÛ„˘ÂÒÍÓÈ Ô‡Ó‰ÓÌÚÓÎÓ„ËË, ‰ÎË̇ Ú‡ÍÓÈ Ë„Î˚ ÒÓÒÚ‡‚ÎflÂÚ
6,6 ÏÏ, ‡ ËÁ„Ë· – 140° (ËÒ. 4.4b). äÓÏ·Ë̇ˆËfl ÓÒÚÓÚ˚ Ë
χÎÓ„Ó ËÁ„Ë·‡ Ó·ÂÒÔ˜˂‡ÂÚ ËÒÍβ˜ËÚÂθÌÓ ‚˚ÒÓÍÛ˛
ÚÓ˜ÌÓÒÚ¸ ÒÓÔÓÒÚ‡‚ÎÂÌËfl ÎÓÒÍÛÚÓ‚ Ë Ì‡ÎÓÊÂÌËfl ¯‚Ó‚.
"лава 4. икрохирургические вмешательства в пародонтологии
19
ŇÁÓ‚˚È ÔË̈ËÔ ıËÛ„˘ÂÒÍÓÈ Ô‡ÍÚËÍË Á‡Íβ˜‡ÂÚÒfl
‚ ‚˚·Ó ҇ÏÓ„Ó ÚÓÌÍÓ„Ó ¯Ó‚ÌÓ„Ó Ï‡ÚÂˇ· ‰Îfl ‰ÓÒÚËÊÂÌËfl ‡‰ÂÍ‚‡ÚÌÓ„Ó ÒÓÔÓÒÚ‡‚ÎÂÌËfl Í‡Â‚ ‡Ì˚ (ÛÍÓ‚Ó‰ÒÚ‚Ó ÍÓÏÔ‡ÌËË ÑÊÓÌÒÓÌ Ë ÑÊÓÌÒÓÌ, 1994, Ò. 15). í‡ÍÓÈ
ÔÓ‰ıÓ‰ ÔÓÁ‚ÓÎflÂÚ ÏËÌËÏËÁËÓ‚‡Ú¸ ÓÚ‚ÂÒÚË ‚ Ú͇Ìflı ‚
ÂÁÛθڇÚ ÔÓ͇Î˚‚‡ÌËfl Ëı Ë„ÎÓÈ Ë, ÚÂÏ Ò‡Ï˚Ï, ÛÏÂ̸¯‡Ú¸ Ú‡‚ÏÛ Ú͇ÌÂÈ. èË ‚˚ÔÓÎÌÂÌËË ÏËÍÓıËÛ„˘ÂÒÍËı Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍËı ÓÔÂ‡ˆËÈ ÔÓ͇Á‡ÌÓ ÔËÏÂÌÂÌË ¯Ó‚Ì˚ı χÚÂˇÎÓ‚ 6-0, 7-0 Ë 8-0.
ÇÒ ¯Ó‚Ì˚ χÚÂˇÎ˚ ÏÓÊÌÓ ‡Á‰ÂÎËÚ¸ ̇ ÂÒÚÂÒÚ‚ÂÌÌ˚Â Ë ÒËÌÚÂÚ˘ÂÒÍËÂ, ÂÁÓ·ËÛÂÏ˚Â Ë ÌÂÂÁÓ·ËÛÂÏ˚Â, ÏÓÌÓÙË·ÏÂÌÚÌ˚Â Ë ÏÛθÚËÙË·ÏÂÌÚÌ˚Â. ä ÌÂÂÁÓ·ËÛÂÏ˚Ï ÓÚÌÓÒflÚÒfl ¯ÂÎÍ, ÌÂÈÎÓÌ Ë ÔÓÎË˝ÙË, ‡
Í ÂÁÓ·ËÛÂÏ˚Ï – ÔÓÒÚÓÈ Ë ıÓÏËÓ‚‡ÌÌ˚È ÍÂÚ„ÛÚ,
ÔÓÎ˄·ÍÚËÌ 910, ÔÓÎË„ÎÂ͇ÔÓÌ 25 Ë ÔÓÎˉËÓÍÒ‡ÌÓÌ.
Ç fl‰Â ̇ۘÌ˚ı ËÒÒΉӂ‡ÌËÈ ·˚ÎÓ ÔÓ‰ÂÏÓÌÒÚËÓ‚‡ÌÓ ÔÂËÏÛ˘ÂÒÚ‚Ó ÔÓÎ˄·ÍÚË̇ 910 Ë ÔÓÎË„ÎÂ͇ÔÓ̇ 25
̇‰ ÍÂÚ„ÛÚÓÏ (LaBabnara, 1995; Anatol et al., 1997).
ис. 4.8. ерехват иглы
ис. 4.9. равильные вкол и выкол иглы на равном расстоянии от
линии разреза
ис. 4.6. $арандашный захват, используемый для удержания
инструментов
ис. 4.7. равильный захват иглы иглодержателем
20
ис. 4.10. %аправление движения иглы задается пинцетом
ÒÚ‚Ó‚‡Ú¸ Ô‡‚ËθÌÓÏÛ Û¯Ë‚‡Ì˲ ‡Ì˚. à„ÎÛ Ë ÌËÚ¸ ÒΉÛÂÚ ÔÓ‚Ó‰ËÚ¸ ÒÚÓ„Ó ÔÂÔẨËÍÛÎflÌÓ ÔÓ‚ÂıÌÓÒÚË
Ú͇ÌË. чÌÌÓ ‰ÂÈÒÚ‚Ë ÒΉÛÂÚ ‚˚ÔÓÎÌflÚ¸ Ò ÔÓÏÓ˘¸˛
ÔË̈ÂÚ‡ (ËÒ. 4.10).
Ç ÏËÍÓıËÛ„ËË ËÒÔÓθÁÛ˛Ú ÚË ÓÒÌÓ‚Ì˚ ‚‡ˇÌÚ‡ Á‡‚flÁ˚‚‡ÌËfl ÛÁÎÓ‚: ÔÓ„ÛÊÌÓÈ, ÌÂÔÓ„ÛÊÌÓÈ Ë ÍÓÏ·ËÌËÓ‚‡ÌÌ˚È. èӢ ‚ÒÂ„Ó Ó‚Î‡‰ÂÚ¸ ‡ÁÌ˚ÏË ÏÂÚÓ‰Ë͇ÏË
ÏÓÊÌÓ Ò ÔÓÏÓ˘¸˛ ÔÓ‰Ó·ÌÂÈ¯Â„Ó ÛÍÓ‚Ó‰ÒÚ‚‡ A Laboratory Manual for Microvascular and Microtubal Surgery
(Cooley, 2001). Ç ÒÚÓχÚÓÎÓ„ËË Ì‡Ë·ÓΠ˜‡ÒÚÓ ÔËÏÂÌfl˛ÚÒfl ÔÓ„ÛÊÌÓÈ Ë ÍÓÏ·ËÌËÓ‚‡ÌÌ˚È ÒÔÓÒÓ·˚ Á‡‚flÁ˚‚‡ÌËfl ÛÁÎÓ‚.
èÓÒÚÓÈ ÏÓÒÍÓÈ ÛÁÂÎ (Í‚‡‰‡ÚÌ˚È) fl‚ÎflÂÚÒfl ̇˷ÓÎÂÂ
̇‰ÂÊÌ˚Ï. Ç ÏËÍÓıËÛ„ËË Ô‰ÔÓ˜ÚËÚÂθÌÓÈ fl‚ÎflÂÚÒfl ÍÓÏ·Ë̇ˆËfl ıËÛ„˘ÂÒÍÓ„Ó (ÔÂ‚Ó„Ó) Ë ÏÓÒÍÓ„Ó
(‚ÚÓÓ„Ó) ÛÁÎÓ‚ (ËÒ. 4.11). ÑÓÔÓÎÌËÚÂθÌ˚ ÔÂÚÎË Ì ‰Ó·‡‚Îfl˛Ú ÔÓ˜ÌÓÒÚË ÛÁÎÛ, ÌÓ Û‚Â΢˂‡˛Ú Â„Ó Ó·˙ÂÏ ÒÓ
‚ÒÂÏË ‚˚ÚÂ͇˛˘ËÏË Ì··„ÓÔËflÚÌ˚ÏË ÔÓÒΉÒÚ‚ËflÏË.
ис. 4.11. икрохирургический узел (после хирургического узла
завязывается квадратный узел)
èÄêéÑéçíéãéÉàóÖëäàÖ
åàäêéïàêìêÉàóÖëäàÖ ÇåÖòÄíÖãúëíÇÄ
Çϯ‡ÚÂθÒÚ‚‡ ̇ Ïfl„ÍËı Ú͇Ìflı
àÒÔÓθÁÓ‚‡ÌË ÚÓÌÍËı ‡Ú‡‚χÚ˘ÂÒÍËı ¯Ó‚Ì˚ı χÚÂˇÎÓ‚ ‚ ÍÓÏ·Ë̇ˆËË Ò ÒËÒÚÂχÏË Û‚Â΢ÂÌËfl ÔÓÁ‚ÓÎflÂÚ ÏËÌËÏËÁËÓ‚‡Ú¸ «ÏÂÚ‚Ó» ÔÓÒÚ‡ÌÒÚ‚Ó Ë Ì‡‰ÂÊÌÓ
ÒÓÔÓÒÚ‡‚ÎflÚ¸ Í‡fl ‡Ì˚ ·ÂÁ ̇ÚflÊÂÌËfl (ËÒ. 4.5).
ᇂflÁ˚‚‡ÌË ÛÁÎÓ‚ ‚ ÏËÍÓıËÛ„ËË
Ç Ô‡Ó‰ÓÌÚÓÎÓ„ËË ÔË Ì‡ÎÓÊÂÌËË ¯‚Ó‚ ÔÓ‰ ·Óθ¯ËÏ
Û‚Â΢ÂÌËÂÏ ÌÂÓ·ıÓ‰ËÏÓ Òӷβ‰‡Ú¸ ÌÂÒÍÓθÍÓ ÔË̈ËÔÓ‚: Á‡ı‚‡Ú ËÌÒÚÛÏÂÌÚ‡, Á‡ı‚‡Ú Ë„Î˚, ·ËχÌۇθÌÓ Á‡‚flÁ˚‚‡ÌË ÛÁÎÓ‚, ÔÓ͇Î˚‚‡ÌË ˄ÎÓÈ Ë Ì‡Ô‡‚ÎÂÌËÂ
ÌËÚË.
å‡ÍÒËχθ̇fl ÒÚ‡·ËθÌÓÒÚ¸ ËÌÒÚÛÏÂÌÚ‡ Ó·ÂÒÔ˜˂‡ÂÚÒfl ÔË Â„Ó Á‡ı‚‡ÚÂ Í‡Í ÔË¯Û˘ÂÈ Û˜ÍË (ËÒ. 4.6). à„ÎÛ
ÒΉÛÂÚ Á‡ı‚‡Ú˚‚‡Ú¸ ̇ ‡ÒÒÚÓflÌËË ‰‚Ûı ÚÂÚÂÈ ÂÂ
‰ÎËÌ˚ ÓÚ ÓÒÚËfl ‰Ó ۯ͇ (ËÒ. 4.7). é‰ËÌ ËÁ ÒÔÓÒÓ·Ó‚
Á‡ı‚‡Ú‡ Ë„Î˚ Á‡Íβ˜‡ÂÚÒfl ‚ Û‰ÂʇÌËË ÌËÚË ÔË̈ÂÚÓÏ
̉ÓÏËÌËÛ˛˘ÂÈ ÛÍÓÈ Ì‡ ‡ÒÒÚÓflÌËË 2–3 ÒÏ ÓÚ Ë„Î˚.
à„· ‰ÓÎÊ̇ Ò‚Ó·Ó‰ÌÓ ‚ËÒÂÚ¸, ÔÓÒΠ˜Â„Ó ÓÒÛ˘ÂÒÚ‚Îfl˛Ú  Á‡ı‚‡Ú Ë„ÎÓ‰ÂʇÚÂÎÂÏ (ËÒ. 4.8). è˘ÂÏ Ë„Î‡
‰ÓÎÊ̇ ·˚Ú¸ ̇Ô‡‚ÎÂ̇ ‚ ÒÚÓÓÌÛ Ô‰ÔÓ·„‡ÂÏÓ„Ó ÔÛÚË ÔÓ͇Î˚‚‡ÌËfl Ë ‚˚‚‰ÂÌËfl.
