Pulp Reconstruction Research Articles

The Experimental Study of the Performance of Nano-Thin Polyelectrolyte Shell for Dental Pulp Stem Cells Immobilization.

Carious is the most frequent disease of mineralized dental tissues which might result in dental pulp inflammation and mortality. In such cases an endodontic treatment is the only option to prolong tooth functioning in the oral cavity; however, in the cases of severe pulpitis, especially when complicated with periodontal tissue inflammation, the endodontic treatment might not be enough to protect against tooth loss. Thus, keeping the dental pulp viable and/or possibility of the reconstruction of a viable dental pulp complex, appears to become a critical factor for carious and/or pulp inflammation treatment. The nowadays technologies, which allow handling dental pulp stem cells (DPSC), seem to bring us closer to the usage of dental stem cells for tooth tissues reconstruction. Thus, DPSC immobilized within nano-thin polymeric shells, allowing for a diffusion of produced factors and separation from bacteria, may be considered as a cover system supporting technology of dental pulp reconstruction. The DPSC were immobilized using a layer-by-layer technique within nano-thin polymeric shells constructed and modified by nanostructure involvement to ensure the layers stability and integrity as well as separation from bacterial cells. The cytotoxity of the material used for membrane production was assessed on the model of adherent cells. The performance of DPSC nano-coating was assessed in vitro. Membrane coatings showed no cytotoxicity on the immobilized cells. The presence of coating shell was confirmed with flow cytometry, atomic force microscopy and visualized with fluorescent microscopy. The transfer of immobilized DPSC within the membrane system ensuring cells integrity, viability and protection from bacteria should be considered as an alternative method for dental tissues transportation and regeneration.

Early detection of pulp necrosis and dental vitality after traumatic dental injuries in children and adolescents by 3-Tesla magnetic resonance imaging

ObjectivesMore than 50% of all children suffer a traumatic dental injury (TDI) during childhood. In many cases, dentists apply root canal treatment (RCT), which is performed on an average of 7–10 days after replantation. Our aim was to evaluate whether RCT is necessary in many cases, and whether revitalization of affected teeth is possible and measurable by visualization using 3T magnetic resonance imaging (MRI). Material and methodsSeven healthy children with TDI were treated by repositioning of the affected teeth and reduction of alveolar process fractures followed by splinting. Two weeks after initial treatment, splints were removed. After 6 weeks, all children received 3-Tesla (3T), three-dimensional, high-resolution MRI with a 20-channel standard head and neck coil. The mean age of the children (male/female = 5:2) was 10.8 years (range, 8–17 years). In addition, all children received conventional dental examination for tooth vitality and dental sensitivity to cold and tenderness on percussion. Results3T MRI provided excellent images that allowed fine discrimination between dental pulp and adjacent tooth. Using four in-house optimized, non-contrast-enhanced sequences, including panoramic reconstruction, the assessment and analysis of the dental pulp was sufficiently feasible. We could demonstrate reperfusion and thus vitality of the affected teeth in 11 sites. In one child, MRI was able to detect nonreperfusion after TDI of the affected tooth. MRI results were confirmed by clinical examination in all cases. As a consequence of this expectant management and proof of reperfusion and tooth vitality by 3T MRI, only one child had to be treated by RCT. Conclusion3T MRI is a very promising tool for visualization and detection in the field of dental and oromaxillofacial diseases. By using new 3T MRI sequences in children with TDI, we could demonstrate that RCT are not necessary in every case, and thus could prevent unnecessary treatment of children in the future. Larger studies should follow to confirm the potential benefit in clinical practice.

Free lateral great toe flap for the reconstruction of finger pulp defects.

