Buccal Mucoperiosteal Flap Research Articles

Clinical case of treatment of complications of the use of plate dental implants on the maxilla

Relevance. According to the conclusion of the European Federation of Periodontology, late complications of dental implantation include inflammation of the tissues in the reimplantation zone after the completion of osseointegration in the form of periimplantation mucositis and reimplantitis. According to many authors, in the first two months after dental implantation, in the case of initial insufficiency of soft tissue thickness in the operation area, when a minimum volume of biological width (3 mm on average) is formed, bone tissue loss is provoked, this property is especially pronounced when using lamellar dental implants. In the maxilla, overimplantation of a massive plate implant can lead to the development of inflammation of the paranasal sinuses. The most traditional options for mucosal augmentation in the area of implantation in the maxilla are grafting with local tissues or autotransplantation of a free flap from a donor site. Also used are resorbable collagen matrices (Resorbable Collagen Matrix – RCM) or membranes that protect the underlying tissues from external influences, completely close the surgical wound, prevent pathological scarring and allow you to control the epithelialization process.The purpose of the study. To increase the effectiveness of complex treatment of complicated reimplantitis in the maxilla, sinusoethmoiditis, by sanitation and the use of a collagen membrane for the combined closure of the oro-antral fistula.Material and methods. The article is devoted to the clinical case of complications of the use of a lamellar dental implant in the maxilla, diagnosis and treatment by an interdisciplinary surgical team of the City Clinical Hospital N.I. Pirogov of the Department of Healthcare of Moscow. A staged surgical intervention for the removal of a detailed laminar implant, unilateral ethmoidotomy and maxillary sinusectomy, and combined closure of the oro-antral communication with the use of local tissue plasty with a flap from the cheek and the installation of a collagen membrane are described.Results. To close a large bone defect in the area of the alveolar part of the maxilla, the bioPLATE Contur membrane was used, which is characterized by increased extensibility up to 50% of the original dimensions and elasticity. The mucoperiosteal flap was laid without tension over the collagen membrane and fixed with two-row interrupted sutures. The sutures were removed on the 14th postoperative day, the wound was epithelialized throughout, without signs of inflammation.Conclusions. Complications of dental implantation in the maxilla are manifested in the form of a loss of bone volume and a defect in the alveolar margin of the maxilla, the development of inflammatory complications of adjacent tissues and anatomical structures. This requires a multidisciplinary approach in diagnosis and surgical treatment with a comprehensive planning of patient rehabilitation. The use of a combined method of closing a bone defect with a collagen resorbable membrane and a buccal mucoperiosteal flap with suturing with a double-row suture makes it possible to achieve a satisfactory course of the postoperative period, avoid recurrence of the oro-antral fistula, and prepare the patient for further dental rehabilitation.

Lingual nerve injury during extraction of mandibular third molars: Are we extracting correctly?

Introduction: Neurological injuries including lingual nerve damage are among the most devastating complications of mandibular third molar extraction. Various causes of lingual nerve damage have been proposed in literature including the surgical technique.
 Objective: This study aims to assess the adverse outcomes of the removal of mandibular third molars in terms of the frequency of lingual nerve injury (LNI).
 Methodology: This prospective case series was carried out at Maroof International Hospital, Islamabad. Surgical extraction was performed after raising both lingual and buccal mucoperiosteal flaps for surgical access. Ostectomy and tooth sectioning was performed while protecting the lingual flap with a passively placed periosteal elevator. Patients were recalled for the assessment of lingual nerve status, one week postoperatively. 
 Results: Out of the total of 1487 teeth extracted temporary lingual nerve injury was observed in just two cases (0.13%) both of which were extracted because of recurrent pericoronitis. None of the patients had a permanent neurological deficit. 
 Conclusion: For improving civility in nursing college, insight into incivility among students and faculty members is to be developed and policies to be in place to address unacceptable behaviors in a timely and effective manner. A surgical technique using careful lingual flap elevation and passive retraction results in the prevention of iatrogenic lingual nerve injury.