ç‡Ô‡‚ÎÂÌË ‚ÍÓ· Ë ‚˚ÍÓ· Ë„Î˚ ‰ÓÎÊÌÓ ·˚Ú¸ ÔÂÔẨËÍÛÎflÌÓ ÎËÌËË ‡ÁÂÁ‡, ÍÓÏ ÚÓ„Ó, ‚ÍÓÎ Ë ‚˚ÍÓÎ ‰ÓÎÊÌ˚ ‡ÒÔÓ·„‡Ú¸Òfl ̇ Ó‰Ë̇ÍÓ‚ÓÏ ‡ÒÒÚÓflÌËË ÓÚ Í‡fl
ÎÓÒÍÛÚ‡ (ËÒ. 4.9). è˘ÂÏ ‰‡ÌÌÓ ‡ÒÒÚÓflÌË Á‡‚ËÒËÚ
ÓÚ ‰Ë‡ÏÂÚ‡ Ë„Î˚ Ë Ô‚˚¯‡ÂÚ Â„Ó ÔË·ÎËÁËÚÂθÌÓ ‚
‰‚‡ ‡Á‡. á‡ı‚‡Ú ·Óθ¯Â„Ó Ó·˙Âχ Ú͇ÌË ÏÓÊÂÚ ÔÂÔflÚ-
èÂ‚˚ ÔÓÔ˚ÚÍË ÛÒÚ‡ÌÂÌËfl ˆÂÒÒËÈ ÍÓÌfl Ò ÔÓÏÓ˘¸˛
Ò‚Ó·Ó‰Ì˚ı ‰ÂÒÌ‚˚ı Ú‡ÌÒÔ·ÌÚ‡ÚÓ‚, ·ÚÂ‡Î¸ÌÓ Ë ÍÓÓ̇θÌÓ ÒÏ¢ÂÌÌ˚ı ÎÓÒÍÛÚÓ‚ ˜‡ÒÚÓ ·˚ÎË ÌÂÔ‰Ò͇ÁÛÂÏ˚. Ç 1985 „. Raetzke ÓÔÛ·ÎËÍÓ‚‡Î ÒÓÓ·˘ÂÌËÂ Ó ÌÓ‚ÓÏ
ÏÂÚӉ ÛÒÚ‡ÌÂÌËfl ÎÓ͇ÎËÁÓ‚‡ÌÌ˚ı ˆÂÒÒËÈ Ò ÔÓÏÓ˘¸˛
ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡.
ë‡‚ÌËÚÂθÌ˚È Ó·ÁÓ ËÒÒΉӂ‡ÌËÈ, ÔÓÒ‚fl˘ÂÌÌ˚ı ÓˆÂÌÍ ˝ÙÙÂÍÚË‚ÌÓÒÚË ÒÔÓÒÓ·Ó‚ ÛÒÚ‡ÌÂÌËfl ˆÂÒÒËÈ,
ÔÓ͇Á‡Î, ˜ÚÓ ËÒÔÓθÁÓ‚‡ÌË ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó
Ú‡ÌÒÔ·ÌÚ‡Ú‡ fl‚ÎflÂÚÒfl ̇˷ÓΠ˝ÙÙÂÍÚË‚Ì˚Ï Ë Ô‰Ò͇ÁÛÂÏ˚Ï ÏÂÚÓ‰ÓÏ (Greenwell et al., 2000). äÓÏ ÚÓ„Ó,
·˚ÎË ÔÓ͇Á‡Ì˚ Á̇˜ËÚÂθÌÓ ÛÎÛ˜¯ÂÌË ‚‡ÒÍÛÎflËÁ‡ˆËË ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡ Ë Û‚Â΢ÂÌË Á‡Í˚ÚËfl ˆÂÒÒËË ÔË ÔËÏÂÌÂÌËË ÏËÍÓıËÛ„˘ÂÒÍÓÈ ÏÂÚÓ‰ËÍË ÔÓ Ò‡‚ÌÂÌ˲ Ò Ú‡‰ËˆËÓÌÌÓÈ
(Burdhardt Ë Land, 2005).
åËÍÓıËÛ„Ëfl ÔË ÔÂÂÒ‡‰ÍÂ
ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡
Ç ÎËÚÂ‡ÚÛ ÓÔËÒ‡ÌÓ ÌÂÒÍÓθÍÓ ÏÂÚÓ‰ËÍ ÔÂÂÒ‡‰ÍË
ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌ˚ı Ú‡ÌÒÔ·ÌÚ‡ÚÓ‚. éÒÌÓ‚Ì˚ ÓÚ΢Ëfl Á‡Íβ˜‡˛ÚÒfl ‚ ÒÔÓÒÓ·‡ı ÔÂÂÍ˚‚‡ÌËfl Ú‡ÌÒÔ·ÌÚ‡Ú‡, ‰Îfl ˜Â„Ó ËÒÔÓθÁÛ˛ÚÒfl ÔÓÎÛÎÛÌÌ˚È, ÍÓÓ̇θÌÓ ËÎË Î‡ÚÂ‡Î¸ÌÓ ÒÏ¢ÂÌÌ˚È ÎÓÒÍÛÚ˚. Langer Ë
Langer (1989) Ô‰ÎÓÊËÎË Ó‰ÌÛ ËÁ ̇˷ÓΠ˝ÙÙÂÍÚË‚Ì˚ı ÏÂÚÓ‰ËÍ ÔÂÂÒ‡‰ÍË ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó
"лава 4. икрохирургические вмешательства в пародонтологии
21
Ú‡ÌÒÔ·ÌÚ‡Ú‡. Ç˚ÔÓÎÌÂÌË ‰‡ÌÌÓÈ Ï‡ÌËÔÛÎflˆËË Ò ÔÓÏÓ˘¸˛ Û‚Â΢ÂÌËfl ÔÓ‚˚¯‡ÂÚ ÚÓ˜ÌÓÒÚ¸ Ôӂ‰ÂÌËfl ‡ÁÂÁÓ‚ Ë ÒÓÔÓÒÚ‡‚ÎÂÌËfl Í‡Â‚ ‡Ì˚, ‡ Ú‡ÍÊ ÔÓÁ‚ÓÎflÂÚ
ÔÓÎÛ˜ËÚ¸ ÎÛ˜¯Ë ÂÁÛθڇÚ˚ (Burdhardt Ë Land, 2005).
äÓÏ ÚÓ„Ó, ‰Îfl ÛÒÚ‡ÌÂÌËfl ÌÂÁ̇˜ËÚÂθÌ˚ı ˆÂÒÒËÈ
ÏÓÊÂÚ ·˚Ú¸ ËÒÔÓθÁÓ‚‡Ì‡ ÏÂÚÓ‰Ë͇, ÍÓÚÓ‡fl Á‡Íβ˜‡ÂÚÒfl ‚ Ôӂ‰ÂÌËË ‚ÌÛÚË·ÓÓÁ‰ÍÓ‚Ó„Ó ‡ÁÂÁ‡, Ó·‡·ÓÚÍÂ
ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl ÎËÏÓÌÌÓÈ ÍËÒÎÓÚÓÈ Ë (ËÎË) ÚÂÚ‡ˆËÍÎËÌÓÏ. í‡ÍËÏ Ó·‡ÁÓÏ, ÔÓ‰„ÓÚ‡‚ÎË‚‡ÂÚÒfl Ò‚ÓÂÓ·‡ÁÌ˚È
«ÍÓÌ‚ÂÚ» ‰Îfl ‚‚‰ÂÌËfl ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡. ê‡ÁÏÂ Ú‡ÌÒÔ·ÌÚ‡Ú‡ ‰ÓÎÊÂÌ ·˚Ú¸ ̇ 3 ÏÏ
¯ËÂ Ë ‰ÎËÌÌ ˆÂÒÒËË.
í‡ÌÒÔ·ÌÚ‡Ú ÔÎÓÚÌÓ ÔËÊËχ˛Ú Í ÔËÌËχ˛˘ÂÏÛ ÎÓÊÛ Ò ÔÓÏÓ˘¸˛ Ó·‚Ë‚ÌÓ„Ó ¯‚‡, ÍÓÚÓ˚È Ì‡Í·‰˚‚‡˛Ú ‡Ú‡‚χÚ˘Ì˚Ï ¯Ó‚Ì˚Ï Ï‡ÚÂˇÎÓÏ Ò ÌËÚ¸˛ 7-0 ËÎË 8-0 Ë
ÒÓ ¯Ô‡ÚÂ΂ˉÌÓÈ Ë„ÎÓÈ. ë̇˜‡Î‡ Ë„ÎÛ ÔÓ‚Ó‰flÚ ˜ÂÂÁ
·ÓÓÁ‰Û, ÔÓÚÓÏ ‡Á‚Ó‡˜Ë‚‡˛Ú Ë ÔÂÌÂÚËÛ˛Ú Ú‡ÌÒÔ·ÌÚ‡Ú, ‡ Á‡ÚÂÏ – ËÌÚÂÔÓÍÒËχθÌÛ˛ Ú̸͇ (ÒÏ. ËÒ.
4.11). èË Á‡‚flÁ˚‚‡ÌËË ÛÁ· Ú‡ÌÒÔ·ÌÚ‡Ú Ó͇Á˚‚‡ÂÚÒfl
ÔÎÓÚÌÓ ÔËʇÚ˚Ï Í ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl. чÌ̇fl ÏÂÚÓ‰Ë͇ ˝ÙÙÂÍÚ˂̇ ÔË ÛÒÚ‡ÌÂÌËË ˆÂÒÒËÈ „ÎÛ·ËÌÓÈ 3 ÏÏ
Ë ÏÂÌÂÂ.
ÑÎfl ÛÒÚ‡ÌÂÌËfl ‚˚‡ÊÂÌÌ˚ı (·ÓΠ3 ÏÏ) ˆÂÒÒËÈ ·˚Î
Ô‰ÎÓÊÂÌ ˆÂÎ˚È fl‰ ÏÂÚÓ‰ËÍ, ̇ÔËÏÂ ÚÓÌÌÂθ̇fl
Ô·ÒÚË͇ ËÎË ÔÂÂÒ‡‰Í‡ ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡ Ò ÔÓÍ˚‚‡ÌËÂÏ Â„Ó Î‡ÚÂ‡Î¸ÌÓ ÒÏ¢ÂÌÌ˚Ï
ÎÓÒÍÛÚÓÏ. чÌÌ˚ ÏÂÚÓ‰ËÍË Ú‡ÍÊ ÏÓ„ÛÚ ·˚Ú¸ Ôӂ‰ÂÌ˚ Ò ÔÓÏÓ˘¸˛ ÏËÍÓıËÛ„˘ÂÒÍÓ„Ó ÔÓ‰ıÓ‰‡.
àÒÔÓθÁÓ‚‡ÌË ÒËÒÚÂÏ Û‚Â΢ÂÌËfl ÔË
Ó·‡·ÓÚÍ ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl
ëÚÂÂÓÏËÍÓÒÍÓÔ˚ ‰Ó‚ÓθÌÓ ‰‡‚ÌÓ ËÒÔÓθÁÓ‚‡ÎËÒ¸ ‚
ÒÚÓχÚÓÎÓ„ËË ‰Îfl ‚˚fl‚ÎÂÌËfl ÂÁˉۇθÌÓ„Ó (ÓÒÚ‡ÚÓ˜ÌÓ„Ó) ͇ÏÌfl ÔÓÒΠÒÌflÚËfl ÓÚÎÓÊÂÌËÈ. åÌÓ„Ë ‡‚ÚÓ˚ Ì·ÂÁÓÒÌÓ‚‡ÚÂθÌÓ Ò˜ËÚ‡˛Ú, ˜ÚÓ ÓÒÌÓ‚Ì˚Ï ÛÒÎÓ‚ËÂÏ ÛÒÔ¯ÌÓ„Ó ËÒıÓ‰‡ Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍÓÈ ÚÂ‡ÔËË fl‚ÎflÂÚÒfl
Ú˘‡ÚÂθ̇fl ҇̇ˆËfl ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl (Lindhe Ë Nyman
1984; Lindhe et al., 1984). èÓ ‰‡ÌÌ˚Ï Fleischer Ë ÒÓ‡‚Ú.
(1989), ‚Ì Á‡‚ËÒËÏÓÒÚË ÓÚ Í‚‡ÎËÙË͇ˆËË ÓÔÂ‡ÚÓ‡ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ÒÌflÚËfl ÓÚÎÓÊÂÌËÈ ÔÓ‚˚¯‡ÂÚÒfl ÔË Ó·ÂÒÔ˜ÂÌËË ıËÛ„˘ÂÒÍÓ„Ó ‰ÓÒÚÛÔ‡. Ç fl‰Â ËÒÒΉӂ‡ÌËÈ
Ò‡‚ÌË‚‡ÎË ÍÓ΢ÂÒÚ‚Ó ÓÒÚ‡ÚÓ˜Ì˚ı ÓÚÎÓÊÂÌËÈ ÔÓÒΠ҇̇ˆËË Ë Ó·‡·ÓÚÍË ÍÓÌÂÈ. é͇Á‡ÎÓÒ¸, ˜ÚÓ ÔË ËÒÔÓθÁÓ‚‡ÌËË ıËÛ„˘ÂÒÍÓ„Ó ‰ÓÒÚÛÔ‡ ÓÒÚ‡ÚÍË ÓÚÎÓÊÂÌËÈ Ó·Ì‡ÛÊË‚‡ÎË ‚ 14–24 % ÒÎÛ˜‡Â‚, ‡ ·ÂÁ Ú‡ÍÓ„Ó ‰ÓÒÚÛÔ‡ – ‚
17–69 % (American Academy of Periodontology, 1996).
