Palatal Healing Research Articles

Oral Wound Healing: A Scoping Review and Proposal of a New Index for Palatal Mucosa.

The aim of this scoping review was to evaluate the wound healing indices available in literature and propose a new intra-oral wound healing index to assess the healing of palatal mucosa. A PubMed database search was conducted to identify relevant studies using the search strategy: ('Oral Wound healing') OR ('Palatal tissue healing') OR ('Healing indices in Oral and Maxillofacial Surgery') OR ('Palatal wound healing') OR ('Complications in wound healing'). A qualitative and quantitative synthesis of the results was done and data was presented following the PRISMA-ScR guidelines. The search resulted in 9 articles published between 2019 and 2022, which were eligible for inclusion in the study. The data revealed that the indices currently available for the assessment of intra-oral healing were limited and primarily concerned with the assessment of gingival and periodontal tissues. The healing indices devised for gingival and periodontal tissues cannot be applied to palatal healing due to the differences in clinical and histological aspects. Therefore, a new index to monitor the healing response specifically for the soft tissues in the palate has been proposed. This maybe particularly useful in cleft palate repair and other procedures performed over the palatal tissues.

A new volume-stable collagen matrix (VCMX) to treat single gingival recession associated with partially restored non-carious cervical lesions: a case series.

Collagen matrixes have been developed as possible connective tissue graft substitutes to overcome patient discomfort, undesired palatal healing, and the limited amount of donor tissue. The aim of this case series is to assess a coronally advanced flap (CAF) with a new volume-stable collagen matrix (VCMX) to treat single gingival recession (GR) associated with partially restored non-carious cervical lesions (NCCL). Twelve patients diagnosed with single GR RT1 + NCCL (B+) were included in this study and received a restorative - partial resin composite with apical margin 1 mm beyond the estimated cementoenamel junction (CEJ) - and a surgical approach - CAF+VCMX. Clinical and patient-centered assessments were recorded at baseline and 6 months postoperatively from ten patients. Significant recession reduction (RecRed:2.1mm), clinical attachment level gain (CAL:1.34mm), and combined defect coverage (CDC) of 51.67% were observed at 6 months. The estimate root coverage (RC) was 69.48%, obtained using the estimated CEJ. No difference in keratinized-tissue width (KTW) was observed over time. A gain in gingival thickness (GT) of 0.42 mm was observed after 6 months (p=.002) and an improvement in patient satisfaction due to better esthetics (p<.001). Within the present study's limits, CAF plus VCMX provided significant improvement in treating single GR combined with partially restored NCCL (B+).

D119. Propeller Buccal Myomucosal Flap: Anatomical Study and Preliminary Experience in 25 Primary Cleft Palate Reconstructions

PURPOSE: Buccal artery myomucosal (BAMM) flap has been well-described for cleft palate reconstruction. However, anatomic analysis and application of a completely islanded propeller flap have not been reported in the literature. METHODS: Anatomical study was performed using Indocyanine green, red and blue latex injected directly into the buccal pedicle of 22 fresh hemifacial cadavers. Then, clinical analysis of the senior authors’ (BBG, AR) experience with 25 consecutive primary cleft palate reconstructions utilizing a propeller islanded BAMM flap was conducted to assess palatal healing and flap outcomes. RESULTS: Mean buccal artery diameter was 0.95±0.29mm. Neurovascular pedicle entered the flap 11.38±2.87mm anterior to the pterygomandibular raphe. Buccal artery advanced inside the flap as much as 66.8%±6.0% of the total flap length. All reconstructions were performed using Furlow palatoplasty. 36 flaps were utilized in 25 patients (mean age 478d). The mean maximum cleft width was 11.7 mm. Mean BAMM flap width was 1.2 cm and 11 cases utilized bilateral flaps. The flap always reached the contralateral pillar and the buccal nerve was always preserved. Mean follow-up was 400 days. There were 2/36 flap loss. In both flap losses, pedicles were aggressively dissected. 4/36 flaps underwent revision for flap debulking. CONCLUSION: This study shows that the buccal pedicle is the main blood supply to the flap and this modification allows preservation of the sensory innervation. The contralateral pillar could always be reached improving the traditional advancement and inset. Traditional extensive propeller flap dissection should be avoided in these neonates to avoid vascular compromise.

