Free Gingival Graft and Collagen Matrix Revascularization in an Enoral Open Wound Situation.

PURPOSE: Vestibuloplasty with free gingival grafting is a frequently performed surgical procedure to generate sufficient keratinized mucosa (KM) around dental implants. Avascular porcine collagen matrices (CM) have been proclaimed to be sufficient substitutes as alternatives to free gingival grafts (FGGs). However, the process of graft integration and vascularization is still incompletely understood. METHODS: In 18 patients a vestibuloplasty in the lower edentulous jaw situation was performed during implant exposure, either with FGGs from the palate or a porcine CM (mucoderm). Tissue perfusion of the soft tissue grafts was measured using laser-doppler-spectrophotometer intraoperatively and on postoperative days 2, 5, 10, 30 and between days 60 and 90. With graft perfusion expressed by oxygen saturation [SO2%], the relative amount of hemoglobin [rHb], blood flow, and velocity [AU] was detected and compared between groups and the surrounding mucosa. RESULTS: Healing was uneventful in both groups, with mature KM around dental implants after healing. Blood flow and velocity significantly increased until postoperative day 10, comparable to perfusion values of the surrounded mucosa. Intergroup comparisons revelated no significant differences concerning the flow between CM and FGGs. Oxygen saturation also significantly increased within the first 5 postoperative days in both groups. Hemoglobin content did not show any differences during the investigated period. CONCLUSIONS: The perfusion mainly progresses within the first postoperative week with only minimal further detectable alterations until the final investigation, comparable in both groups. Although integration of FGGs (revascularized) and the CM (new tissue formation) is biologically different, both transplants show comparable perfusion patterns, leading to sufficient KM.

Perioperative Management in Patients With Cleft Lip and Palate.

In cleft care, perioperative treatment strategies like ear nose and throat (ENT) diagnostics as well as postoperative antibiotics, feeding, and duration of inpatient stay are nonstandardized procedures varying between different centers. Likewise, intraoperative choice of suture materials and time of suture removal are performed inconsistently. Therefore, we wanted to collect information on protocols focusing on these topics to summarize and subsume currently approved treatment strategies of centers around the world. We ask members of international cleft centers for their respective treatment strategies and performed descriptive statistics.Absorbable suture material is used for reconstruction of the outer lip skin in 20 of 70 centers. Removal of skin sutures is conducted after 7.0 ±â€Š1.5 days. Suturing of the orbicularis oris muscle, the enoral and nasal mucosa, as well as the palatal musculature is predominantly performed with absorbable suture materials. Intraoperative antibiotic prophylaxis is applied in 82.9% of the participating centers. In contrast, 31.9% of the departments do not apply any antibiotic postoperatively. Postoperative feeding is performed in 27 centers via a nasogastric tube for 4.6 ±â€Š2.3 days on average. Mean length of postoperative inpatient stay is 4.1 ±â€Š2.6 days in children after cleft lip surgery and 4.5 ±â€Š2.7 days after cleft palate surgery. ENT consultation before surgery is routinely conducted in 52.8% of the centers and 82.9% of ENT colleagues investigate middle ear pathologies in the same operation in which cleft repair is performed.Closure of the lip skin is predominantly performed with nonabsorbable suture material followed by a suture removal after 1 week. Intraoperative antibiotic prophylaxis as well as inpatient hospital stay of 4 to 5 days in combination with oral feeding and a preoperative consultation and intraoperative cooperation with the ENT department seems to be well-proven concepts in cleft lip palate patient care. However, this analysis illustrated the variations and differing approaches in perioperative care emphasizing the need to verify perioperative management concepts in cleft surgery-preferably in the context of multicenter studies.

Collagen Matrix Vascularization in a Peri-Implant Vestibuloplasty Situation Proceeds Within the First Postoperative Week.

PURPOSE: Vestibuloplasty is a frequently performed surgical procedure to create or increase soft tissue mucosal sealing around dental restorations. Collagen matrices have exhibited comparable clinical results as free gingival grafts in the context of intraoral tissue augmentation. However, the process of matrix vascularization, the basic requirement for local healing, is incompletely understood. Therefore, this study investigated collagen matrix perfusion in a clinical intraoral setting. MATERIALS AND METHODS: In a prospective cohort study, vestibuloplasty was performed during implant exposure using prefabricated collagen matrices. Matric perfusion was determined intraoperatively and at days 2, 5, 7, 14, 30, and 90 using a laser Doppler spectrophotometer measuring oxygen saturation, relative amount of hemoglobin, blood flow, and blood velocity as primary outcome variables. These parameters were compared with perfusion of the oral mucosa surrounding the matrices. Statistical analysis was performed by applying variance and regression models. RESULTS: In 10 patients (average age, 60.9 yr), vestibuloplasty was performed exclusively in the anterior mandible. Blood flow and tissue oxygen saturation in the augmented zones markedly increased until postoperative day 5 and approximated perfusion values of the adjacent mucosa at the following 2 time points. Likewise, matrix oxygen saturation markedly increased until day 7 and subsequently converged to perfusion parameters of the surrounding mucosa at the following time points. CONCLUSION: Flow signals in incorporated collagen matrices occurred on day 2 after vestibuloplasty and further increased until days 5 to 7. Therefore, matrix perfusion mainly occurs within the first postoperative week, converging to perfusion levels of the surrounding mucosa with minimal alterations during the following course.