䇘ÂÒÚ‚Ó Ó·‡·ÓÚÍË ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl Á̇˜ËÚÂθÌÓ
ÔÓ‚˚¯‡ÂÚÒfl ÔË ËÒÔÓθÁÓ‚‡ÌËË ‰ÓÔÓÎÌËÚÂθÌÓ„Ó ÓÒ‚Â˘ÂÌËfl (Reinhardt et al., 1985), ËÒÚÓ˜ÌËÍÓÏ ÍÓÚÓÓ„Ó ‚ÔÓÎÌ ÏÓÊÂÚ ÒÎÛÊËÚ¸ ÓÔÂ‡ˆËÓÌÌ˚È ÏËÍÓÒÍÓÔ. çÂÒÏÓÚfl
22
̇ ÓÚÒÛÚÒÚ‚Ë ·Óθ¯Ó„Ó ˜ËÒ· ËÒÒΉӂ‡ÌËÈ, ÔÓÒ‚fl˘ÂÌÌ˚ı Ò‡‚ÌÂÌ˲ Ó·‡·ÓÚÍË ÍÓÌÂÈ ÔÓ‰ Û‚Â΢ÂÌËÂÏ
ËÎË ·ÂÁ Ì„Ó, ‚ÔÓÎÌ Îӄ˘ÌÓ Ô‰ÔÓÎÓÊËÚ¸, ˜ÚÓ ÔËÏÂÌÂÌË ÓÔÂ‡ˆËÓÌÌÓ„Ó ÏËÍÓÒÍÓÔ‡ ÔÓ‚˚ÒËÚ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ χÌËÔÛÎflˆËË.
àëèéãúáéÇÄçàÖ éèÖêÄñàéççéÉé
åàäêéëäéèÄ Ç ëíéåÄíéãéÉàóÖëäéâ
èêÄäíàäÖ
ëÚÓχÚÓÎÓ„Ë ‚ÔÓÎÌ ÒÔÓÒÓ·Ì˚ ӂ·‰ÂÚ¸ ̇‚˚͇ÏË Ôӂ‰ÂÌËfl ÏËÍÓıËÛ„˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚, ÔÓÒÍÓθÍÛ
˜‡ÒÚÓ ‡·ÓÚ‡˛Ú ‚ ÛÒÎÓ‚Ëflı Ó„‡Ì˘ÂÌÌÓ„Ó ÔÓÒÚ‡ÌÒÚ‚‡.
ÅÂÁÛÒÎÓ‚ÌÓ, Ó·Û˜ÂÌË ‡·ÓÚÂ Ò ÏËÍÓÒÍÓÔÓÏ Ú·ÛÂÚ
ÏÌÓ„Ó˜‡ÒÓ‚˚ı ÚÂÌËÓ‚ÓÍ, ÔÓÒÍÓθÍÛ Í‡Ê‰˚È ÓÔÂ‡ÚÓ
‰ÓÎÊÂÌ ÔË‚˚ÍÌÛÚ¸ Í ÔÂÂıÓ‰Û ÓÚ ÔflÏÓÈ ‚ËÁÛ‡ÎËÁ‡ˆËË
Í ÌÂÔflÏÓÈ (ÁÂ͇θÌÓÈ). ÑÎfl ӂ·‰ÂÌËfl ÓÒÌÓ‚Ì˚ÏË
ÔË̈ËÔ‡ÏË ÏËÍÓıËÛ„ËË Í Ó·Û˜ÂÌ˲ ÒΉÛÂÚ ÔÓ‰ıÓ‰ËÚ¸ ·ÂÁ Ô‰۷ÂʉÂÌËfl. èÓ ÒÛÚË, ÓÚ‡·ÓÚ͇ ̇‚˚ÍÓ‚
Ôӂ‰ÂÌËfl ÏËÍÓıËÛ„˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚ fl‚ÎflÂÚÒfl ÔÓ‚ÂÍÓÈ ÒÔˆˇÎËÒÚ‡ ̇ ÔÓ˜ÌÓÒÚ¸. äÓÏ ÚÓ„Ó, ÂÍÓÏẨÛÂÚÒfl „ÛÎflÌÓ ÔÓ‚ÚÓflÚ¸ Ó·Û˜ÂÌËÂ. ÇÌ ‚ÒflÍËı
ÒÓÏÌÂÌËÈ, Û˜‡ÒÚË ‚ ÒÔˆˇÎËÁËÓ‚‡ÌÌ˚ı ÍÛÒ‡ı ̇ ·‡ÁÂ
ÂÒÔÂÍÚ‡·ÂθÌ˚ı ۘ·Ì˚ı ËÎË Î˜·Ì˚ı Á‡‚‰ÂÌËÈ ÔÓ‰
ÛÍÓ‚Ó‰ÒÚ‚ÓÏ ÔËÁ̇ÌÌ˚ı ˝ÍÒÔÂÚÓ‚ ‚Ó ÏÌÓ„ÓÏ Ó·Î„˜‡ÂÚ Ë ÛÒÍÓflÂÚ Ó‚Î‡‰ÂÌË ̇‚˚͇ÏË ÏËÍÓıËÛ„ËË.
ÇÓ ‚ÂÏfl ÏËÍÓıËÛ„˘ÂÒÍÓÈ ÔÓ‰„ÓÚÓ‚ÍË ÓÔÂ‡ÚÓ
‰ÓÎÊÂÌ Ì‡Û˜ËÚ¸Òfl ÔÂÓ‰Ó΂‡Ú¸ ÏÌÓ„Ë ÔÂÔflÚÒÚ‚Ëfl.
íÂÏÓ ËÎË ÌÂÓÒÓÁ̇ÌÌ˚ ÒÓÍ‡˘ÂÌËfl Ï˚¯ˆ Á‡ÚÛ‰Ìfl˛Ú ‡·ÓÚÛ Ò ÒËÒÚÂχÏË Û‚Â΢ÂÌËfl. èÓ ÏÌÂÌ˲ ÏÌÓ„Ëı
ÓÔ˚ÚÌ˚ı ÒÔˆˇÎËÒÚÓ‚ ‚ ӷ·ÒÚË ÏËÍÓıËÛ„ËË, ÚÂÏÓ Û‚Â΢˂‡ÂÚÒfl ÔË Ì‰ÓÒÚ‡ÚÓ˜ÌÓÏ ÒÌÂ, ̇ÔflÊÂÌËË
‚ÂıÌÂÈ ˜‡ÒÚË Ú· ‚ Ú˜ÂÌË ÔÓÒΉÌËı 24 ˜ ÔÂ‰ ÓÔÂ‡ˆËÂÈ, Ú‡·‡ÍÓÍÛÂÌËË, ˜ÂÁÏÂÌÓÏ ÛÔÓÚ·ÎÂÌËË ÍÓÙÂË̇, ÔË Ì‡Î˘ËË ÔÒËıÓÎӄ˘ÂÒÍÓ„Ó ‡Á‰‡ÊÂÌËfl Ë
˜Û‚ÒÚ‚‡ Ú‚ӄË. èÓ˝ÚÓÏÛ ÔË Ô·ÌËÓ‚‡ÌËË ÏËÍÓıËÛ„˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚ ÒΉÛÂÚ ËÁ·Â„‡Ú¸ ‚ÎËflÌËfl
ÔÂ˜ËÒÎÂÌÌ˚ı ‚˚¯Â Ù‡ÍÚÓÓ‚.
äÓÏ ÚÓ„Ó, ÒΉÛÂÚ ÓÚ‡·ÓÚ‡Ú¸ ˜Û‚ÒÚ‚Ó ‚ÓÒÔËflÚËfl „ÎÛ·ËÌ˚ ‡·Ó˜Â„Ó ÔÓÎfl. í‡Í ÊÂ, Í‡Í ÔË ‡·ÓÚÂ Ò ·ËÌÓÍÛÎfl‡ÏË, ÌÂÓ·ıÓ‰ËÏÓ ÌÂÍÓÚÓÓ ‚ÂÏfl ‰Îfl ÔË‚˚͇ÌËfl Í
ÌÓ‚˚Ï ‚ËÁۇθÌ˚Ï Ó˘Û˘ÂÌËflÏ, ÔË ËÒÔÓθÁÓ‚‡ÌËË ıËÛ„˘ÂÒÍÓ„Ó ÏËÍÓÒÍÓÔ‡ ÌÛÊÌÓ ÔËÒÔÓÒÓ·ËÚ¸Òfl Í ÌÓ‚ÓÏÛ ‚ÓÒÔËflÚ˲ ‡·Ó˜Â„Ó ÔÓÎfl.
èË ‡·ÓÚ ‚ ‰ËÒڇθÌ˚ı Óډ·ı ÔÓÎÓÒÚË Ú‡ ÂÍÓÏẨÛÂÚÒfl Ô˷„‡Ú¸ Í ÔÓÏÓ˘Ë ÁÂ͇Î, ÍÓÚÓ˚ ӷ˚˜ÌÓ
Û‰ÂÊË‚‡˛Ú ̇ ÌÂÍÓÚÓÓÏ ‡ÒÒÚÓflÌËË ÓÚ ÁÛ·Ó‚. ÑÎfl
Û‰Ó·ÒÚ‚‡ ÏÓÊÌÓ ËÒÔÓθÁÓ‚‡Ú¸ χÎÂ̸ÍË ÁÂ͇· Ë
(ËÎË) ÁÂ͇· Ò ËÁÓ„ÌÛÚ˚ÏË ÛÍÓflÚ͇ÏË. é˜Â̸ ‚‡ÊÌÓ
̇ۘËÚ¸Òfl Ô‡‚ËθÌÓ ÔÓÁˈËÓÌËÓ‚‡Ú¸ ÏËÍÓÒÍÓÔ ‚ Á‡‚ËÒËÏÓÒÚË ÓÚ ÍÎËÌ˘ÂÒÍËı Ú·ӂ‡ÌËÈ.
ùÚ‡Ô˚ Ôӂ‰ÂÌËfl χÌËÔÛÎflˆËÈ ÏÓÊÌÓ ‰ÓÍÛÏÂÌÚËÓ‚‡Ú¸ Ò ÔÓÏÓ˘¸˛ ‚ˉÂÓÁ‡ÔËÒÂÈ Ë ÙÓÚÓ„‡ÙËÈ. Ä‚ÚÓ˚
‰‡ÌÌÓÈ ÍÌË„Ë Ì ÒÚ‡‚ËÎË Ò‚ÓÂÈ ˆÂθ˛ ËÌÙÓÏËÓ‚‡Ú¸
˜ËÚ‡ÚÂÎÂÈ Ó ÒÛ˘ÂÒÚ‚Û˛˘Ëı ÒËÒÚÂχı ÙÓÚÓÒ˙ÂÏÍË. èÓËÁ‚Ó‰ËÚÂÎË ÓÔÂ‡ˆËÓÌÌ˚ı ÏËÍÓÒÍÓÔÓ‚ Ó·˚˜ÌÓ ÔÓÏÓ„‡˛Ú ÔÓ‰Ó·‡Ú¸ ËÎË ÔÓÂÍÓÏẨӂ‡Ú¸ ÒÓÓÚ‚ÂÚÒÚ‚Û˛˘ËÂ
ÔËÒÔÓÒÓ·ÎÂÌËfl ‰Îfl Ôӂ‰ÂÌËfl ‚ˉÂÓ- ËÎË ÙÓÚÓÒ˙ÂÏÍË ‚Ó ‚ÂÏfl ‚˚ÔÓÎÌÂÌËfl ÏËÍÓıËÛ„˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚.
áÄäãûóÖçàÖ
èËÏÂÌÂÌË ÓÔÂ‡ˆËÓÌÌÓ„Ó ÏËÍÓÒÍÓÔ‡ Ó·ÂÒÔ˜˂‡ÂÚ
Á̇˜ËÚÂθÌÓ ۂÂ΢ÂÌËÂ Ë ‰ÓÔÓÎÌËÚÂθÌÓ ÓÒ‚Â˘ÂÌËÂ, ‡ Ú‡ÍÊ ‚ÓÁÏÓÊÌÓÒÚ¸ ËÒÔÓθÁÓ‚‡ÌËfl Ì·Óθ¯Ëı
ËÌÒÚÛÏÂÌÚÓ‚ Ë ÚÓÌÍËı ¯Ó‚Ì˚ı χÚÂˇÎÓ‚, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ÔÓ‚˚ÒËÚ¸ ÚÓ˜ÌÓÒÚ¸ Ë Í‡˜ÂÒÚ‚Ó Ôӂ‰ÂÌËfl ıËÛ„˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚ ‚ Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍÓÈ ıËÛ„ËË.