Emerging peril of post–dengue mucormycosis

Rationale: Dengue fever is a leading cause of death in tropical and subtropical countries. Although most patients have a self-limited febrile illness, the viral infection can induce virus-mediated host changes, making immunocompetent persons susceptible to deadly fungal infections. However, there are only a few reports of such an association. Here we present a case of this deadly co-infection. Patient’s Concern: A 17-year-old male patient was diagnosed with dengue fever. He presented to us with facial swelling, periorbital edema, and black discoloration over the palate during the second week of his illness. Diagnosis: Diagnostic tests confirmed the presence of fungal hyphae. A diagnosis of post-dengue mucormycosis was made. No other comorbidity or underlying immune deficit was detected. Interventions: The patient underwent surgical debridement and antifungal treatment. Outcomes: The patient recovered and showed signs of palatal healing with an advancing mucosal edge. Lessons: Dengue virus and mucor co-infection has brought to light a new pathogenic paradigm. Clinicians need to be aware of this emerging medical condition and maintain a high index of suspicion for mucor co-infections while treating dengue patients.

Is the use of platelet-rich fibrin effective in the healing, control of pain, and postoperative bleeding in the palatal area after free gingival graft harvesting? A systematic review of randomized clinical studies.

A systematic review (SR) was conducted to answer the following focused question based on PICO strategy: In patients who were submitted to harvesting palatal free gingival graft, could platelet-rich fibrin (PRF) application in comparison with another method improve the healing, pain, and control of postoperative bleeding in the palatal area in randomized clinical trials? A SR was conducted according to the PRISMA guidelines. The MEDLINE (PubMed), Scopus, Embase, and Web of Science databases were searched, and hand searches were made, covering the period up to August 2020, for randomized clinical trials (RCTs) reporting the effect of PRF membrane in postoperative palatal healing management compared with any other methods. The risk of bias (RoB) of the studies included was assessed by using the RoB 2 tool. The electronic search strategy identified 150 articles. After title screening and abstract reading, 141 studies were excluded, and 9 full-text publications were comprehensively evaluated. Finally, 8 articles were included in the systematic review. Six studies showed that the PRF membrane was effective in improving wound healing during the first 2 weeks. As regards patient-centered outcomes, five studies showed that PRF promoted less postoperative pain. Finally, five studies that evaluated bleeding showed that the PRF membrane improved control of postoperative bleeding. RoB was classified as low in 4 studies, 3 with some concerns, and only one study did not describe the outcome data, and as this was missing, it was not possible to verify the protocol of data analysis for this study; therefore, it was classified as having high RoB. Within the limitations of this study, the collective evidence emerging from this SR may support the use of PRF membrane in the palatal area after free gingival graft harvesting. The results of this review must be interpreted with caution, due to the low number of RCTs included and high degree of heterogeneity among the PRF protocols. Further well-designed RCTs with accurate protocol and standard PRF parameters are required in order to gain clear understanding of the influence of PRF on wound healing and patient-centered outcomes. The use of PRF membrane for the protection of the palatal donor site following free gingival graft harvesting procedures improves wound healing and patients' quality of life.

Periostin and matrix stiffness combine to regulate myofibroblast differentiation and fibronectin synthesis during palatal healing

Although the matricellular protein periostin is prominently upregulated in skin and gingival healing, it plays contrasting roles in myofibroblast differentiation and matrix synthesis respectively. Palatal healing is associated with scarring that can alter or restrict maxilla growth, but the expression pattern and contribution of periostin in palatal healing is unknown. Using periostin-knockout (Postn−/−) and wild-type (WT) mice, the contribution of periostin to palatal healing was investigated through 1.5 mm full-thickness excisional wounds in the hard palate. In WT mice, periostin was upregulated 6 days post-wounding, with mRNA levels peaking at day 12. Genetic deletion of periostin significantly reduced wound closure rates compared to WT mice. Absence of periostin reduced mRNA levels of pivotal genes in wound repair, including α-SMA/acta2, fibronectin and βigh3. Recruitment of fibroblasts and inflammatory cells, as visualized by immunofluorescent staining for fibroblast specific factor-1, vimentin, and macrophages markers Arginase-1 and iNOS was also impaired in Postn−/−, but not WT mice. Palatal fibroblasts isolated from the hard palate of mice were cultured on collagen gels and prefabricated silicon substrates with varying stiffness. Postn−/− fibroblasts showed a significantly reduced ability to contract a collagen gel, which was rescued by the exogenous addition of recombinant periostin. As the stiffness increased, Postn−/− fibroblasts increasingly differentiated into myofibroblasts, but not to the same degree as the WT. Pharmacological inhibition of Rac rescued the deficient myofibroblastic phenotype of Postn−/− cells. Low stiffness substrates (0.2 kPa) resulted in upregulation of fibronectin in WT cells, an effect which was significantly reduced in Postn−/− cells. Quantification of immunostaining for vinculin and integrinβ1 adhesions revealed that Periostin is required for the formation of focal and fibrillar adhesions in mPFBs. Our results suggest that periostin modulates myofibroblast differentiation and contraction via integrinβ1/RhoA pathway, and fibronectin synthesis in an ECM stiffness dependent manner in palatal healing.