Osteonecrosis of the jaw in a Crohn's disease patient following a course of Bisphosphonate and Adalimumab therapy: a case report.

BACKGROUND: Bisphosphonates have a widespread indication for osteoporosis and are also applied in cancer patients with skeletal-related conditions. Bisphosphonate-associated osteonecrosis of the jaw (BRONJ) is a feared side effect which is hard to treat and often affects patient's quality of life in an extensive manner. Adalimumab (Humira®), a fully human recombinant antibody specific for tumor necrosis factor- α, is approved for treatment in patients with Inflammatory Bowel Disease like ulcerative colitis or Crohn's disease. CASE PRESENTATION: In March 2013, a 36-year-old female presented with right-sided perimandibular swelling, recurrent facial pain and exposed necrotic bone after previous extraction of tooth 47. She had the medical history of Crohn's disease for more than one decade with chronic active enterocolitis, fistula disease as well as previous oral manifestation and was currently treated with Adalimumab since September 2008. Due to steroid-induced osteoporosis, diagnosed in 2004, she received oral Bisphosphonates (Risedronate) from 2004 until 2007 followed by two infusions of Zoledronic acid in 2008 and 2009. CONCLUSION: This patient with a medical history of Crohn's disease and gastrointestinal remission under Adalimumab therapy presented with osteonecrosis of the jaw after suspended oral and intravenous Bisphosphonate therapy implicating that the biologic therapy with an anti-TNF-α antibody might promote the manifestation of osteonecrosis and compromise oral healing capacity.

Lineage-associated connexin 43 expression in bisphosphonate-exposed rat bones.

Expression of signaling proteins in bone cells depends on their embryological mesoderm-derived (e.g. tibia) or cranial neural crest (CNC)-derived (e.g. jaw) origin. Connexin 43 (Cx43) is a gap junction protein that plays an essential role in the mode of action of bisphosphonates (BP). This study aimed to investigate Cx43 expression and the influence of BP application on mesoderm- and CNC-derived bone. Using a rat model, molar extraction and tibia osteotomy with (Group 4) or without (Group 3) previous BP application was performed. Untreated (Group 1) and animals selectively treated with BPs (Group 2) served as controls. Cx43 expression was immunohistochemically determined 12 and 16 weeks postoperatively via a labeling index. Cx43 expression in CNC-derived bone was significantly higher compared with mesodermal bone. BP application decreased Cx43 expression; however, detected expression levels were still higher in jawbone (Group 2 tibia vs jaw: 5.83 ± 5.06 vs 23.52 ± 6.42; p = 0.007). During bone healing after surgical intervention (Group 3) there were no expression differences between tibia and jawbone. BP treatment prior to surgery resulted in significantly lower Cx43 expression in CNC-derived compared with tibia bone (Group 4 tibia vs jaw: 56.84 ± 15.57 vs 16.40 ± 5.66; p < 0.01). Increased Cx43 expression in jaw compared with tibia bone is in line with their embryological origins. A significant Cx43 suppression in jawbone after BP application and surgery might contribute to the selectively altered osseous turnover and development of MRONJ in CNC-derived bone.

Fluorescence-guided bone resection: A histological analysis in medication-related osteonecrosis of the jaw.

PURPOSE: Surgical treatment of medication-related osteonecrosis of the jaw (MRONJ) consists of necrotic bone removal followed by dense mucosal closure. Fluorescence-guided surgery has become a promising tool to intraoperatively distinguish between healthy and necrotic bone. Until now, there has been a lack of histopathological studies correlating the intraoperative fluorescence situation to histopathological analyses of the respective bone areas in order to further validate this method. MATERIALS AND METHODS: Histopathological sections from intraoperatively detected fluorescence- and non-fluorescence-labeled bone were analyzed detecting osteocyte and collagen content, RANK(L) and TRAP expression as well as proportion of immature bone regeneration. Samples were compared with viable-looking bone areas according to the intraoperative clinical situation. RESULTS: Staining revealed a significant decrease of osteocytes and collagen type-I fibers in necrotic, non-fluorescing areas compared to fluorescing bone (R/RGB [%]: 0.56 ± 0.38 (fluorescence positive) vs. 3.18 ± 2.22 (fluorescence negative), p = 0.041). Furthermore, the number of osteocytes was higher in fluorescing, clinically viable bone samples (cell/mm2: 151.26 ± 95.77 (fluorescence positive) vs. 0.56 ± 0.38 (fluorescence negative), p = 0.028). Additionally, the amount of immature bone was substantially increased in luminescent jaw bone (proportion of red [%]: 6.78 ± 7.00 (fluorescence positive) vs. 2.24 ± 1.36 (fluorescence negative), p = 0.442). RANK(L) and TRAP expression did not differ between the investigated areas, resembling a generalized decrease in osteocyte-osteoclast function all over the jaw (RANK(L) -positive cells per mm2: 8.97 ± 7.85 (fluorescence positive) vs. 7.76 ± 6.41 (fluorescence negative), p = 0.793; TRAP-positive cells per mm2: 0.36 ± 0.38 (fluorescence positive) vs. 0.33 ± 0.41 (fluorescence negative), p = 0.887). CONCLUSION: Intraoperative fluorescence-guided surgery might be more precise in identifying and resecting the necrotic bone compared to previous indicators like bone bleeding, which could be useful to further improve surgical therapy in MRONJ patients.