Influence of Immediate Implant Placement and Provisionalization with or without Soft Tissue Augmentation on Hard and Soft Tissues in the Esthetic Zone: A One-Year Retrospective Study.

The purpose of this clinical research was to evaluate peri-implant marginal changes around immediate implants placed either with the application of SCTG or XCM or without soft tissue grafting. A total of 48 patients requiring a single implant-supported restoration in the anterior jaw were selected for inclusion. Three surgical procedures were performed, as follows: type 1 implant with subepithelial connective tissue graft (SCTG), type 1 implant with xenogenic collagen matrix (XCM), and type 1 implant without soft tissue augmentation (NG) (control group). The marginal change of peri-implant soft tissue, facial soft tissue thickness (FSTT), peri-implant health status, esthetics, and patient satisfaction were assessed at one year after surgery. All of the placed implants showed a survival rate of 100%. No significant differences in FSTT were recorded between the SCTG group and the XCM group after treatment (P > 0.05), while the NG group presented a significant difference (P < 0.05). Patients in the NG group lost significantly more in the buccal marginal level than did patients in the SCTG group and those in the XCM group (P < 0.05). The favourable success rate recorded in all groups confirmed immediate tooth replacement as a choice of treatment for a missing anterior single tooth. The NG group presented significant changes of FSTT and buccal marginal level, while XCM constituted a viable alternative to SCTG.

Overgrowth of soft tissues after transplantation of a connective tissue graft for the treatment of gingival recession.

The application of free connective tissue graft (CTG) is the gold standard in the treatment of gingival recession in the area of teeth and implants. The aim of this case report is to demonstrate a possible mucosal overgrowth complication in the soft tissue grafting area. A 24-year-old patient underwent the treatment of gingival recession in the tooth 2.3 region by an envelope technique using a free CTG from the hard palate region. Seven years after the surgery, a mucosal overgrowth was observed, which developed asymptomatically and did not cause any problems to the patient.

Anatomic factors influencing dimensions of soft tissue graft from the hard palate. A clinical study.

OBJECTIVES: The aim of the present study was to measure the thickness of the palatal mucosa in a Jordanian (Middle Eastern) population as well as identify possible factors that may influence the thickness of palatal mucosa. MATERIAL AND METHODS: Sixty period on tally healthy subjects (29 males and 31 females) were selected. Fifteen measurement points were defined on the palate. The mucosal thickness in the hard palate was determined by "bone sounding" with a Hu-Friedy® round periodontal probe. RESULTS: The overall mean thickness of the palatal masticatory mucosa was 3.23 ± 0.47 mm.The mean thickness increased from the gingival margin to a more apical position irrespective of the tooth measured or side of the mouth in the following sequence: canine, second molar, first premolar, second premolar and lastly, the first molar. No significant difference between gender, smoking status, gingival phenotype andsides of the mouth with the thickness of palatal masticatory mucosa was determined. A significant difference between palatal shape and palatal gingival thickness was found. CONCLUSIONS: The most appropriate site for graft harvesting is the canine-premolar area 8-13 mm from the mid-palatal aspect of each respective tooth in a Jordanian population. Except for the palatal shape, the side of the mouth, smoking, gender or gingival phenotype does not affect the graft harvest. CLINICAL RELEVANCE: SCIENTIFIC RATIONALE FOR STUDY: Knowledge on the thickness of the masticatory mucosa is crucialin making decisions for surgical treatment modality and may affect surgical outcome. We measured the thickness of the palatal mucosa in a Jordanian population and identified possible influencing factors. PRINCIPAL FINDINGS: The thickness varied according to the teeth and the canine to premolar region was found to be the appropriate donor site. PRACTICAL IMPLICATIONS: This information on safe zone for graft harvest can guide the periodontist to make appropriate incisions and choose the appropriate location to obtain a graft of adequate thickness and dimensions.

Hard palate-dermis fat composite graft for reconstruction of contracted anophthalmic socket.