&lt;p&gt;Amniotic Membrane In Palatal Epithelial-Connective Tissue Reconstruction&lt;/p&gt;

Mucogingival surgery has the objective to obtain coverage of the recession, with a favorable long-term prognosis, but also to minimize postoperative problems and surgery-related risks. Human amniotic membrane is increasingly employed for periodontal tissue repair in order to promote epithelialization and to reduce pain and scar tissue formation. A 38-year-old female patient reports dental hypersensitivity resulting from gingival recession affecting tooth 4.1. A mucogingival surgical procedure was proposed and a partial-thickness flap of epithelial-connective tissue was harvested from the palate and grafted on to the receiving site. The amniotic membrane was positioned at the donor site to reduce postoperative morbidity and to encourage rapid palatal healing. One week after the application of HAM (human amniotic membrane), the wound was healed and 1 month after the donor site was completely re-epithelialized. The present case report suggests that in the surgical treatment of gingival recession with palatal epithelial-connective tissue graft, HAM promotes rapid epithelialization of the palatal donor site wound with a reduction in morbidity.

Differences in Weight Loss and Recovery After Cleft Lip and Palate Repair.

To determine the degree of weight loss, time to regain lost weight, and impact on postoperative outcomes after primary cleft lip (CL) and cleft palate (CP) repair. Single institution retrospective. Two hundred seven patients who underwent primary CL and/or CP repair procedures. One hundred thirty primary CL repairs (isolated CL = 59; cleft lip and palate [CLP] = 71) and 140 primary CP repairs (isolated CP = 72; CLP = 69): At the first postoperative visit, 21.54% of CL and 57.14% of CP repair patients had not returned to their immediate preoperative weights ( P < .0001). Maximum weight loss after CL repair was 0.44 kg (mean = 0.15 kg; standard deviation [SD]: 0.11) and for CP repair was 0.85 kg (mean = 0.31 kg; SD: 0.21; P = .002). Maximum percentage body weight loss was 6.11% after CL repair (mean = 2.08%; SD: 1.56) and 9.2% after CP repair (mean = 3.10%; SD: 2.13; P = .02). If not returned to preoperative weight by first postoperative visit, CP repair took significantly longer. Median time to return to preoperative weight was CL = 14.08 days (interquartile range [IQR]: 7.26) and CP = 25.37 days (IQR: 21.07; P < .0001). Patients undergoing CP repair with slowed weight recovery had a 22.5% rate of unintentional fistula/partial dehiscence compared to 10.0% of those who recovered quickly ( P = .052). Primary CP repair involves significantly higher risk and degree of postoperative weight loss and slower rates of weight recovery when compared with primary CL repair. Postoperative weight loss is associated with increased risk of complications with palatal healing. Cleft palate repair patients should be monitored closely for weight recovery and considered for nutritional interventions to support improved postoperative outcomes.

A Histologic Evaluation of Various Stages of Palatal Healing Following Subepithelial Connective Tissue Grafting Procedures: A Comparison of Eight Cases

It is often necessary to procure tissue from the same area of the palate in cases where connective autogenous grafting procedures are warranted due to limitations caused by anatomical features. The purpose of this study was to determine whether the length of time between a first procurement and a second would have any bearing on the quality of tissue available for recipient sites. Eight patients requiring more than one grafting procedure underwent surgery at baseline and again at various intervals ranging from 6 weeks to 11 months. Specimens were taken from the palate and evaluated microscopically, and photographs were taken for purposes of visual comparison. The 6.9- to 7.7-week specimens exhibited complete reepithelialization. The lamina propriae were composed of a cellular proliferation of fibroblasts with loosely arranged collagen deposition and an occasional thin vascular channel. However, remodeling of the wound appeared complete in the specimens removed at the 9-week interval and beyond. The lamina propria was, in general, composed of thick, dense, interlacing bundles of collagen. Small-caliber blood vessels were interspersed throughout the fibrous element. Reharvesting of tissue performed earlier than at 9 weeks may result in poorer autogenous graft quality due to indications that remodeling of the connective tissue is still progressing and not as mature as specimens noted at weeks 9 to 47.