The aim of this study was to evaluate the esthetic and sensory outcomes after reconstruction of finger pulp defects with free toe flaps from the lateral aspect of the great toe. From June 2006 to October 2011, we performed 48 free toe pulp transfers for finger pulp reconstruction in 43 patients; 18 male and 25 female patients with a mean age of 31.8 years (range, 16-47 years). Six patients suffered multiple digital pulp defects and five received two synchronous pulp transfers. The defects involved 20 thumbs, 15 index fingers, 10 long fingers, and 4 ring fingers, and flap size ranged from 24 × 18 to 55 × 30 mm. Follow-up evaluation included the functional and esthetic outcomes of the reconstructed pulps and donor toes. All but one flap survived completely. Overall, 32 cases (35 pulp flaps) were followed for more than 1 year (range, 12-48 months; average, 22.8 months). The Semmes-Weinstein sensitivity score was 2.83 to 4.74 at the flaps and the mean static two-point discrimination was 6.17 mm (range, 3-10 mm). A total of 13 patients (40.6%) experienced mild (10 cases) to moderate (3 cases) cold intolerance, and 1 patient (3.1%) suffered severe cold intolerance. According to the Michigan Hand Outcome Questionnaire the mean esthetic appearance score was 16 (range, 12-19). The free neurovascular great toe pulp flap is an efficient and reliable flap for the reconstruction of finger pulp defects.

New technique "graft reposition on flap" in allen type iv amputation: a report of six cases.

Allen type IV fingertip amputations were treated by a modified technique, when the replantation is difficult to be performed or not an option. The pre-existing technique involves nail bed grafting and local flap. In the modified technique, a free bone graft is added, bone and free nail bed repositioned and pulp reconstruction by local flap. This can be best described "graft reposition on flap" (GRF). GRF was found to be simple and cost effective. It allows preservation of finger length and a fully functional and cosmetically acceptable nail.

Aesthetic and Functional Results From Nailfold Recession Following Fingertip Amputations

To analyze the aesthetic and functional results of a technique for nail salvage by recessing the nailfold to increase the exposed nail matrix after fingertip amputation. Thirty cases of fingertip amputation with distal partial nail bed defects underwent nailfold recession and pulp reconstruction. We increased nail bed exposure by recessing a rectangle flap of eponychium and reconstructed the pulp with different local flaps depending on the injury geometry. A 0.3- to 0.4-cm-wide rectangular strip of eponychium was de-epithelialized. The eponychial flap was separated from the nail matrix and slid proximally to expose more nail matrix, thereby effectively lengthening the exposed nail bed. The flaps survived in all patients. The exposed nail beds were lengthened 0.3 to 0.4 cm and enlarged 38% to 100%. The fingertips had smooth and natural nail plates with inconspicuous scars on both the eponychium and pulp and no deformities. The sensation and mobility of injured and uninjured contralateral fingers did not differ statistically. All patients were satisfied with the appearance and function of the reconstructed fingertips. Nailfold recession combined with different local flaps provided for the aesthetic and functional restoration of the fingertip after amputation with partial nail bed defect.

Microsurgical Reconstruction of Partial and Total Amputation of the Finger Nail Apparatus

Introduction: Amputation and defect of the finger nail system is a relatively frequent pathology often associated to the injury and amputation of the finger pulp. Its reconstruction is often neglected instead of the reconstruction of the skin finger pulp.

Dorsal digital advancement flaps vascularized with digital arteries for repair of finger pulp defect