Purpose: To describe a novel technique of using a hard palate-dermis fat composite graft (HPDFG) for reconstruction of a contracted anophthalmic socket. Methods: Retrospective, noncomparative, interventional case series of four patients who underwent HPDFG placement by one surgeon between 2010 and 2017. Results: Six harvested HPDFGs were placed in four patients with contracted anophthalmic sockets. A harvested hard palate graft (HPG) and a dermis fat graft (DFG) were adjoined with sutures to form a composite graft. All adhesions and symblephara between the eyelid and the anterior surface of the anophthalmic socket were lysed. The HPG component was attached to the tarsal margin to vertically lengthen the eyelid. The free edge of the DFG was sutured to the cut edge of the bulbar conjunctiva to simultaneously expand the anterior conjunctival surface area and fornix volume. The line of union between the two grafts formed the apex of the new fornix. Four HPDFG were used to reconstruct both the upper and lower lid fornices in two severely contracted sockets. Three patients received post-operative 5-fluorouracil (5-FU) injections. Three patients underwent additional revisions with buccal mucous membrane graft, amniotic membrane graft, full-thickness skin graft, pedicle flap, and dermal fillers. All four patients achieved excellent cosmesis and comfortable prosthesis fit. Conclusions: Composite HPDFG is an effective method of reconstructing a contracted anophthalmic socket by restoring volume, lengthening the posterior lamella, and expanding the fornix to allow for successful prosthesis retention. Adjunctive use of 5-FU injections can delay post-operative cicatrization.

Correction of lower eyelid retraction with hard palate graft in the anophthalmic socket.

OBJECTIVE: Lower eyelid retraction is a common and challenging complication of the anophthalmic socket. The underlying pathophysiology includes contraction of the posterior lamellae of the eyelid, shortening of the inferior fornix, and lateral canthal tendon laxity. This study aimed to evaluate the surgical efficacy of hard palate mucosa as a posterior spacer graft in the lower eyelid retraction repair in the anophthalmic socket. METHODS: The surgical technique involved hard palate grafting combined with recession of inferior retractors and lateral tarsal strip suspension to lengthen the posterior lamellar and strengthen the support of the lower eyelid. The records of anophthalmic patients with lower eyelid retraction who underwent this technique from January 2009 through August 2014 were reviewed. Postoperative outcomes were determined by lower eyelid elevation, presence of lagophthalmos, complications, prosthesis fitting, and patient satisfaction. RESULTS: A total of 12 patients (12 eyelids) were included. The mean age at surgery was 36 years (range, 29-52 years) and the mean follow-up period was 53 months (range, 20-71 months). The lower eyelids of the operated eyes significantly elevated by 2.9 ± 0.8 mm, and mild residual lagophthalmos was observed in 3 patients. All patients were satisfied with the surgical outcomes. Minor complications occurred in 3 cases, including mild recurrent retraction, granuloma, and mucous discharge. There were no complications detected at the donor site. CONCLUSION: Hard palate grafting combined with recession of lower eyelid retractors achieves long-term stable outcomes in lower eyelid retraction repair in the anophthalmic socket.

Frontal axial pattern flap combined with hard palate mucosa transplant in the reconstruction of midfacial defects after the excision of huge basal cell carcinoma.

BACKGROUND: Our article describes our experience with using a frontal axial pattern flap combined with hard palate mucosa transplant to reconstruct midfacial defects after the excision of huge basal cell carcinoma. METHODS: We retrospectively reviewed four patients diagnosed with midface huge basal cell carcinoma through biopsy between 2014 and 2016. Both the eyelid and nose were involved in all the patients. All the patients underwent the studied surgical method and were followed up from 12 to 36 months. RESULTS: All the patients preserved good eyelid function and relatively good esthetic satisfaction. No basal cell carcinoma recurred. CONCLUSIONS: This combined surgical procedure is a good method for reconstructing defects after the excision of huge basal cell carcinomas in the midface.

Atypical Clinical Presentation of a Newer Generation Anti-Fungal Drug-Resistant Fusarium Infection After a Modified Multi-Visceral Transplant.