The Everted Flap: Preliminary Results

Introduction: Attainment of primary soft tissue closure at the time of guided bone regeneration (GBR) therapy often requires significant crestal repositioning of the buccal mucoperiosteal flap, resulting in compromise of the buccal vestibule and loss of mucogingival confluence in the area. The everted flap technique (EFT) is used at the time of extraction of teeth demonstrating bone loss beyond their apices and complete epithelialization of the extraction socket. The EFT uses the tissues within the extraction socket as part of the buccal mucoperiosteal flap, thus obviating the need for crestal mucoperiosteal flap repositioning after placement of regenerative material and covering membranes.Case Presentation: Out of 118 patients treated using the EFT in the authors' private practices, one primary case and two supplementary cases are presented here. Soft tissue primary closure was attained and maintained throughout the course of regeneration in all patients. No patients required repositioning of a buccal mucoperiosteal flap at a second surgical visit to reform the buccal vestibule and/or reestablish mucogingival confluence in the area.Conclusion: The EFT offers a means by which to help attain passive soft tissue primary closure after GBR therapy without crestal repositioning of the buccal mucoperiosteal flap and to lessen the need for buccal soft tissue repositioning.

Closure of chronic oroantral fistula with repair of the Schneiderian membrane : Report of three cases

An oro-antral fistula(OAF) is one of the most common complications after procedures at the maxillary posterior area. The purpose of this study was to introduce the closure of OAF with repair of the Schneiderian membrane. This case report includes three patients with OAF arising after dental surgery on molar region of maxilla. Under general anesthesia, fistulectomy was achieved in all three patients and the full thickness flap around OAF was raised. After removal of inflammatory tissue, the Schneiderian membrane was repaired with suture or application of fibrin sealant. Additional closures were then performed with a buccal fat pad flap and a buccal mucoperiosteal flap. All OAF in three patients enrolled in this study were closed successively without recurrence of fistula. Treatment of oroantral fistula using repair of the Schneiderian membrane is a good alternative option for patients with OAF accompanied by chronic maxillary sinusitis.

Use of Auricular Cartilage for Closure of Oroantral Fistula: A Prospective Clinical Study.

The term oro-antral fistula is understood to mean of fistular canal covered with epithelia which may or may not be filled with granulation tissue or polyposis of the sinus mucous membrane. With the presence of a fistula the sinus is permanently open, which enables the passage of microbial flora of the oral cavity into the maxillary sinus and the occurrence of inflammation with all possible consequences. Every now and then various researchers have proposed innumerable techniques to treat this defect. Starting from simple tissue flaps to autogenous grafts to alloplastic materials, an array of procedures have been evaluated in literature but the most promising technique still needs to be evaluated. Consequently, after reviewing an array of such procedures, our present study focussed on a new technique for the closer of oro-antral fistulas using autogenous auricular cartilage graft supported by buccal advancement flap. A total of 20 patients of oro-antral fistula were included in the study and after excising the fistular tract a double layer closure was done by placing auricular cartilage over the defect followed by buccal mucoperiosteal flap. The graft was harvested using posterior auricular approach. Assessment of patients was done at the end of 1week, 3weeks, 6weeks, and 3months. We found that the autogenous auricular cartilage graft is an effective sealing material in oro-antral fistula closure. We recommend this technique for the defect size ≤10mm2 in which future dental implant placement is sought as it allows easy sinus lifting procedure.

Closure of oroantral communications with Bichat´s buccal fat pad. Level of patient satisfaction.

Purpose: To report the closure of oroantral communications with the pedicled buccal fat pad in a series of patients, and to determine the level of patient satisfaction after the surgery. Study Design: A prospective study of patients diagnosed of unilateral or bilateral oroantral communication (OAC) closed using the buccal fat pad between May 2012 and January 2013 was performed. Data analysis extended to: age, sex, and cause, location and size of oroantral communication. Complications and success related to buccal fat pad surgery were evaluated. Also, patient satisfaction was assessed after six months of surgery. Results: Nine patients (3 men and 6 women) with a mean age of 50.5 years and 11 OAC treated with buccal fat pads were included. The most common cause of oroantral communication was the extraction of molars. The average widest diameter of the oroantral communication was 7.1 mm. One week after the surgeries no complications were found. One month after surgery, one patient presented persistence of the oroantral communication; in this patient, the buccal fat pad technique was considered a failure, and a second intervention was performed using a buccal mucoperiosteal flap to achieve primary closure of soft tissues. After six months, patient showed closure of the communication and complete healing. All the other communications had been solved with Bichat´s ball technique, yielding a success rate of 90.9%. Mean patient overall satisfaction was 9.1 out of 10; patients were satisfied with phonetics (9.4), aesthetics (9) and chewing (9). Conclusions: The buccal fat pad technique was successful in closing 10 out of 11 oroantral communications and few complications were found. Patients were highly satisfied in overall with the treatment and with phonetics, aesthetics and chewing. Key words:Bichat’s fat pad, buccal fat pad, oroantral communication.