çÂÒÏÓÚfl ̇ ÚÓ ˜ÚÓ ÛÎÛ˜¯ÂÌË ÍÎËÌ˘ÂÒÍÓ„Ó ËÒıÓ‰‡ ıËÛ„˘ÂÒÍËı ‚ϯ‡ÚÂθÒÚ‚ ÔË ÔËÏÂÌÂÌËË Û‚Â΢ÂÌËfl
ÔÓ‰Ú‚Âʉ‡ÂÚÒfl Î˯¸ Ì·Óθ¯ËÏ ˜ËÒÎÓÏ ËÒÒΉӂ‡ÌËÈ, Îӄ˘ÌÓ Ô‰ÔÓÎÓÊËÚ¸, ˜ÚÓ ÛÎÛ˜¯ÂÌË ‚ËÁÛ‡ÎËÁ‡ˆËË Ò ÔÓÏÓ˘¸˛ ÓÔÂ‡ˆËÓÌÌÓ„Ó ÏËÍÓÒÍÓÔ‡ ÔÓ‚˚¯‡ÂÚ
˝ÙÙÂÍÚË‚ÌÓÒÚ¸ Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍËı ÓÔÂ‡ˆËÈ.
ãàíÖêÄíìêÄ
Anatol, T.I., Roopchand, R., Holder, Y., & Shing-Hon, G. (1997) A comparison of the
use of plain catgut, skin tapes and polyglactin sutures for skin closure: A prospective clinical trial. Journal of the Royal College of Surgeons of Edinborough 42,
124–127.
Apotheker, H., & Jako, G.H. (1981) A microscope for use in dentistry. Journal of Microsurgery 3, 7–10.
Barraquer, J.I. (1980) The history of the microscope in ocular surgery. Journal of
Microsurgery 1, 288–299.
Belcher, J.M. (2001) A perspective on periodontal microsurgery. International Journal
of Periodontology and Restorative Dentistry 21, 191–196.
Burdhardt, R., & Land, N.P. (2005) Coverage of localized gingival recessions: Comparison of micro- and macrosurgical techniques. Journal of Clinical Periodontology 32, 287–293.
Campbell, D. (1989) Magnification is major aid to dentists . . . and how microdentistry’s time has come! Future of Dentistry 4(3), 11.
Carr, G.B. (1992) Microscopes in endodontics. Journal of California Dentistry 20, 55–61.
Cobb, C.M. (1996) Non-surgical pocket therapy: Mechanical. Annals of Periodontology 1, 443–490.
Cooley, B.C. (2001) A Laboratory Manual for Microsulcular and Microtubal Surgery.
Reading, PA: Surgical Specialties, 28–33.
Dohlman, G.F. (1969) Carl Olof Nylen and the birth of the otomicroscope and microsurgery. Archives of Otolaryngology 90, 813–817.
Fleischer, H.C., Mellonig, J.T., Brayer, W.K., Gray, J.L., & Barnett, J.D. (1989) Scaling
and root planing efficacy in multirooted teeth. Journal of Periodontology 60, 402–409.
Greenwell, H., Bissada, N.F., Henderson, R.D., & Dodge, J.R. (2000) The deceptive
nature of root coverage results. Journal of Periodontology 71, 1327–1337.
Johnson & Johnson (1994) Wound Closure Manual. Somerville, NJ: Ethicon.
LaBabnara, J. (1995) A review of absorbable suture materials in head and neck surgery and introduction of monocryl: A new absorbable suture. Ear, Nose, and
Throat Journal 74, 409–416.
Langer, B., & Langer, L. (1989) Subepithelial connective tissue graft technique for root
coverage. Journal of Periodontology 56, 715–720.
Leknius, C., & Geissberger, M. (1995) The effect of magnification on the performance
of fixed prosthodontic procedures. Journal of the California Dental Association 23,
66–70.
Lindhe, J., & Nyman, S. (1984) Long-term maintenance of patients treated for
advanced periodontal disease. Journal of Clinical Periodontology 11, 504–514.
Lindhe, J., Westfelt, E., Nyman, S., Socransky, S.S., & Haffajee, A.D. (1984) Longterm effect of surgical/nonsurgical treatment of periodontal disease. Journal of
Clinical Periodontology 11, 448–458.
Raetzke, P.B. (1985) Covering localized areas of root exposure employing the “envelope” technique. Journal of Periodontology 56, 397–402.
Reinhardt, R.A., Johnson, G.K., & Tussing, G.J. (1985) Root planing with interdental
papillae reflection and fiber optic illumination. Journal of Periodontology 56, 721–726.
Tibbetts, L.S., & Shanelec, D.A. 1998. Periodontal microsurgery. Dental Clinics of
North America 42, 339–359.
"лава 4. икрохирургические вмешательства в пародонтологии
23
лава 5. вободный десневой трансплантат
ëÂÊ ÑË·‡Ú
àëíéêàü êÄáÇàíàü åÖíéÑàäà
ïàêìêÉàóÖëäéÖ éÅÖëèÖóÖçàÖ
àÒÔÓθÁÓ‚‡ÌË ҂ӷӉÌ˚ı ‰ÂÒÌ‚˚ı Ú‡ÌÒÔ·ÌÚ‡ÚÓ‚
ÓÔË҇ΠBjorn (1963), ‡ Ú‡ÍÊ Sullivan Ë Atkins (1968), ÍÓÚÓ˚ ̇˜‡ÎË ÔËÏÂÌflÚ¸ ‚ Ô‡Ó‰ÓÌÚÓÎÓ„ËË ÔË̈ËÔ˚
Ô·ÒÚ˘ÂÒÍÓÈ ıËÛ„ËË. ÄÛÚÓ„ÂÌÌ˚È Ú‡ÌÒÔ·ÌÚ‡Ú ÔÂ‚Ó̇˜‡Î¸ÌÓ ËÒÔÓθÁÓ‚‡ÎË ‰Îfl Û‚Â΢ÂÌËfl ÁÓÌ˚ ÍÂ‡ÚËÌËÁËÓ‚‡ÌÌÓÈ ÔËÍÂÔÎÂÌÌÓÈ ‰ÂÒÌ˚ Ë ‰Îfl Û„ÎÛ·ÎÂÌËfl
Ô‰‰‚ÂËfl, ‡ ÔÓÁÊ ‰Îfl ÛÒÚ‡ÌÂÌËfl ˆÂÒÒËÈ (Sullivan
Ë Atkins, 1968; Holbrook Ë Ochsenbein, 1983; Miller,
1985). чÌ̇fl ÏÂÚÓ‰Ë͇ ÓÚ΢‡ÂÚÒfl ÔÓÒÚÓÚÓÈ, ‚˚ÒÓÍÓÈ
˝ÙÙÂÍÚË‚ÌÓÒÚ¸˛ Ë ÛÌË‚Â҇θÌÓÒÚ¸˛. èÓÏËÏÓ ÔÂ˜ËÒÎÂÌÌ˚ı ÔÓ͇Á‡ÌËÈ, Ò‚Ó·Ó‰Ì˚Ï ‰ÂÒÌ‚˚Ï Ú‡ÌÒÔ·ÌÚ‡ÚÓÏ ÏÓÊÌÓ Á‡Í˚Ú¸ ÎÛÌÍÛ Û‰‡ÎÂÌÌÓ„Ó ÁÛ·‡ ËÎË ÍÓÒÚÌ˚È Ú‡ÌÒÔ·ÌÚ‡Ú (Ellegaard et al., 1974).
ÑÎfl Ôӂ‰ÂÌËfl ÓÔÂ‡ˆËË ÌÂÓ·ıÓ‰ËÏ Òڇ̉‡ÚÌ˚È ıËÛ„˘ÂÒÍËÈ Ì‡·Ó, ‡ Ú‡ÍÊÂ:
• Ü·ÚËÌÓ‚‡fl „۷͇ (ÑÊÂÎÙÓ‡Ï, î‡χˆËfl-ÄÔ‰ÊÓÌ;
Gelfoam, Pharmacia-Upjohn) ËÎË ÓÍÒˉËÓ‚‡Ì̇fl ˆÂÎβÎÓÁ‡ (ëÂ‰ÊËÒÂÎ, ÑÊÓÌÒÓÌ Ë ÑÊÓÌÒÓÌ; Surgicel, Jonson & Jonson).
• é˜Ë˘ÂÌÌ˚È ˆË‡Ì‡ÍËÎ‡Ú (èÂËÄÍËÎ; PeriAcryl).
• ãËÏÓÌ̇fl ÍËÒÎÓÚ‡ (pH=1, Ú.Â. 40 %) ËÎË Ó‰Ì‡ ͇ÔÒÛ·
ÚÂÚ‡ˆËÍÎË̇ „ˉÓıÎÓˉ‡ (250 Ï„).
èéäÄáÄçàü
àëèéãúáéÇÄçàÖ ëÇéÅéÑçéÉé
ÑÖëçÖÇéÉé íêÄçëèãÄçíÄíÄ
Ñãü ìÇÖãàóÖçàü áéçõ
äÖêÄíàçàáàêéÇÄççéâ
èêàäêÖèãÖççéâ ÑÖëçõ
ë‚Ó·Ó‰Ì˚È ‰ÂÒÌ‚ÓÈ Ú‡ÌÒÔ·ÌÚ‡Ú ËÒÔÓθÁÛ˛Ú ÔÓ
ÒÎÂ‰Û˛˘ËÏ ÔÓ͇Á‡ÌËflÏ:
• ì‚Â΢ÂÌË ÁÓÌ˚ ÍÂ‡ÚËÌËÁËÓ‚‡ÌÌÓÈ ÔËÍÂÔÎÂÌÌÓÈ ‰ÂÒÌ˚.
• ì‚Â΢ÂÌË „ÎÛ·ËÌ˚ Ô‰‰‚ÂËfl.
• ì‚Â΢ÂÌË ӷ˙Âχ Ïfl„ÍËı Ú͇ÌÂÈ ‚ ӷ·ÒÚË ‡‰ÂÌÚËË
(ÔÓ‰„ÓÚӂ͇ Í ÔÓÚÂÁËÓ‚‡Ì˲).
• ìÒÚ‡ÌÂÌË ˆÂÒÒËÈ ‰ÂÒÌ˚.
åÂÚÓ‰Ë͇
ис. 5.1. ецессия и недостаток кератинизированной
прикрепленной десны в области зуба 41
ис. 5.2. акончена подготовка реципиентного участка.
ровоточивший сосуд перевязан шелковой лигатурой
одготовка реципиентного участка
ãÂÁ‚ËÂÏ ‹15 ̇Ϙ‡˛Ú „ÓËÁÓÌڇθÌ˚È ‡ÁÂÁ ‡ÔË͇θÌ ˆÂÒÒËË (ËÒ. 5.1 Ë 5.2). áÛ·Ó‰ÂÒÌÂ‚Û˛ ·ÓÓÁ‰Û
ÏÓÊÌÓ ÒÓı‡ÌËÚ¸ ËÎË ËÒÒ˜¸. èÓÒΠ˝ÚÓ„Ó ÔÓËÁ‚Ó‰flÚ
‰‚‡ ‚ÂÚË͇θÌ˚ ‡ÁÂÁ‡ Á‡ Ô‰ÂÎ˚ ÒÎËÁËÒÚÓ-‰ÂÒÌÂ‚Ó„Ó ÒÓ‰ËÌÂÌËfl Ë ÓÚÍˉ˚‚‡˛Ú ‡Ò˘ÂÔÎÂÌÌ˚È ÎÓÒÍÛÚ.
25
ç‡ ˝ÚÓÏ ˝Ú‡Ô ˜ÂÁ‚˚˜‡ÈÌÓ ‚‡ÊÌÓ ÔÂÔ‡ËÓ‚‡Ú¸ ÎÓÒÍÛÚ Í‡Í ÏÓÊÌÓ ·ÎËÊÂ Í Ì‡‰ÍÓÒÚÌˈÂ, ˜ÚÓ·˚ ÓÚÒ˜¸ ‚ÒÂ
Ï˚¯Â˜Ì˚ ‚ÓÎÓÍ̇ Ë ÓÒÚ‡‚ËÚ¸ ̇ ÍÓÒÚË Í‡Í ÏÓÊÌÓ ÏÂ̸¯Â ÔÓ‰‚ËÊÌ˚ı Ú͇ÌÂÈ. ùÚÓ ÛÏÂ̸¯‡ÂÚ ‚ÂÓflÚÌÓÒÚ¸ ÒÓÁ‰‡ÌËfl ÁÓÌ˚ ÔÓ‰‚ËÊÌÓÈ ÒÎËÁËÒÚÓÈ ‚ ӷ·ÒÚË ÔÂÂÒ‡ÊÂÌÌÓ„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡.