BACKGROUND Fusarium spp. infections have become an emerging and lethal threat to the immunocompromised patient population, especially those with neutropenia. Recently there have been increased reports in solid organ transplant recipients. Presentation is commonly as soft tissue infections several months post-transplant. With high morbidity and mortality, efficacious antifungal therapy is essential. This remains challenging with limited data and no established clinical breakpoints defined. CASE REPORT We report on a modified multi-visceral transplant patient that developed a Fusarium infection only 7 weeks post-transplant in the native hard palate and esophagus, without any soft tissue lesions, which persisted despite aggressive combination treatment with amphotericin B lipid complex and voriconazole. CONCLUSIONS Fusarium spp. infection in solid organ transplant is a significant challenge without clear diagnostic clinical indicators of infection, or specific time of onset, in addition to possible emergence of a more aggressive drug-resistant strain.

[Transplants from the hard palate: method for mucosal graft reconstruction of the upper eyelid]. / Transplantate vom harten Gaumen: Methode zur Schleimhautrekonstruktion im Oberlid.

BACKGROUND: Mucosal grafts from the hard palate for reconstruction of the posterior lamella of the upper eyelid were compared for three different indications. The plastic reconstruction of the upper eyelid was carried out in patients with symblepharon and upper eyelid entropion following an autoimmune disease, in patients with subtotal or total upper eyelid resection due to a neoplasm and in patients with mucous membrane trauma using autogenous mucosal grafts from the hard palate. PATIENTS: In this retrospective comparative interventional case series 23 eyes from 19 patients were included in whom upper eyelid reconstruction was undertaken at the University Eye Hospital in Salzburg between 2001 and 2012. Reconstruction with hard palate grafts was performed in 5 eyes following extensive tumor resection, in 5 eyes of 3 patients after autoimmune diseases and in 13 eyes of 11 patients following trauma rehabilitation. RESULTS: In the total collective of patients who underwent upper eyelid reconstruction with hard palate grafts, no graft rejection or loss of graft occurred. Hard palate grafts are useful for reconstruction after tumor surgery in addition to other techniques in order to achieve good functional and esthetic results. For patients suffering from autoimmune disease (e.g. ocular pemphigus and Stevens-Johnson syndrome) the use of hard palate grafts was found to be equally useful, although results can possibly deteriorate over time due to the underlying disease. Hard palate grafts were shown to be very useful in reconstruction of the upper eyelid for correction of entropium due to symblepharon and distichiasis following thermal and chemical burns. CONCLUSION: Hard palate grafts are suitable as mucosal grafts replacing conjunctiva in systemic disease and are equally effective in the treatment of traumatic upper eyelid defects - such as defects after tumor surgery.

Keloidal scarring in hard palate grafts.

Hard palate grafts are a commonly accepted treatment for lower eyelid retraction and are typically associated with low complication rates. The authors present a case of bilateral keloidal scarring within hard palate grafts requiring surgical excision. A 72-year-old woman who had undergone bilateral hard palate grafts to her lower eyelids for lower eyelid retraction was referred for the evaluation of ocular irritation. She was diagnosed with bilateral hypertrophy of the grafts with secondary entropion. The grafts were excised; the pathology was consistent with keloidal scarring. To the authors' knowledge, there is no previously reported case of bilateral keloidal scarring in normal donor tissue, which required excision of the hard palate grafts. It is important for oculoplastic surgeons to be aware of this potential complication when considering, discussing, and consenting patients for eyelid reconstruction with hard palate grafting.

[Palatal fibromucosal graft to correct lower eyelid retraction]. / Greffe de fibromuqueuse palatine pour corriger la rétraction de la paupière inférieure.