Expansion of the Alveolar Bone Crest with Ultrasonic Surgery Device: Clinical Study in Mandible

The purpose of this paper was to document the application to the split-crest mandibular procedure in two stage in order to avoid cortical resorption due to periosteal detachment in buccal cortical bone of the alveolar crest. Twenty-two healthy patients with non-contributory past medical history (14 women and 8 men, all non-smokers, mean age 59 years, range 54-65 years) were included in this study. After buccal mucoperiosteal flap was followed by a sagittal corticotomy in the coronal area of the alveolar crest and a second sagittal corticotomy, but in a lower (basal) position and two vertical corticotomies in the buccal wall, using a ultrasonic surgery device (Surgysonic, Esacrom, Imola Italy). Adequate crest expansion was achieved without compromising cortical vascularisation by utilising a combination of scalpel, thin chisels and threaded osteotomes (Bone System, Milano, Italy). Postoperative results were assessed by panoramic and periapical radiographs. Ossification of the osteotomy lines was evident and could be observed as sites with increasing radiopacity on panoramic and periapical radiographs 3 months after implants insertion. No dehiscence of the mucosa was observed. No patient suffered from hypoaesthesia. The mean horizontal bone increase in coronal area was 5±3 mm. Mandibular ridge expansion using a split-crest technique that included grafting the implant sites with a ultrasonic surgery device is a viable therapeutic alternative for implant placement in this patient population.

Histologic assessment of Mineral Trioxide Aggregate as a root‐end filling in monkeys‡

Mineral Trioxide Aggregate (MTA) has been shown in a number of experiments to be a potential rootend filling material. The purpose of this study was to examine the periradicular tissue response of monkeys to MTA and amalgam as root-end fillings. The pulps were removed from all the maxillary incisors of three monkeys. The root canals were prepared and filled with laterally condensed guttapercha and sealer, and the access cavities were restored with amalgam. Buccal mucoperiosteal flaps were raised, and root-end resections were performed before root-end cavity preparation with burs. The root-end cavities in half of the teeth were filled with MTA, while amalgam was placed in the other cavities. After 5 months the periradicular tissue response was evaluated histologically. The results showed no periradicular inflammation adjacent to five of six root ends filled with MTA; also five of six root ends filled with MTA had a complete layer of cementum over the filling. In contrast, all root ends filled with amalgam showed periradicular inflammation, and cementum had not formed over the root-end filling material, although it was present over the cut root end. Based on these results and previous investigations, MTA is recommended as a root-end filling material in man.

Atypical Stafne Bone Cavity

A patient was referred to the Department of Oral and Maxillofacial Surgery for extraction of the lower-left third molar tooth. There had been one episode of pericoronitis 5 years previously, since which there had been no symptoms. A panoramic radiograph showed a partially erupted mesioangularly impacted third molar without associated disease. Clinically no inflammation was present, and in the absence of specific indications for its removal, the tooth was left in situ. However, the radiograph revealed a radiolucency in the contralateral side of the mandible, below the fully-erupted lower-right third molar. The radiolucency measured approximately 2.5 cm £ 2.0 cm and was rhomboidal in shape. It extended from the apices of the lower-right second and third molars to the lower border of the mandible and was well defined with a corticated smooth but irregular margin (Fig. 1). The roots of the teeth were not resorbed and the periodontal ligament space and lamina dura appeared normal. The lesion was asymptomatic, and all teeth in the lower-right quadrant proved vital on electric pulp testing. Further radiographic views, a lower 908 occlusal and postero-anterior jaws were taken but did not add any further information. The most likely diagnosis was a Stafne bone cavity, but because of the unusual shape and extent, axial computed tomography (CT) (volume scan, 3 mm slices) was performed, and this showed a well-defined lingual defect in the posterior aspect of the right side of the mandible (Fig. 2). The buccal cortex was thinned and expanded and possibly perforated, though this last feature could not be differentiated from partial volume artefact. The cavity was partially filled by soft tissue that appeared to be continuous with the submandibular gland, but contained areas of a lower density, similar to the density of parotid gland. However a benign soft tissue tumour could not be excluded Based on these investigations the patient was informed of the likely diagnosis of Stafne bone cavity, and review to observe the lesion and thus confirm the diagnosis was recommended. However, aware of the unusual features, the patient was keen to obtain a definitive diagnosis and requested biopsy despite the proximity of the inferior alveolar nerve and the risk of nerve injury. Under general anaesthesia an intraoral buccal mucoperiosteal flap was raised and buccal bone removed with a bur. The cavity was found to be filled with salivary gland tissue and an incisional biopsy performed. Histopathological examination revealed an un-inflamed salivary gland with a normal duct and lobular structure and mild adipose replacement. At higher power the gland was found to be composed almost exclusively of serous acini with occasional clusters of mucous acini, consistent with the distal pole of the submandibular gland. A final diagnosis of Stafne idiopathic salivary gland inclusion was made (Fig. 3). Two months postoperatively the patient had some residual but resolving paraesthesia of the right mental nerve and did not return for further followup.