12 ÏÏ
èÓÒΠÔÓ‰„ÓÚÓ‚ÍË ˆËÔËÂÌÚÌÓ„Ó Û˜‡ÒÚ͇ ÎÓÒÍÛÚ ÏÓÊÌÓ
Û‰‡ÎËÚ¸ ÌÓÊÌˈ‡ÏË. ÖÒÎË ÎÓÒÍÛÚ Ô·ÌËÛÂÚÒfl ÓÒÚ‡‚ËÚ¸,
ÚÓ Â„Ó ÙËÍÒËÛ˛Ú ¯‚‡ÏË ‡ÔË͇θÌ ‰ÂÒÌÂ‚Ó„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡.
çÂÍÓÚÓ˚ ‡‚ÚÓ˚ Ô‰ÔÓ˜ËÚ‡˛Ú ÔÂÂÒ‡ÊË‚‡Ú¸ Ú‡ÌÒÔ·ÌÚ‡Ú Ì‡ ÍÓÒÚ¸ (Dordick et al., 1976; James Ë McFall,
1978), ÏÓÚË‚ËÛfl ˝ÚÓ ÏÂ̸¯ÂÈ Â„Ó ÛÒ‡‰ÍÓÈ Ë ·ÓÎÂÂ
ÔÎÓÚÌ˚Ï ÔËÍÂÔÎÂÌËÂÏ. Ç Ú‡ÍÓÏ ÒÎÛ˜‡Â ‚ ˆËÔËÂÌÚÌÓÏ Û˜‡ÒÚÍ ÓÚÍˉ˚‚‡˛Ú ÔÓÎÌÓÒÎÓÈÌ˚È ÎÓÒÍÛÚ.
éÚÒ·˂‡ÌË ÔÓÎÌÓÒÎÓÈÌÓ„Ó (ÒÎËÁËÒÚÓ-̇‰ÍÓÒÚÌ˘ÌÓ„Ó)
ÎÓÒÍÛÚ‡ ÔÓ‚Ó‰flÚ ÚÛÔ˚Ï ÔÛÚÂÏ, ‡ ‡Ò˘ÂÔÎÂÌÌÓ„Ó (ÒÎËÁËÒÚÓ„Ó) – ÓÒÚ˚Ï. èË ÔÂÂÒ‡‰Í ‰ÂÒÌÂ‚Ó„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡ ÌÂÔÓÒ‰ÒÚ‚ÂÌÌÓ Ì‡ ÍÓÒÚ¸ ÒΉÛÂÚ ‚˚ÔÓÎÌËÚ¸ ÂÂ
‰ÂÍÓÚË͇ˆË˛ χÎÂ̸ÍËÏ ¯‡ӂˉÌ˚Ï ·ÓÓÏ (‹ 1/2).
í‡ÍÓÈ ÔËÂÏ ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ·ÓΠ·˚ÒÚÓÈ ‚‡ÒÍÛÎflËÁ‡ˆËË Ú‡ÌÒÔ·ÌÚ‡Ú‡.
èÓÎÛ˜ÂÌË Ú‡ÌÒÔ·ÌÚ‡Ú‡
ÑÂÒÌ‚ÓÈ Ú‡ÌÒÔ·ÌÚ‡Ú ÏÓÊÌÓ ÔÓÎÛ˜ËÚ¸ ̇ Ì· ‚ ӷ·ÒÚË ÓÚ ÔÂ‚Ó„Ó ÏÓÎfl‡ ‰Ó ÍÎ˚͇, „‰Â Ïfl„ÍË Ú͇ÌË
ËÏÂ˛Ú Ï‡ÍÒËχθÌÛ˛ ÚÓ΢ËÌÛ (Reiser et al., 1996). íÂÏ
Ì ÏÂÌÂÂ, ‚ ͇˜ÂÒÚ‚Â ‰ÓÌÓÒÍÓ„Ó Û˜‡ÒÚ͇ ÏÓÊÌÓ Ò ÛÒÔÂıÓÏ ËÒÔÓθÁÓ‚‡Ú¸ ӷ·ÒÚË ‡‰ÂÌÚËË, ·Û„Ó‚ ‚ÂıÌÂÈ ˜ÂβÒÚË ËÎË Î˛·˚ ‰Û„Ë ۘ‡ÒÚÍË ÔËÍÂÔÎÂÌÌÓÈ ‰ÂÒÌ˚.
èË ÔÓÎÛ˜ÂÌËË Ú‡ÌÒÔ·ÌÚ‡Ú‡ ÒΉÛÂÚ ËÁ·Â„‡Ú¸ ÔÓ‚ÂʉÂÌËfl ÒÓÒÛ‰ËÒÚÓ-ÌÂ‚ÌÓ„Ó Ô͇ۘ, ‚Íβ˜‡˛˘Â„Ó ‚ Ò·fl
·Óθ¯ÓÈ Ë Ï‡Î˚È Ì·Ì˚È ÌÂ‚˚, ‡ Ú‡ÍÊ ÒÓÒÛ‰˚. Ç Í‡˜ÂÒÚ‚Â ‰ÓÌÓÒÍÓ„Ó Û˜‡ÒÚ͇ Ì ÂÍÓÏẨÛÂÚÒfl ËÒÔÓθÁÓ‚‡Ú¸ ӷ·ÒÚ¸ Ì·Ì˚ı ÒÍ·‰ÓÍ (Cohen, 1994). ëÓÒÛ‰ËÒÚÓÌÂ‚Ì˚È ÔÛ˜ÓÍ ‚˚ıÓ‰ËÚ Ì‡ ÌÂ·Ó ˜ÂÂÁ ·Óθ¯ÓÂ Ë Ï‡ÎÓÂ
Ì·Ì˚ ÓÚ‚ÂÒÚËfl, ‡ÒÔÓÎÓÊÂÌÌ˚ ‡ÔË͇θÌ ÚÂÚ¸Ëı
ÏÓÎflÓ‚, ‡ Á‡ÚÂÏ ÒΉÛÂÚ ‚‰Óθ Ì·‡ ‰Ó ÂÁˆÓ‚Ó„Ó ÓÚ‚ÂÒÚËfl.
12 ÏÏ
ÑÂÒ̇
12 ÏÏ
ÄÚÂËfl
ÜÂÎÂÁËÒÚ‡fl
Ú̸͇
ÜËÓ‚‡fl
Ú̸͇
ис. 5.3. Анатомия донорского участка. ебные сосуды и нерв
следуют из большого и малого небных отверстий к резцовому
отверстию. # переднем отделе подслизистый слой содержит
преимущественно жировую ткань, а в дистальном – железистую
Ú‡‚ÎflÂÚ 14,9±2,93 ÏÏ, ‡ Û ÊÂÌ˘ËÌ – 12,7±2,45 ÏÏ (Redman et al., 1965).
ÑÎfl ÓÔ‰ÂÎÂÌËfl ÚÓ΢ËÌ˚ Ïfl„ÍËı Ú͇ÌÂÈ, ‡ Ú‡ÍÊ ‡ÒÔÓÎÓÊÂÌËfl ÒÓÒÛ‰ËÒÚÓ-ÌÂ‚ÌÓ„Ó Ô͇ۘ ÏÓÊÌÓ ÔÓ‚ÂÒÚË
ÁÓ̉ËÓ‚‡ÌË ÍÓÒÚË Ë„ÎÓÈ ‰Îfl ‡ÌÂÒÚÂÁËË ‚Ó ‚ÂÏfl ÂÂ
Ôӂ‰ÂÌËfl. àÒÔÓθÁÓ‚‡ÌË ӷ·ÒÚË ÒÍ·‰ÓÍ Ì‡ Ì·Â
ÌÂÊ·ÚÂθÌÓ, ÔÓÒÍÓθÍÛ ˝ÚÓ ÏÓÊÂÚ Ì„‡ÚË‚ÌÓ Ò͇Á‡Ú¸Òfl
̇ ˝ÒÚÂÚ˘ÂÒÍÓÏ ÂÁÛθڇÚ ‚ϯ‡ÚÂθÒÚ‚‡. Ç Ú˜ÂÌËÂ
‰ÎËÚÂθÌÓ„Ó ‚ÂÏÂÌË ÔÓÒΠÔÂÂÒ‡‰ÍË Ú‡ÌÒÔ·ÌÚ‡Ú
ÒÓı‡ÌflÂÚ Ò‚Ó˛ ËÒıÓ‰ÌÛ˛ ÙÓÏÛ, Ë ÒÍ·‰ÍË ÓÒÚ‡˛ÚÒfl
ÌÂÒÏÓÚfl ̇ ÔÓÔ˚ÚÍË Ëı ıËÛ„˘ÂÒÍÓ„Ó Û‰‡ÎÂÌËfl
(Breault et al., 1999).
êˆËÔËÂÌÚÌÛ˛ ӷ·ÒÚ¸ ËÁÏÂfl˛Ú χÍËÓ‚‡ÌÌ˚Ï Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍËÏ ÁÓ̉ÓÏ, ÔÓÒΠ˜Â„Ó Ì‡ Ì· ÓÚϘ‡˛Ú
ÍÓÌÚÛ ·Û‰Û˘Â„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡ Ò͇θÔÂÎÂÏ (ËÒ. 5.4).
èÓ ‰‡ÌÌ˚Ï Reiser Ë ÒÓ‡‚Ú. (1996), Ì·Ì˚È ÒÓÒÛ‰ËÒÚÓ-ÌÂ‚Ì˚È ÔÛ˜ÓÍ Ì‡ıÓ‰ËÚÒfl ̇ ‡ÒÒÚÓflÌËË 7–17 ÏÏ ÓÚ ˆÂÏÂÌÚÌÓ-˝Ï‡ÎÂ‚Ó„Ó ÒÓ‰ËÌÂÌËfl (ñùë) ÔÂÏÓÎflÓ‚ Ë ÏÓÎflÓ‚
‚ÂıÌÂÈ ˜ÂβÒÚË, ˜ÚÓ Á‡‚ËÒËÚ ÓÚ ‚˚ÒÓÚ˚ Ì·‡ (˜ÂÏ ‚˚¯Â Ì·Ó, ÚÂÏ ·Óθ¯Â ‡ÒÒÚÓflÌË ‰Ó Ô͇ۘ). ëӄ·ÒÌÓ
ÚÂÏ Ê ‡‚ÚÓ‡Ï, Ò‰Ì ‡ÒÒÚÓflÌË ÓÚ ñùë ‰Ó ÒÓÒÛ‰ËÒÚÓ-ÌÂ‚ÌÓ„Ó Ô͇ۘ ÒÓÒÚ‡‚ÎflÂÚ 12 ÏÏ (ËÒ. 5.3).
ê‡ÒÒÚÓflÌË ÓÚ ñùë ÔÂ‚Ó„Ó ÏÓÎfl‡ ‰Ó ÒÓÒÛ‰ËÒÚÓ-ÌÂ‚ÌÓ„Ó Ô͇ۘ Á‡‚ËÒËÚ Ú‡ÍÊ ÓÚ ÔÓ· Ë Û ÏÛʘËÌ ‚ Ò‰ÌÂÏ ÒÓÒ-
26
ис. 5.4. &онорский участок в области неба. онтур
трансплантата очерчен скальпелем №15
íÓ΢Ë̇ Ú‡ÌÒÔ·ÌÚ‡Ú‡ ‰ÓÎÊ̇ ÒÓÒÚ‡‚ÎflÚ¸ ÓÍÓÎÓ 1,5 ÏÏ,
˜ÚÓ ÔËÏÂÌÓ ÒÓÓÚ‚ÂÚÒÚ‚ÛÂÚ ‰ÎËÌ ÒÍÓÒ‡ ÎÂÁ‚Ëfl ‹ 15.
èË ‚˚‰ÂÎÂÌËË Ú‡ÌÒÔ·ÌÚ‡Ú‡ ÎÂÁ‚Ë ‰ÂÊ‡Ú Ô‡‡ÎÎÂθÌÓ ÔÓ‚ÂıÌÓÒÚË ‰ÂÒÌ˚, ‡ Ì ‰ÎËÌÌÓÈ ÓÒË ÁÛ·‡.