INTRODUCTION: Retraction of the lower eyelids has multiple etiologies. Its surgical treatment is a vertical elongation of the tarsus. This can be obtained by using a graft. We describe a sampling and grafting technique using palatal fibromucosa intratarsal graft. TECHNICAL NOTE: The procedure is performed in two steps under general anesthesia. The graft is harvested on the lateral sides of the palatine vault to avoid neurovascular bundles. This area corresponds to the maxillary fibromucosa according to Delaire's classification. The graft is then inserted in the lower eyelid tarsus. DISCUSSION: Many "spacers" are available to extend the posterior lamella vertically; the palatal fibromucosa graft may be used directly and is easy to harvest. It has a similar stiffness to that of the tarsus and there is no need to harvest periosteum. Sparing the periosteum allows for a better healing of the donor site and decreases postoperative pain. The lateral harvesting area, away from the anterior palatine artery, seems more accessible than the median area, especially in ogival palates.

Orbital, periorbital, and ocular reconstruction.

The repair and restoration of the eyelids and orbit can be a medical and surgical challenge. Inadequate orbital volume restoration could lead to poor functional and cosmetic defects. With advances in technology, our surgical techniques are constantly improving. This article focuses on ocular and orbital reconstruction following traumatic, iatrogenic, and acquired defects. Optimal outcomes can only be expected with appropriate diagnosis treatment planning in consultation with other specialists.

Repeat posterior lamellar grafting for recalcitrant lower eyelid retraction is effective.

PURPOSE: To review one surgeon's (J.H.O.) experience with repeat retractor release and posterior lamellar grafting in patients with residual lower eyelid retraction. To quantify the amount of eyelid elevation expected from each procedure. METHOD: Retrospective chart review of patients with repeat posterior lamellar grafting between 1992 and 2010. Patients were grouped into thyroid associated orbitopathy (TAO) and other causes. Hard palate mucosa or free tarsoconjunctiva grafts were used. Preoperative and postoperative inferior scleral show, lagophthalmos, superficial punctate keratopathy, and patient symptoms were recorded. Outcome measures were changes in scleral show and lagophthalmos with each procedure. Combined results were examined.Results in patients with TAO were analysed separately and compared with other etiologies. RESULTS: In this series, a single procedure is expected to reduce scleral show by a mean of 1.63 mm (76%) and lagophthalmos by a mean of 0.48 mm (55%). A second procedure can further reduce residual scleral show by a mean of 0.71 mm (80%) and residual lagophthalmos by a mean of 0.43 mm (76%). Patients with TAO were more likely to have larger measurements of preoperative scleral show (1.40 mm versus 0.46 mm, p < 0.001). Patients with other etiologies were more likely to have larger measurements of preoperative lagophthalmos (1.25 mm versus 0.47 mm, p = 0.004). CONCLUSIONS: This is the first study to evaluate outcomes of recalcitrant lower lid retraction requiring repeat posterior lamellar grafting. Mean reductions in scleral show and lagophthalmos can be used as a guide in the preoperative evaluation and counseling of patients with lower lid retraction.

[Application of three dimensional model in evaluating the effect of artificial bone implantation of hard cleft palate on the development of maxilla].

OBJECTIVE: To observe the effect of artificial bone implantation of hard cleft palate on the development of maxilla. METHODS: From January 1997 to December 1999, 40 patients with hard cleft palate were randomly divided into two groups: control group and implantation group (n = 20 each). The patients in the implantation group received an implantation of compound artificial bone of HA-Bone cement. All patients had a follow-up since 16 years old. A three dimensional model was established with computed tomography and rapid prototype technique to analyze the maxilla in three dimension. At the same time, a dentognathic model was employed. RESULTS: There were no differences in the results between the three dimensional and dentognathic models. No difference was found in the development of maxilla in length and height between the control and implantation groups. There were marked differences in the development of maxilla in width between two groups (67.6 mm ± 4.3 mm vs 61.3 mm ± 4.1 mm, 63.5 mm ± 3.9 mm vs 57.3 mm ± 3.1 mm, 26.2 mm ± 1.8 mm vs 26.4 mm ± 1.9 mm, all P < 0.05). The width of maxilla in the implantation group was markedly wider than that in the control group. CONCLUSIONS: The application of three dimensional model for evaluating the development of maxilla is both straightforward and accurate. Bone implantation of hard cleft palate is an obvious boost to the development of maxilla in width. It should be included into a comprehensive orthodontic treatment for patients with hard cleft palate.