Short-term periradicular tissue response to mineral trioxide aggregate (MTA) as root-end filling material.

The aim of the present study was to evaluate the short-term response of periradicular tissues to MTA when used as a root-end filling material in ideal tissue conditions. The experimental procedures were performed on the healthy teeth of dogs. Pulps were removed and root canals prepared and filled with gutta-percha and sealer. At the same session, buccal mucoperiosteal flaps were reflected and the root ends resected. MTA or IRM were used as root-end filling materials. The periradicular tissue reactions were evaluated histologically from 1 to 5 weeks. Hard tissue formed on the MTA surface was further examined by scanning electron microscopy. The most characteristic tissue reaction to MTA was the presence of connective tissue after the first postoperative week. Inflammation was seen occasionally. Early tissue healing events after MTA root-end filling were characterized by hard tissue formation, activated progressively from the peripheral root walls along the MTA-soft tissue interface. In contrast, hard tissue was not seen over the IRM root-end filling. MTA is a biocompatible material that stimulates periradicular tissue repair at the root-end situation; however, the nature of the newly formed tissues requires further elucidation.

Investigation of the bone tissue response to glass-ionomer microimplants in the canine maxillary alveolar ridge

This paper reports the results of experimental use of glass-ionomer microimplants in the augmentation of the maxillary alveolar ridge in dogs. The study included ten adult mongrel dogs 5 years of age, weighing between 50 and 70 pounds (25-30 kg), divided into 2 groups of 5 dogs each. In both groups, the maxillary 4th premolar and 1st molar were removed after the elevation of a buccal mucoperiosteal flap. The alveolar bone adjacent to the extracted teeth was also removed. In the experimental group (5 dogs), Ionogran a glass-ionomer microimplants (GIMIs) (Ionogran particle size of 0.5-1.0 mm, IONOS Medizinische Produkte GmbH & Co. KG, D-8031 Seefeld, Gemany) were used for augmentation and were inserted in the created defects. The extraction sockets and bone defects were augmented with an average amount of 2 g of GIMIs. In the control group, the bone defects were left unfilled as a control for bone healing. Histological examination showed that the glass-ionomer microimplants were extremely osteoconductive and inert materials. Stimulation of growth of new bone tissue in contact with the glass-ionomer microimplants was evident. No inflammatory cells were detected on or adjacent to the GIMIs. In the control group, incomplete bone healing with fibrous scar tissue and inflammatory cells was noted. These results indicate that glass-ionomer microimplants represent highly osteoconductive and biocompatible materials for use in bone surgery.

Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys

Mineral Trioxide Aggregate (MTA) has been shown in a number of experiments to be a potential root-end filling material. The purpose of this study was to examine the periradicular tissue response of monkeys to MTA and amalgam as root-end fillings. The pulps were removed from all the maxillary incisors of three monkeys. The root canals were prepared and filled with laterally condensed guttapercha and sealer, and the access cavities were restored with amalgam. Buccal mucoperiosteal flaps were raised, and root-end resections were performed before root-end cavity preparation with burs. The root-end cavities in half of the teeth were filled with MTA, while amalgam was placed in the other cavities. After 5 months the periradicular tissue response was evaluated histologically. The results showed no periradicular inflammation adjacent to five of six root ends filled with MTA; also five of six root ends filled with MTA had a complete layer of cementum over the filling. In contrast, all root ends filled with amalgam showed periradicular inflammation, and cementum had not formed over the root-end filling material, although it was present over the cut root end. Based on these results and previous investigations, MTA is recommended as a root-end filling material in man.