Ç ÔÂ‰ÌÂÏ ÓÚ‰ÂΠ̷‡ ÔÓ‰ ÒÎËÁËÒÚÓÈ ÔÂ‰ÌËı ÓÚ‰ÂÎÓ‚ ÎÂÊËÚ ÊËÓ‚‡fl ÍÎÂÚ˜‡Ú͇ (Orban, 1996), ÍÓÚÓÛ˛ ÌÂ
ÒΉÛÂÚ ‚Íβ˜‡Ú¸ ‚ Ú‡ÌÒÔ·ÌÚ‡Ú. ÖÒÎË ˝ÚÓ ÔÓËÁÓ¯ÎÓ, ÚÓ
 ËÒÒÂ͇˛Ú Ò͇θÔÂÎÂÏ. í‡ÌÒÔ·ÌÚ‡Ú ‚˚‰ÂÎfl˛Ú ‡Ú‡‚χÚ˘ÌÓ, Â„Ó ÒÓ‰ËÌËÚÂθÌÓÚ͇Ì̇fl ÔÓ‚ÂıÌÓÒÚ¸ ‰ÓÎÊ̇
·˚Ú¸ „·‰ÍÓÈ Ë Ó‚ÌÓÈ. é˜Â̸ ‚‡ÊÌÓ ‰Ó·Ë‚‡Ú¸Òfl ‡‚ÌÓÏÂÌÓÈ ÚÓ΢ËÌ˚ Ú‡ÌÒÔ·ÌÚ‡Ú‡ (ËÒ. 5.5 Ë 5.6), ÔÓÒÍÓθÍÛ
˝ÚÓ ÔÓÁ‚ÓÎflÂÚ ÏËÌËÏËÁËÓ‚‡Ú¸ «ÏÂÚ‚Ó» ÔÓÒÚ‡ÌÒÚ‚Ó
ÏÂÊ‰Û ˆËÔËÂÌÚÌ˚Ï Û˜‡ÒÚÍÓÏ Ë Ú‡ÌÒÔ·ÌÚ‡ÚÓÏ Ë ÒÔÓÒÓ·ÒÚ‚ÛÂÚ Â„Ó ·˚ÒÚÓÈ ‚‡ÒÍÛÎflËÁ‡ˆËË.
îËÍÒ‡ˆËfl Ú‡ÌÒÔ·ÌÚ‡Ú‡
ис. 5.7. *рансплантат фиксирован тремя отдельными узловыми
швами 5-0. 3осле завершения этого этапа натягивание губы
не должно вызывать смещение трансплантата
Ç˚·Ó ÏÂÊ‰Û ÂÁÓ·ËÛÂÏ˚Ï Ë ÌÂÂÁÓ·ËÛÂÏ˚Ï
¯Ó‚Ì˚ÏË Ï‡ÚÂˇ·ÏË Á‡‚ËÒËÚ ÓÚ Î˘Ì˚ı Ô‰ÔÓ˜ÚÂÌËÈ
ıËÛ„‡. òÂÎÍ Ó·Î‡‰‡ÂÚ ıÓÓ¯ËÏË Ï‡ÌËÔÛÎflˆËÓÌÌ˚ÏË
ис. 5.8. (оризонтальный компрессионный шов
ис. 5.5. *рансплантат из области неба
ис. 5.6. *рансплантат имеет равномерную толщину (1,5 мм)
ис. 5.9. 3омимо четырех отдельных узловых швов наложены два
компрессионные шва (коронально проведены через межзубный
промежуток, а апикально – фиксированы к надкостнице)
(лава 5. )вободный десневой трансплантат
27
ı‡‡ÍÚÂËÒÚË͇ÏË, ÌÓ ‰ÓÎÊÂÌ ·˚Ú¸ Û‰‡ÎÂÌ Ì ÔÓÁ‰ÌÂÂ,
˜ÂÏ ˜ÂÂÁ Ó‰ÌÛ Ì‰Âβ. ïÓÏËÓ‚‡ÌÌ˚È ÍÂÚ„ÛÚ ÂÁÓ·ËÛÂÚÒfl ˜ÂÂÁ Ó‰ÌÛ-‰‚ Ì‰ÂÎË. í‡ÌÒÔ·ÌÚ‡Ú Ó·˚˜ÌÓ ÙËÍÒËÛ˛Ú ÓÚ‰ÂθÌ˚ÏË ÛÁÎÓ‚˚ÏË ¯‚‡ÏË Ò Ï‰ˇθÌÓÈ Ë
‰ËÒڇθÌÓÈ ÒÚÓÓÌ˚ (ËÒ. 5.7). ÑÎfl ÔËʇÚËfl Ú‡ÌÒÔ·ÌÚ‡Ú‡ Í ÎÓÊÛ Ì‡Í·‰˚‚‡˛Ú „ÓËÁÓÌڇθÌ˚È ËÎË ÍÂÒÚÓÓ·‡ÁÌ˚È ¯Ó‚ ÔÓ‚Âı ÌÂ„Ó (ËÒ. 5.8 Ë 5.9). ùÚÓ ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ÛÏÂ̸¯ÂÌ˲ ‡ÁÏÂ‡ Ò„ÛÒÚ͇ ÔÓ‰ Ú‡ÌÒÔ·ÌÚ‡ÚÓÏ,
ÛÎÛ˜¯‡ÂÚ Â„Ó ‡‰‡ÔÚ‡ˆË˛ Ë ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ·ÓΠ·˚ÒÚÓÈ
‚‡ÒÍÛÎflËÁ‡ˆËË.
èÓÒΠۯ˂‡ÌËfl Ú‡ÌÒÔ·ÌÚ‡Ú ÔËÊËχ˛Ú ԇθˆ‡ÏË ˜ÂÂÁ ‚·ÊÌÛ˛ Ò‡ÎÙÂÚÍÛ ‚ Ú˜ÂÌË ÌÂÒÍÓθÍËı ÏËÌÛÚ ‰Îfl
ÛÏÂ̸¯ÂÌËfl „ÂχÚÓÏ˚. ᇠ˝ÚÓ ‚ÂÏfl ÙË·ËÌÓ„ÂÌ Ô·ÁÏ˚
Ô‚‡˘‡ÂÚÒfl ‚ ÙË·ËÌ, ÍÓÚÓ˚È ÔËÍÎÂË‚‡ÂÚ Ú‡ÌÒÔ·ÌÚ‡Ú Í ÎÓÊÛ Ë ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ‚‡ÒÚ‡Ì˲ ‚ ÌÂ„Ó ÒÓÒÛ‰Ó‚. óÂÂÁ ÙË·ËÌÓ‚Û˛ ÔÎÂÌÍÛ ÔÓËÒıÓ‰ËÚ ‰ËÙÙÛÁËfl ÍËÒÎÓÓ‰‡
Ë ÔËÚ‡ÚÂθÌ˚ı ‚¢ÂÒÚ‚ Í Ú‡ÌÒÔ·ÌÚ‡ÚÛ, ‡ Ú‡ÍÊ ÔÓ‰ÛÍÚÓ‚ Ó·ÏÂ̇ ‚¢ÂÒÚ‚ ‚ Ó·‡ÚÌÓÏ Ì‡Ô‡‚ÎÂÌËË (Foman,
1960). èÓ‚ÂËÚ¸ ÙËÍÒ‡ˆË˛ Ú‡ÌÒÔ·ÌÚ‡Ú‡ ÏÓÊÌÓ, Ò΄͇
ÔÓÚflÌÛ‚ Á‡ „Û·Û: ÔË Â„Ó ÒÏ¢ÂÌËË ÙËÍÒ‡ˆËfl ̇‰ÂÍ‚‡Ú̇.
ÑÎfl Á‡˘ËÚ˚ ˆËÔËÂÌÚÌÓ„Ó Û˜‡ÒÚ͇ ̇Í·‰˚‚‡˛Ú Ô‡Ó‰ÓÌÚÓÎӄ˘ÂÒÍÛ˛ ÔÓ‚flÁÍÛ, ÍÓÚÓ‡fl Ì ‰ÓÎÊ̇ ÍÓÌÚ‡ÍÚËÓ‚‡Ú¸ Ò ÓÍÍβÁËÓÌÌÓÈ ÔÓ‚ÂıÌÓÒÚ¸˛, ‚ ÔÓÚË‚ÌÓÏ ÒÎÛ˜‡Â Ó̇ ·Û‰ÂÚ ÛÚ‡˜Â̇ ‚ Ú˜ÂÌË ÌÂÒÍÓθÍËı ˜‡ÒÓ‚.
ÑÓÌÓÒÍËÈ Û˜‡ÒÚÓÍ
Ç ‰ÓÌÓÒÍÓÏ Û˜‡ÒÚÍ ÔÓ‚flÁÍÛ Ì ̇Í·‰˚‚‡˛Ú, ‰‡‚‡fl
ÂÏÛ „‡ÌÛÎËÓ‚‡Ú¸ (ËÒ. 5.10 Ë 5.11). èË ÔÓÎÛ˜ÂÌËË
Ú‡ÌÒÔ·ÌÚ‡Ú‡ ·Óθ¯Ó„Ó ‡ÁÏÂ‡ Ë ÚÓ΢ËÌ˚ ‰Îfl ̇‰ÂÊÌÓ„Ó „ÂÏÓÒÚ‡Á‡ Ë ÍÓÏÙÓÚ‡ Ô‡ˆËÂÌÚ‡ ‰ÓÌÓÒÍËÈ Û˜‡ÒÚÓÍ
ÏÓÊÌÓ Á‡Í˚Ú¸ ÍÛÒÓ˜ÍÓÏ ëÂ‰ÊËÒÂÎ (ËÎË ÑÊÂÎÙÓ‡Ï),
ÍÓÚÓ˚È ÙËÍÒËÛ˛Ú ÍÂÒÚÓÓ·‡ÁÌ˚Ï ¯‚ÓÏ Ë ÌÂÒÍÓθÍËÏË Í‡ÔÎflÏË Ï‰ˈËÌÒÍÓ„Ó ˆË‡Ì‡ÍË·ÚÌÓ„Ó ÍÎÂfl.
ис. 5.10. #ид донорского участка во время операции
28
ис. 5.11. #ид донорского участка через одну неделю после операции
èËÊË‚ÎÂÌË Ú‡ÌÒÔ·ÌÚ‡Ú‡
ÑÓ ‚‡ÒÍÛÎflËÁ‡ˆËË Ú‡ÌÒÔ·ÌÚ‡Ú‡ (24–48 ˜) Â„Ó ÔËÚ‡ÌË ÓÒÛ˘ÂÒÚ‚ÎflÂÚÒfl Á‡ Ò˜ÂÚ ‰ËÙÙÛÁËË ËÁ ˆËÔËÂÌÚÌÓ„Ó
Û˜‡ÒÚ͇. ùÚÓÚ ÔÓˆÂÒÒ Ë̇˜Â ̇Á˚‚‡ÂÚÒfl Ô·ÁχÚ˘ÂÒÍÓÈ
ˆËÍÛÎflˆËÂÈ Ë ÔÓËÒıÓ‰ËÚ ˜ÂÂÁ ÙË·ËÌÓ‚˚È Ò„ÛÒÚÓÍ
(Foman, 1960; Reese Ë Stark, 1961). 燘‡ÎÓ ÔÓÎËÙÂ‡ˆËË
͇ÔËÎÎflÓ‚ ÏÓÊÌÓ Ó·Ì‡ÛÊËÚ¸ Í ÍÓÌˆÛ ÔÂ‚Ó„Ó ‰Ìfl ÔÓÒΠÓÔÂ‡ˆËË, ‡ ÍÓ ‚ÚÓÓÏÛ ËÎË ÚÂÚ¸ÂÏÛ ‰Ì˛ ͇ÔËÎÎfl˚
‰ÓÒÚË„‡˛Ú Ú‡ÌÒÔ·ÌÚ‡Ú‡, Ô˘ÂÏ ÌÂÍÓÚÓ˚ ËÁ ÌËı Ó·‡ÁÛ˛Ú ‡Ì‡ÒÚÓÏÓÁ˚ Ò ÒÓÒÛ‰‡ÏË ÔÓÒΉ̄Ó. íÂÏ Ì ÏÂÌÂÂ, ‡‰ÂÍ‚‡ÚÌÓ ÍÓ‚ÓÒ̇·ÊÂÌË ‚ÓÒÒڇ̇‚ÎË‚‡ÂÚÒfl
ÔË·ÎËÁËÚÂθÌÓ Ì‡ ‚ÓÒ¸Ï˚ ÒÛÚÍË ÔÓÒΠÚ‡ÌÒÔ·ÌÚ‡ˆËË
(Davis Ë Traut, 1925). ë ˜ÂÚ‚ÂÚ˚ı ÔÓ ‰ÂÒflÚ˚ ÒÛÚÍË ÔÓÒÎÂ
ÓÔÂ‡ˆËË ÔÓËÒıÓ‰ËÚ Ó·˙‰ËÌÂÌË ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓ„Ó Ï‡ÚËÍÒ‡ Ú‡ÌÒÔ·ÌÚ‡Ú‡ Ë ˆËÔËÂÌÚÌÓ„Ó Û˜‡ÒÚ͇,
˜ÚÓ ÔË‚Ó‰ËÚ ÍÓ ‚ÚÓ˘ÌÓÈ ÂÚ‡ÍˆËË Ú‡ÌÒÔ·ÌÚ‡Ú‡ ‰Ó
33 % Â„Ó Ó·˙Âχ (Egli et al., 1975) (ËÒ. 5.12).