Primary alveolar bone grafting and gingivoperiosteoplasty or gingivomucoperiosteal flap at the time of 1-stage repair of unilateral cleft lip and palate.

It takes quite a long time to finish treating patients with cleft lip and palate. Usually, lip closure, palate repair, secondary alveolar bone grafting, and secondary repair of lip/nose have been given to patients at appropriate time according to their growth. However, these series of surgical interventions impose a considerable burden on the patients and their families. As for palate repair, it is considered that the earlier the better for the sake of speech, but it should be delayed to approximately 1(1/2) years of age for maxillary growth. However, we have developed a palate repair technique that will hardly result in marked maxillary growth impairment by modifying the Furlow method, so we have become able to perform palate repair between 3 and 10 months after birth. Accordingly, we can perform lip and palate repair simultaneously, which have been performed separately. As we have developed a 1-stage repair of cleft lip and palate including primary alveolar bone grafting from nasal concha and/or hard plate and gingivoperiosteoplasty or gingivomucoperiosteal flap, we report on our technique and treatment outcome.

Lower lip reconstruction with a hard palate mucoperiosteal graft.

Reconstruction of a lower lip deformity associated with leakage of saliva (drooling) and food spillage is challenging. To achieve complete closure of the mouth, the lips must have a sufficient and uniform thickness. Here we report a patient with lower lip deformity secondary to resection of a malignant tumor, in whom reconstruction was done with a hard palate mucoperiosteal graft. Perfect mouth closure without any leakage of saliva and a natural contour of the reconstructed lower lip were obtained, thus providing good aesthetic and functional results. This is the first report about the repair of a lower lip deformity with a hard palate mucoperiosteal graft. This type of graft seems to be a useful option for reconstructing lip deformities, and it can be widely applied to treat deformities caused by tumor resection, trauma, or cleft lip.

[Margin eyelid reconstruction with hard palate graft]. / Reconstrução marginal de pálpebras utilizando enxerto de palato duro.

PURPOSE: To investigate the advantages and the complications of the use of hard palate graft in the reconstruction of the inferior eyelids with large basocelular carcinoma. METHODS: Review of specialized articles and report of the technique used in the Oculoplastic Department of the "Hospital Santa Casa de Porto Alegre". RESULTS: The hard palate graft is an excellent replacement for posterior lamellar defects in eyelid reconstruction, because it presents the benefit of a mucous layer in addition to a semirigid support. CONCLUSION: The sandwich technique using hard palate was shown to be efficient, with good functional and esthetic results.

Cicatricial entropion repair with hard palate mucous membrane graft: surgical technique and outcomes.

BACKGROUND: The use of a hard palate mucous membrane graft (HPMMG) has been previously described for upper and lower eyelid cicatricial entropion repair. The objective of this paper is to review the surgical technique and postoperative complications in a large series of patient who underwent hard palate grafting for the management of cicatricial entropion. METHODS: The medical records of 107 patients representing 147 eyelids undergoing surgical management of cicatricial entropion with HPMMG were reviewed. The surgical technique is described. RESULTS: 147 eyelid operations (74 upper, 73 lower) were performed on 107 patients (46 male, 61 female), with a mean age of 63 years (range 12-87). The aetiology of the cicatricial entropion included idiopathic (41%), trauma (5.6%), chronic blepharitis (16.8%), chemical injury (3.7%), ocular cicatricial pemphigoid (8.4%), trachoma (7.5%) and other (16.8%). Patients were followed postoperatively for an average of 21 months (range 6-120). Ninety-four per cent of patients noted symptomatic improvement. The postoperative complications included excess keratin (29%), recurrence of cicatricial entropion (4.1%), punctuate epithelial erosion (2.7%), graft shrinkage (0.7%) and donor site bleeding (2.0%). CONCLUSIONS: Cicatricial Entropion with hard palate mucous membrane grafting for both upper and lower eyelid surgery offers high symptomatic and anatomical cure rates. The requirement for further surgical intervention is low.