Localized Ridge Augmentation in Dogs: A Pilot Study Using Membranes and Hydroxyapatite

This study was designed to evaluate the potential to reconstruct localized ridge defects with bone by preventing non-osteogenic extraskelatal connective tissue from participating in the process of healing following experimental ridge augmentation treatment procedures. Following the elevation of buccal muco-periosteal flaps, buccal, interproximal, and interradicular bone was removed to the apical level of the second and third premolar teeth and the teeth were extracted to create bucco-lingual ridge defects that averaged 13 mm x 7 mm x 3.5 mm in each quadrant of two adult beagle dogs. The defects were permitted to heal for 90 days. The defects did not fill in with new bone. Subsequently, buccal muco-periosteal flaps were elevated and a membrane was placed over the defect and positioned so that it rested on bone that was exposed adjacent to the defect. In two quadrants test support materials were used to ensure that a space was maintained between the surface of the defect and the membrane. One quadrant was maintained as a sham-operated control site, three sites received membranes and no supporting implants and two sites received supporting implants and no membranes. The surgical schedule was designed to yield sacrifice times of 8 to 12 weeks. In the three quadrants available for study that were covered with membranes, bone and/or non-mineralized connective tissue was found to fill all of the space that had been provided by the membrane. Histologic examination confirmed that the space was filled with young, actively growing bone by 90 days. No new bone formation (bone fill) was observed in the sham-operated control site.

Closure of oroantral fistula

Oroantral fistula is an uncommon complication in oral surgery. Although smaller fistulas of less than 5 mm in diameter may close spontaneously, larger fistulas always require surgical closures. The literature review revealed various procedures for the closure of oroantral fistulas. These procedures may be subdivided into local flap, distant flap and grafting. Procedures involving local flaps are usually adequate to close minor to moderate size defects. Those procedures utilizing the buccal mucoperiosteal flap as the tissue closure include straight-advancement, rotated, sliding and transversal flap procedures; while those involving the palatal mucoperiosteum are straight advancement, rotational-advancement, hinged and island flap procedures. The combinations of various local flaps to strengthen the tissue closure are also being advocated. The advantages and the limitations of these procedures are discussed. Distant flaps and bone grafts are usually indicated in the closure of larger defects in view of their greater tissue bulks. Tongue flaps have superseded extra-oral flaps from extremities and forehead for aesthetic reasons and also in view of their similar tissue replacement. Various tongue flap procedures are described. At present, various alloplastic materials such as gold, tantalum and polymethylmethacrylate are infrequently reported in the closure of oroantral fistulas. However, in the light of successful reports over the use of biological materials, collagen and fibrin, in the closure of oroantral fistulas, there seems to be another simple alternative technique for treating oroantral fistulas.

New Attachment Formation Following Controlled Tissue Regeneration Using Biodegradable Membranes

The present study evaluated the potential for reestablishment of connective tissue attachment after exclusion of the gingival connective tissue and epithelium during healing after periodontal surgery in a dog model. Buccal mucoperiosteal flaps were elevated in all four premolar regions in two dogs. The buccal bone was reduced to approximately 25% of its original level on 24 roots. Before the elevated flaps were replaced and sutured, membranes were adjusted to cover the exposed root surfaces. On eight surfaces Millipore filters were used and on eight surfaces biodegradable polylactic acid membranes were used. No membranes were placed over the remaining eight root surfaces which served as controls. After two months of healing, the animals were sacrificed and all the roots were subjected to histological analysis. In all of the roots covered with the polylactic acid membrane, newly formed cementum with inserting collagen fibers was observed and covered on the average 46% of the initial defect. Newly formed bone covered 39% of the initial defect. The roots covered by Millipore filters were characterized by significantly less new attachment and bone. In the control roots only minor new attachment was found in the bottom of the defect in some roots. The results suggest that the establishment of a connective tissue attachment is clearly favored by the placement of a polylactic acid membrane to exclude the epithelium and gingival connective tissue during healing.

Treatment of large antro-alveolar fistulas.

Conclusion and SummaryThe treatment of sinusitis is of essential importance in the management of patients with small antro-alveolar fistulas. The reverse is the case if the fistulous tract is large. The presence of a large fistula ensures good drainage and a possible sinusitis is cured as a result. Sinusitis was present in none of the four cases of large antro-alveolar fistula treated at the Oto-Laryngological Department, University Central Hospital, Helsinki. The method of closure is of prime importance for a successful result in these large fistulas, in contrast to cases of small fistula. A doubleplastic, described in detail, was performed in three cases. The result was good in all of these, whereas it was poor in one case in which the fistula was closed with the conventional buccal mucoperiosteal flap.