ис. 5.12. #ид через два года после вмешательства. 3олучена
широкая зона прикрепленной кератинизированной десны в
области зуба 41
ÇÓÁÏÓÊÌ˚Â ÓÒÎÓÊÌÂÌËfl
èÓ‰‚ËÊÌÓÒÚ¸ Ú‡ÌÒÔ·ÌÚ‡Ú‡
ç‡Ë·ÓΠ˜‡ÒÚ˚Ï ÓÒÎÓÊÌÂÌËÂÏ ÓÔÂ‡ˆËË fl‚ÎflÂÚÒfl
ÍÓ‚ÓÚ˜ÂÌË ËÁ ‰ÓÌÓÒÍÓ„Ó Û˜‡ÒÚ͇ ‚Ó ‚ÂÏfl ‚ϯ‡ÚÂθÒÚ‚‡ ËÎË ÔÓÒÎÂ Â„Ó Á‡‚Â¯ÂÌËfl.
èÓ‰‚ËÊÌÓÒÚ¸ Ú‡ÌÒÔ·ÌÚ‡Ú‡ ÔÓÒΠÔËÊË‚ÎÂÌËfl ‚ÓÁÌË͇ÂÚ ‚ ÂÁÛθڇÚ ÌÂÔ‡‚ËθÌÓ„Ó ÔÂÔ‡ËÓ‚‡ÌËfl ˆËÔËÂÌÚÌÓ„Ó Û˜‡ÒÚ͇, ‡ ËÏÂÌÌÓ ÒÓı‡ÌÂÌËfl ̇ ̇‰ÍÓÒÚÌˈÂ
ÔÓ‰‚ËÊÌ˚ı Ú͇ÌÂÈ ËÎË Ï˚¯Â˜Ì˚ı ‚ÓÎÓÍÓÌ. ÑÎfl ¯ÂÌËfl ˝ÚÓÈ ÔÓ·ÎÂÏ˚ ÌÂÓ·ıÓ‰ËÏÓÒÚ¸ ‚ ÔÓ‚ÚÓÌÓÈ Ú‡ÌÒÔ·ÌÚ‡ˆËË ÓÚÒÛÚÒÚ‚ÛÂÚ. ÑÓÒÚ‡ÚÓ˜ÌÓ ‡Ò˘ÂÔËÚ¸ ÎÓÒÍÛÚ ‚
ӷ·ÒÚË Ô‰˚‰Û˘Â„Ó ‚ϯ‡ÚÂθÒÚ‚‡, Û‰‡ÎËÚ¸ ÔÓ‰‚ËÊÌ˚ Ú͇ÌË Ò Ì‡‰ÍÓÒÚÌˈ˚ Ë Ì‡ÎÓÊËÚ¸ ¯‚˚.
äÓ‚ÓÚ˜ÂÌË ‚Ó ‚ÂÏfl ÓÔÂ‡ˆËË
èË ÔÓ‚ÂʉÂÌËË Ì·ÌÓ„Ó ÒÓÒÛ‰ËÒÚÓ„Ó Ô͇ۘ ÌÂÓ·ıÓ‰ËÏÓ Ì‡ÎÓÊËÚ¸ Ó‰ËÌ ËÎË ÌÂÒÍÓθÍÓ ÍÓÏÔÂÒÒËÓÌÌ˚ı ¯‚Ó‚
ÔÓÍÒËχθÌ ÍÓ‚ÓÚÓ˜‡˘Â„Ó Û˜‡ÒÚ͇, ˜ÚÓ ÔÓÏÓ„‡ÂÚ
ÛÏÂ̸¯ËÚ¸ ËÎË ÓÒÚ‡ÌÓ‚ËÚ¸ ÍÓ‚ÓÚ˜ÂÌË (ËÒ. 5.13). ò‚˚
̇Í·‰˚‚‡˛Ú ‚‰Óθ ÎËÌËË, ÒÓ‰ËÌfl˛˘ÂÈ ÍÓ‚ÓÚÓ˜‡˘ËÈ
Û˜‡ÒÚÓÍ Ò ÔÓÂ͈ËÂÈ Ì·ÌÓ„Ó ÓÚ‚ÂÒÚËfl. (ëÓÒÛ‰ËÒÚÓ-ÌÂ‚Ì˚È ÔÛ˜ÓÍ ÎÂÊËÚ ‚ ·ÓÓÁ‰Â, „ÎÛ·Ë̇ ÍÓÚÓÓÈ ‚‡¸ËÛÂÚÒfl,
ÔÓ˝ÚÓÏÛ ÔÂ‚flÁ‡Ú¸ „Ó, Í‡Í ÔÓ͇Á‡ÌÓ Ì‡ ËÒÛÌÍÂ, Ì Ô‰ÒÚ‡‚ÎflÂÚÒfl ‚ÓÁÏÓÊÌ˚Ï. ëÏ˚ÒÎ Ôӯ˂‡ÌËfl Á‡Íβ˜‡ÂÚÒfl
‚ ÒÓÁ‰‡ÌËË ÍÓÏÔÂÒÒËË Ú͇ÌÂÈ Ì‡‰ ÒÓÒÛ‰ÓÏ. èÓ˝ÚÓÏÛ ¯‚˚
Ë Ì‡Á˚‚‡˛ÚÒfl ÍÓÏÔÂÒÒËÓÌÌ˚ÏË. – èËϘ. ÔÂ.)
ÄãúíÖêçÄíàÇçÄü åÖíéÑàäÄ: èÖêÖëÄÑäÄ
ëÇéÅéÑçéÉé ëéÖÑàçàíÖãúçéíäÄççéÉé
íêÄçëèãÄçíÄíÄ
ÑÎfl Û‚Â΢ÂÌËfl ÁÓÌ˚ ÍÂ‡ÚËÌËÁËÓ‚‡ÌÌÓÈ ÔËÍÂÔÎÂÌÌÓÈ ‰ÂÒÌ˚ ÏÓÊÌÓ ÔÂÂÒ‡‰ËÚ¸ Ò‚Ó·Ó‰Ì˚È ÒÓ‰ËÌËÚÂθ-
éÒÚ‡ÌÓ‚Í ÍÓ‚ÓÚ˜ÂÌËfl ÒÔÓÒÓ·ÒÚ‚ÛÂÚ Ó·Í‡Î˚‚‡ÌËÂ
ÍÓ‚ÓÚÓ˜‡˘Â„Ó Û˜‡ÒÚ͇ Ì·Óθ¯ËÏ Ó·˙ÂÏÓÏ 2%-ÌÓ„Ó
ÎˉÓ͇Ë̇ Ò ‡‰Â̇ÎËÌÓÏ (1 : 50 000). èÓÒΠÙËÍÒ‡ˆËË
Ú‡ÌÒÔ·ÌÚ‡Ú‡ ‚ ‰ÓÌÓÒÍËÈ Û˜‡ÒÚÓÍ ÛÍ·‰˚‚‡˛Ú ÍÛÒÓ˜ÂÍ
ÑÊÂθÙÓ‡Ï (ËÎË ëÂ‰ÊËÒÂÎ) Ë ÙËÍÒËÛ˛Ú Â„Ó ÍÂÒÚÓÓ·‡ÁÌ˚Ï ¯‚ÓÏ. èÓÒΠ˝ÚÓ„Ó ÓÒÛ˘ÂÒÚ‚Îfl˛Ú ԇθˆÂ‚ÓÂ
ÔËʇÚË ˜ÂÂÁ ‚·ÊÌÛ˛ Ò‡ÎÙÂÚÍÛ ‚ Ú˜ÂÌË 5–10 ÏËÌ
Ë Ì‡ÌÓÒflÚ ÌÂÒÍÓθÍÓ Í‡ÔÂθ ωˈËÌÒÍÓ„Ó ˆË‡Ì‡ÍË·ÚÌÓ„Ó ÍÎÂfl.
֢ ӉÌËÏ ÒÔÓÒÓ·ÓÏ ÓÒÚ‡ÌÓ‚ÍË ÍÓ‚ÓÚ˜ÂÌËfl fl‚ÎflÂÚÒfl
ËÒÔÓθÁÓ‚‡ÌË ˝ÎÂÍÚÓÍÓ‡„ÛÎflÚÓ‡. Ç Í‡˜ÂÒÚ‚Â ÔÓÒΉÌÂ„Ó Ò‰ÒÚ‚‡ ÌÂÍÓÚÓ˚ ‡‚ÚÓ˚ Ô‰·„‡˛Ú ÓÚÒÎÓÈÍÛ
ÔÓÎÌÓÒÎÓÈÌÓ„Ó ÎÓÒÍÛÚ‡ ‰Îfl ‚ËÁÛ‡ÎËÁ‡ˆËË ÒÓÒÛ‰Ó‚ Ë Ëı
ÎË„ËÓ‚‡ÌËfl (Hollingshead, 1968).
äÓ‚ÓÚ˜ÂÌË ÔÓÒΠÓÔÂ‡ˆËË
ÄÚÂËfl
ис. 5.13. омпрессионный шов в проекции небной артерии
èË ‡Á‚ËÚËË ÍÓ‚ÓÚ˜ÂÌËfl ÔÓÒΠÓÔÂ‡ˆËË ÌÂÓ·ıÓ‰ËÏÓ
ÛÒÔÓÍÓËÚ¸ Ô‡ˆËÂÌÚ‡ Ë ÔÓÔÓÒËÚ¸ Â„Ó ÔËʇڸ ÒÏÓ˜ÂÌÌ˚È
Ô‡ÍÂÚËÍ ˜‡fl Í ÌÂ·Û Ì‡ 10–15 ÏËÌ. èË ÓÚÒÛÚÒÚ‚ËË ˝ÙÙÂÍÚ‡
Ë ÔÓ‰ÓÎÊÂÌËË ÍÓ‚ÓÚ˜ÂÌËfl Ô‡ˆËÂÌÚ‡ ÔÓÒflÚ ‚ÂÌÛÚ¸Òfl
‚ ÍÎËÌËÍÛ. ÇÓ ‚ÂÏfl ˝ÚÓ„Ó ‚ËÁËÚ‡ ÔÓ‚Ó‰flÚ ÏÂÓÔËflÚËfl,
ÓÔËÒ‡ÌÌ˚ ‚˚¯Â (ËÌÙËθÚ‡ˆËfl 2%-Ì˚Ï ÎˉÓ͇ËÌÓÏ Ò
‡‰Â̇ÎËÌÓÏ (1 : 50 000), ÍÓÏÔÂÒÒËÓÌÌ˚ ¯‚˚, ÑÊÂθÙÓ‡Ï Ë Ú.‰.), ËÎË Ì‡Ô‡‚Îfl˛Ú Ô‡ˆËÂÌÚ‡ ‚ ÒÚ‡ˆËÓ̇.
ÑÛ„ËÂ ÓÒÎÓÊÌÂÌËfl
éÚÂÍ Ë „ÂχÚÓχ
Ç ˆËÔËÂÌÚÌÓÏ Û˜‡ÒÚÍ ÏÓ„ÛÚ Ó·‡ÁÓ‚‡Ú¸Òfl ÓÚÂÍ Ë „ÂχÚÓχ. ÑÎfl Ô‰ÛÔÂʉÂÌËfl ˝ÚËı ÓÒÎÓÊÌÂÌËÈ Ì‡Á̇˜‡˛Ú ÔÓÚË‚Ó‚ÓÒÔ‡ÎËÚÂθÌ˚ Ò‰ÒÚ‚‡, ıÓÎÓ‰ ‚ Ú˜ÂÌËÂ
24 ˜ ÔÓÒΠÓÔÂ‡ˆËË, ‡ Á‡ÚÂÏ ÚÂÔÎÓ.