Role of Secreted Frizzled-related Protein 1 (SFRP1) in Wound Healing

Wound healing is a complex cascade of events, which diminishes the size of the wound and reestablishes tissue integrity. Secreted frizzled-related protein 1 (SFRP1) contributes to the inhibition of apoptosis in fibroblast populations. We investigated the role of SFRP1 in a mouse wound-healing model; 2.0-mm excisional wounds were created in the scalp and hard palate. Healing responses were measured by histomorphometric analysis, apoptosis assay, and immunohistochemistry. Dermal wounds did not harbor SFRP1, but healed faster than palatal wounds which expressed significant levels of SFRP1. Antibody experiments aimed at blocking SFRP1 in palatal wounds resulted in promotion of wound closure, enhancement of new tissue formation, decrease of inflammatory cell infiltrate, and increase of apoptotic fibroblasts. Analysis of the present data suggests that SFRP1 may be partly responsible for the poorer healing performance of the palatal wounds compared with dermal wounds. Blocking SFRP1 results in improvement of palatal healing outcomes.

The fetal cleft palate: II. Scarless healing after in utero repair of a congenital model.

The role of fetal surgery in the treatment of non-life-threatening congenital anomalies remains a source of much debate. Before such undertakings can be justified, models must be established that closely resemble the respective human anomalies, and the feasibility and safety of these in utero procedures must be demonstrated. The authors recently described and characterized a congenital model of cleft palate in the goat. The present work demonstrates the methodology they developed to successfully repair these congenital cleft palates in utero, and it shows palatal healing and development after repair. A surgically created cleft model was developed for comparative purposes. Palatal shelf closure normally occurs at approximately day 38 of gestation in the caprine species. Six pregnant goats were gavaged twice daily during gestational days 32 to 41 (term, 145 days) with a plant slurry of Nicotiana glauca containing the piperidine alkaloid anabasine; the 12 fetuses had complete congenital clefts of the secondary palate. Repair of the congenital clefts was performed at 85 days of gestation using a modified von Langenbeck technique employing lateral relaxing incisions with elevation and midline approximation of full-thickness, bilateral, mucoperiosteal palatal flaps followed by single-layer closure. Six congenitally clefted fetuses underwent in utero repair, six remained as unrepaired controls. Twelve normal fetuses underwent surgical cleft creation by excision of a 20 x 3 mm full-thickness midline section of the secondary palate extending from the alveolus to the uvula, at 85 days of gestation. Six surgically clefted fetuses underwent concurrent repair of the cleft at that time; six clefted fetuses remained as unrepaired controls. At 2 weeks of age, no congenitally or surgically created clefts repaired in utero demonstrated gross or histologic evidence of scar formation. A slight indentation at the site of repair was the only remaining evidence of a cleft. At 6 months of age, normal palatal architecture, including that of mucosal, muscular, and glandular elements, was seen grossly and histologically. Cross-section through the mid-portion of the repaired congenitally clefted palates demonstrated reconstitution of a bilaminar palate, with distinct oral and nasal mucosal layers, after single-layer repair. In utero cleft palate repair is technically feasible and results in scarless healing of the mucoperiosteum and velum. The present work represents the first in utero repair of a congenital cleft palate model in any species. The use of a congenital cleft palate model that can be consistently reproduced with high predictability and little variation represents the ideal experimental situation. It provides an opportunity to manipulate specific variables, assess the influence of each change on the outcome and, subsequently, extrapolate such findings to the clinical arena with a greater degree of relevance.

Nasopharyngeal brachytherapy with access via a transpalatal flap

We used a posteriorly based transpalatal flap for interstitial nasopharyngeal brachytherapy in five patients with nasopharyngeal carcinoma. All of these implants were done with iodine 125 seeds. The disease in three of five patients has been controlled locally for 27, 30, and 40 months, respectively. Two patients experienced local failure and died. There have been no palatal healing problems despite high doses of previous radiation in all of our patients. No palatal incompetence has been seen. This technique appears safe and should be considered for discrete lesions of the high posterior or superior nasopharynx that cannot be approached by less invasive methods.

Early closure of cleft lip and palate

1. 1. Always be seated to correct cleft lips and palates. 2. 2. Seasons of the year have no influence on the optimum time for operation. 3. 3. The future happiness of the child and the parents is made or broken by surgery. 4. 4. The baby is not to be operated upon before one or two weeks of age; it is not an emergency. 5. 5. The lip is to be closed first at about two weeks of age and the palate is to be closed in three to six months. 6. 6. The baby is placed in Trendelenburg position for operation. 7. 7. There may be lack of development of upper jaw in some cases. A denture or orthodontia ill compensate for this. 8. 8. Many serious conditions develop if the palate is closed at two years of age or older. 9. 9. Early closure of the palate (at three to six months of age) will prevent abnormalities of development. 10. 10. Early closure of palate is a “must” when a child has an associated otitis media or a micrognathia. 11. 11. Indications and contraindication for the wearing of a prosthetic appliance are as follows: The use of a denture is indicated (a) when a cleft cannot be closed surgically, (b) to close the nasopharyngeal space, (c) to restore vertical dimension, (d) to restore anteroposterior dimension, (e) to restore lateral dimension, and (f) to restore the occlusal plane. A denture is contraindicated in patients whose defect (a) can be corrected by orthodontia; (b) can be corrected by bridgework; (c) can be corrected by exercise; (d) has a possible chance of developing normally. 12. 12. Failure of palatal healing is not due to infection but to tension and destruction of blood supply. 13. 13. Suggestions for facilitating the technic of early closure are as follows: (a) use a suture in the tongue; (b) use a tongue depressor and elevator (“tongue controller”); (c) use a catheter and wire for administering anesthesia for repairing bilateral cleft lips; (d) use an aspirator instead of a sponge; (e) use the smallest atraumatic needle and suture; (f) cut sutures short on the knot or 1 mm. long; (g) leave the tongue suture in until the baby is fully conscious; (h) administer fluids and food as soon as tolerated; (i) administer penicillin for the first week; (j) administer sedation as required; (k) use an indwelling catheter for one or two weeks for feeding; (l) do not restrain the baby for inspection of the palate postoperatively; (m) have an aspirator in the room at all times; (n) use straight arm restraints during the healing period to prevent fingers from getting into the mouth; and (o) feed the baby with an ear syringe, medicine glass, teaspoon or plastic cup with a cover and spout.

Correct time and sequence for closure of cleft lip and palate

1. 1. Always be seated to correct cleft lips and palates. 2. 2. Seasons of the year bear no influence on the optimum time for operation. 3. 3. Child's and parents' future happiness is made or broken by surgery. 4. 4. Baby is not to be operated upon before one or two weeks of age; it is not an emergency. 5. 5. Lip is to be closed first, as a rule, at about two weeks of age. 6. 6. Palate is to be closed in three to six months. 7. 7. The baby is placed in Trendelenburg position for operation. 8. 8. There may be lack of development of upper jaw in some cases. A denture or orthodontia will compensate for this lack of development. 9. 9. Many serious conditions develop if the palate is closed at two years or older. 10. 10. Early closure of palate, at three to six months, will prevent the abnormalities of development. 11. 11. Early closure of palate is a “must” when a child has an associated otitis media or a micrognathia. 12. 12. Indications and contraindications for the wearing of a prosthetic appliance are as follows: Denture indicated when: ( a) a cleft cannot be closed surgically; ( b) to close the nasopharyngeal space; ( c) to restore vertical dimension; ( d) to restore anteroposterior dimension; ( e) to restore lateral dimension; ( f) to restore occlusal plane. Denture contraindications in: ( a) case that can be corrected by orthodontia; ( b) case that can be corrected by bridgework; ( c) case that can be corrected by exercise; ( d) any case that has a possible chance of developing normally. 13. 13. Failure of palatal healing is not due to infection but to tension and destruction of blood supply. 14. 14. Suggestions for facilitating technic of early closure are as follows: ( a) use of suture in tongue; ( b) use of tongue depressor and elevator, “tongue controller”; ( c) use of catheter and wire for anesthetic in bilateral cleft lip cases; ( d) use of aspirator instead of sponge; ( e) use of smallest atraumatic needle and suture; ( f) cutting sutures short on the knot or 1 mm. long; ( g) leaving tongue suture in until baby is fully conscious; ( h) administration of fluids and food as soon as tolerated; ( i) penicillin routine for first week; ( j) sedation, as required; ( k) use of indwelling catheter for one or two weeks for food; ( l) no restraining of baby for inspection of palate postoperatively; ( m) availability of aspirator in room at all times; ( n) straight arm restraints of elbows during healing period to prevent fingers from getting into the mouth; and ( o) feeding with ear syringe, medicine glass, teaspoon or plastic cup with cover and spout.