ис. 5.14. Устранение рецессии с помощью свободного десневого
трансплантата
(лава 5. )вободный десневой трансплантат
29
ÌÓÚ͇ÌÌ˚È Ú‡ÌÒÔ·ÌÚ‡Ú (Edel, 1974). ÑÂÒ̇ ÓÒÚ‡ÂÚÒfl
ÒÚ‡·ËθÌÓÈ ‚ Ú˜ÂÌË ¯ÂÒÚË ÏÂÒflˆÂ‚, ‡ ÂÚ‡ÍˆËfl ÒÓÒÚ‡‚ÎflÂÚ ‚ Ò‰ÌÂÏ 28 %. èÓÎ̇fl ˝ÔËÚÂÎËÁ‡ˆËfl ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÓÈ ÔÓ‚ÂıÌÓÒÚË ÔÓËÒıÓ‰ËÚ ˜ÂÂÁ ‰‚ Ì‰ÂÎË, ‡ ËÌÚ„‡ˆËfl Ú‡ÌÒÔ·ÌÚ‡Ú‡ Ò ÓÍÛʇ˛˘ËÏË
Ú͇ÌflÏË – ˜ÂÂÁ ¯ÂÒÚ¸ ̉Âθ.
ìëíêÄçÖçàÖ êÖñÖëëàâ ë èéåéôúû
ëÇéÅéÑçéÉé ÑÖëçÖÇéÉé íêÄçëèãÄçíÄíÄ
åÂÚÓ‰Ë͇
ис. 5.15. 3одготовлено обширное реципиентное ложе, что
позволяет компенсировать неваскуляризованные участки (корни
зубов) и устранить тягу уздечек
ÑÎfl ÛÒÚ‡ÌÂÌËfl ˆÂÒÒËË Ú·ÛÂÚÒfl ÚÓÚ Ê ̇·Ó ËÌÒÚÛÏÂÌÚÓ‚, ˜ÚÓ Ë ‰Îfl ‡Ò¯ËÂÌËfl ÁÓÌ˚ ÍÂ‡ÚËÌËÁËÓ‚‡ÌÌÓÈ
ÔËÍÂÔÎÂÌÌÓÈ ‰ÂÒÌ˚. åÂÚÓ‰Ë͇ ËÏÂÂÚ ÌÂÒÍÓθÍÓ ÓÒÓ·ÂÌÌÓÒÚÂÈ, ÔÂ˜ËÒÎÂÌÌ˚ı ÌËÊ (ËÒ. Ò 5.14 ÔÓ 5.17).
èÓ‰„ÓÚӂ͇ ˆËÔËÂÌÚÌÓ„Ó Û˜‡ÒÚ͇
èÓÒΠ‡ÌÂÒÚÂÁËË ÔÓ‚Ó‰flÚ Ú˘‡ÚÂθÌÓ ۉ‡ÎÂÌË ÓÚÎÓÊÂÌËÈ Ë Ò„Î‡ÊË‚‡ÌË ÔÓ‚ÂıÌÓÒÚË ÍÓÌÂÈ. çÂÓ‚ÌÓÒÚË
ÔÓ‚ÂıÌÓÒÚË Û‰‡Îfl˛Ú ËÎË ÛÏÂ̸¯‡˛Ú Ò ÔÓÏÓ˘¸˛ Û˜Ì˚ı Ë ‚‡˘‡˛˘ËıÒfl ËÌÒÚÛÏÂÌÚÓ‚.
ис. 5.16. *рансплантат фиксирован отдельными узловыми и
компрессионными швами
ë‡ÁÛ ÔÓÒΠ˝ÚÓ„Ó ÔÓÚ‡‚ÎË‚‡˛Ú ÔÓ‚ÂıÌÓÒÚË ÍÓÌÂÈ
ÁÛ·Ó‚ ̇Ò˚˘ÂÌÌ˚Ï ‡ÒÚ‚ÓÓÏ ÎËÏÓÌÌÓÈ ÍËÒÎÓÚ˚ ‚ Ú˜ÂÌË 5 ÏËÌ (Miller, 1985). Ç Í‡˜ÂÒÚ‚Â ‡Î¸ÚÂ̇ÚË‚˚ ÏÓÊÌÓ
ËÒÔÓθÁÓ‚‡Ú¸ ‡ÔÔÎË͇ˆË˛ ÚÂÚ‡ˆËÍÎË̇ „ˉÓıÎÓˉ‡
(50–100 Ï„/ÏÎ) ‚ Ú˜ÂÌË 3–5 ÏËÌ. èÓÏËÏÓ ÔÓ˜Â„Ó ˝ÚÓ
ÔË‚Ó‰ËÚ Í Ó·Ì‡ÊÂÌ˲ ‰ÂÌÚËÌÌ˚ı ͇̇θˆÂ‚ (Polson et
al., 1984) Ë Û‰‡ÎÂÌ˲ ÒχÁ‡ÌÌÓ„Ó ÒÎÓfl, ÔÂÔflÚÒÚ‚Û˛˘Â„Ó
ÔËÍÂÔÎÂÌ˲ ÒÓ‰ËÌËÚÂθÌÓÈ Ú͇ÌË Í ÔÓ‚ÂıÌÓÒÚË ÍÓÌfl (Isik et al., 2000). é·Î‡ÒÚ¸ ‚ϯ‡ÚÂθÒÚ‚‡ Ú˘‡ÚÂθÌÓ
ÔÓÏ˚‚‡˛Ú, ÔÓÒΠ˜Â„Ó ÔÓËÁ‚Ó‰flÚ „ÓËÁÓÌڇθÌ˚ ‡ÁÂÁ˚ ̇ ÛÓ‚Ì ñùë, ÒÓı‡Ìflfl ÒÓÒÓ˜ÍË.
Ñ‚‡ ‚ÂÚË͇θÌ˚ ‡ÁÂÁ‡ ÔÓËÁ‚Ó‰flÚ Ì‡ ‡ÒÒÚÓflÌËË ÌÂ
ÏÂÌ ӉÌÓ„Ó ÁÛ·‡ ÓÚ Ó·Î‡ÒÚË ˆÂÒÒËË. ùÚÓ ˜ÂÁ‚˚˜‡ÈÌÓ ‚‡ÊÌÓ, ÔÓÒÍÓθÍÛ ÓÚÒÛÚÒÚ‚Ë ‡‰ÂÍ‚‡ÚÌÓ„Ó ÍÓ‚ÓÒ̇·ÊÂÌËfl ÒÓ ÒÚÓÓÌ˚ ˆËÔËÂÌÚÌÓ„Ó Û˜‡ÒÚ͇ Ô˂‰ÂÚ Í
ÌÂÍÓÁÛ ‰ÂÒÌÂ‚Ó„Ó Ú‡ÌÒÔ·ÌÚ‡Ú‡. êÂÍÓÏẨÛÂÚÒfl ÒÓÁ‰‡‚‡Ú¸ ÔËÌËχ˛˘Â ÎÓÊ χÍÒËχθÌÓ„Ó ‡ÁÏÂ‡ Ò
Û˜ÂÚÓÏ ‡Ì‡ÚÓÏ˘ÂÒÍËı Ó„‡Ì˘ÂÌËÈ, Ӊ̇ÍÓ Â„Ó ‡ÔË͇θ̇fl „‡Ìˈ‡ ‰ÓÎÊ̇ ̇ıÓ‰ËÚ¸Òfl ̇ ‡ÒÒÚÓflÌËË ÌÂ
ÏÂÌ 3 ÏÏ ‡ÔË͇θÌ Í‡fl ӷ̇ÊÂÌÌÓÈ ÔÓ‚ÂıÌÓÒÚË
ÁÛ·‡. óÂÏ ¯Ë ÎÓÊ Ú‡ÌÒÔ·ÌÚ‡Ú‡, ÚÂÏ ‚˚¯Â ‚ÂÓflÚÌÓÒÚ¸ ÛÒÔÂı‡ ‚ϯ‡ÚÂθÒÚ‚‡.
èËÊË‚ÎÂÌË Ú‡ÌÒÔ·ÌÚ‡Ú‡
ис. 5.17. Область вмешательства через один год после операции.
ецессия в области зуба 41 устранена, увеличена зона
кератинизированной прикрепленной десны, устранено натяжение
уздечек
30
Ç Ó·Î‡ÒÚË ÓÔÂ‡ˆËË ÔÓËÒıÓ‰flÚ ÓÔËÒ‡ÌÌ˚ ‚˚¯Â ÔÓˆÂÒÒ˚, ‡ Ú‡ÍÊ ̇ÔÓÎÁ‡ÌË ÔËÍÂÔÎÂÌËfl (Matter, 1980).
ùÚÓÚ ÙÂÌÓÏÂÌ ÏÓÊÌÓ Ì‡·Î˛‰‡Ú¸ ‚ ÔÂËÓ‰ Ò ÔÂ‚Ó„Ó ÏÂÒflˆ‡ ‰Ó ÍÓ̈‡ ÔÂ‚Ó„Ó „Ó‰‡ ÔÓÒΠÓÔÂ‡ˆËË. ᇠÛ͇-
Á‡ÌÌ˚È ÒÓÍ ÔËÍÂÔÎÂÌË ‚ Ò‰ÌÂÏ ÒÏ¢‡ÂÚÒfl ̇
1,2 ÏÏ ÍÓÓ̇θÌ (Matter, 1980).
ãàíÖêÄíìêÄ
Bjorn, H. (1963) Free transplantation of gingival propria. Svensk Tandlakare Tidskrift
22, 684–685.
Breault, L.G., Fowler, E.B., & Billman, M.A. (1999) Retained free gingival graft rugae:
A 9-year case report. Journal of Periodontology 70, 438–440.
Cohen, E.S. (1994) Atlas of Cosmetic and Reconstructive Periodontal Surgery.
Philadelphia: Lea and Febiger.
Davis, J.S., & Traut, H.F. (1925) Origin and development of the blood supply of wholethickness skin grafts. Annals of Surgery 82, 871–879.
Dordick, B., Coslet, J.G., & Seibert, J.S. (1976) Clinical evaluation of free autogenous
gingival grafts placed on alveolar bone. Journal of Periodontology 41, 559–567.
Edel, A. (1974) Clinical evaluation of free connective tissue grafts used to increase the
width of keratinized tissue. Journal of Clinical Periodontology 1, 185–196.
Egli, U., Vollmer, W., & Rateitschak, K.H. (1975) Follow-up studies of free gingival
grafts. Journal of Clinical Periodontology 2, 98–104.
Ellegaard, B., Karring, T., & Loe, H. (1974) New periodontal attachment procedure
based on retardation of epithelial migration. Journal of Clinical Periodontology 1,
75–88.
Foman, S. (1960) Cosmetic Surgery. Philadelphia: Lippincott.
Holbrook, T., & Ochsenbein, C. (1983) Complete coverage of the denuded root surface with a one stage gingival graft. International Journal of Periodontics and
Restorative Dentistry 3(3), 9–27.
Hollingshead, W.H. (1968) The Head and Neck Anatomy for Surgeons, vol. 1, 2nd edition. Hagerstown, MD: Harper & Row.
Isik, A.G., Tarim, B., Hafez, A.A., Yalcin, F.S., Onan, U., & Cox, C.F. (2000) A comparative scanning electron microscopic study on the characteristics of demineralized
dentin root surface using different tetracycline HCl concentrations and application
times. Journal of Periodontology 71, 219–225.
James, W.C., & McFall, W.T. (1978) Placement of free gingival grafts on denuded
alveolar bone. Journal of Periodontology 49, 283–290.
Matter, J. (1980) Creeping attachment of free gingival grafts: A 5-year follow-up study.
Journal of Periodontology 51, 681–685.
Miller, P.D. (1985) Root coverage using the free soft tissue autograft following citric
acid application. III. A successful and predictable procedure in areas of deep wide
recession. International Journal of Periodontics and Restorative Dentistry 5(2),
15–37.
Orban, B.J. (1996) Oral Histology and Embryology, 6th edition. Edited by H. Sicher. St.
Louis: C.V. Mosby.
Polson, A.M., Frederick, G.T., Ladenheim, S., & Hanes, P.J. (1984) The production of
a root surface smear layer by instrumentation and its removal by citric acid. Journal of Periodontology 55, 443–446.
Redman, R.S., Shapiro, B.L., & Gonlin, R.J. (1965) Measurement of normal and
reportedly malformed palatal vaults. II. Normal juvenile measurements. Journal of
Dental Research 45, 266–267.
Reese, J.D., & Stark, R.B. (1961) Principles of free skin grafting. Bulletin of New York
Academy of Medicine (Ser 2) 37, 213.
Reiser, G.M., Bruno, J.F., Mahan, P.E., & Larkin, L.H. (1996) The subepithelial connective tissue graft palatal donor site: Anatomic considerations for surgeons. International Journal of Periodontics and Restorative Dentistry 16, 131–137.
Sullivan, H., & Atkins, J. (1968) Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics 6, 121–129.
(лава 5. )вободный десневой трансплантат
31