Objective To investigate the effect of dorsal digital island advancement flaps accompanied with digital arteries in reconstruction of finger pulp defect.Methods The study enrolled 36 cases (43 fingers) of pulp soft tissue defect treated from October 2007 to July 2011.There were 25 males (30 fingers) and 1l females(13 fingers),at age of 12-62 years (mean 34.5 years).Causes of injury included crushing in 19 cases (16 fingers),squeezing in 13 (16 fingers) and cutting in 4 (5 fingers).The fingers involved were the index (11),the middle (18),the ring (9),and the little (5).All wounds revealed the exposed bone with defect area ranging from 1.2 cm × 1.0 cm to 2.6 cm × 2.0 cm.Dorsal digital island flaps accompanied with digital artery were used for finger reconstruction and sensation was restored by anastomosing to dorsal branch of digital nerve.Donor sites were closed using skin grafts.Results All flaps survived.Thirty-three cases (39 fingers) were followed up for 5-26 months (mean 14.5 months).The flaps revealed satisfactory appearance,soft texture and good elasticity.The injured fingers were pain-free.Two point discrimination was 5-8 mm (mean 6.7 mm).According to the upper limb function criteria formulated by Hand Surgery Branch of Chinese Medical Association,the results were excellent in 24 fingers,good in 13 fingers,and fair in 2 fingers,with the excellence rate of 95％.Conclusion Dorsal digital advancement island flap vascularized with digital artery is relatively the best for finger pulp coverage,for the procedure is easy and safe,with satisfactory result. Key words: Finger injuries; Surgical flaps; Reconstruction

A Comparison of the Dorsal Digital Island Flap with the Dorsal Branch of the Digital Nerve versus the Dorsal Digital Nerve for Fingertip and Finger Pulp Reconstruction

Traumatic fingertip and finger pulp defects can be treated with dorsal digital island flaps. Either the dorsal branch of the digital nerve or the dorsal digital nerve can be included in the flap for sensory reconstruction. However, it is still unclear whether there are differences in the results between the two donor nerves. A retrospective study was conducted in 71 patients who had a fingertip or finger pulp defect treated with an innervated dorsal digital island flap from February of 2005 to June of 2011. The patients were divided into two groups based on which donor nerve was chosen. The donor nerve was coaptated to the digital nerve in the defect. At the final follow-up, the two groups were compared for static two-point discrimination, Semmes-Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, and patient satisfaction. Significant differences were found in static two-point discrimination, pain, cold intolerance, and patient satisfaction (p < 0.05). The dorsal branch group presented slightly better discriminatory sensation in the flap and lower incidence of pain and cold intolerance in the injured finger. In addition, the dorsal branch group had a larger degree of satisfaction than the dorsal digital nerve group. No significant differences were found regarding Semmes-Weinstein monofilament flap score and total active motion of the finger. When utilizing dorsal digital island flaps to reconstruct traumatic fingertip and finger pulp defects, choosing the dorsal branch rather than the dorsal digital nerve as the donor may attain better outcomes. Therapeutic, III.

Free medial plantar artery flap for the reconstruction of great toe pulp

The great toe is an important body structure both functionally and cosmetically. The defect over the great toe is very challenging to treat. Our patient was a 9-year-old boy, presenting with posttraumatic loss of partial right great toe pulp. The mode of injury was the toe getting caught in the cycle wheel and sustaining amputation of the plantar aspect of the great toe. The great toe with exposed bone was reconstructed with a free medial plantar artery flap, harvested from the same limb. To our best knowledge, this was the first reported case of free medial plantar artery flap used for the reconstruction of great toe defects.

Deletion of Serotonin 2B Receptor Provokes Structural Alterations of Mouse Dental Tissues

Rampant caries and periodontal diseases occur in patients treated with antidepressants such as serotonin reuptake inhibitors (SRIs; e.g., Prozac) which target the serotonin transporter (SERT). As the serotonin 2B receptor (5HT2BR) regulates SERT functionality and capacity to recognize SRIs, we investigated the potential role of 5HT2BR on dental tissues by exploiting 5HT2BR knockout (KO) mice. Compared to wild-type (WT) mice, several structural differences were identified in the teeth of KO mice. In the molar of KO mice, rod curvatures and twisting were altered compared to WT mice, suggesting involvement of 5HT2BR at early stages of enamel formation. The volume of the KO enamel layer was also reduced, and larger porosities were observed in the prismatic enamel, with smaller crystallite thickness. Crystallite pattern disorganization and occlusal abrasion were enhanced in female KO mice, indicating a sexual dimorphism. In the incisor, no difference was detected in the width of the enamel layer between KO and WT mice; however, enamel maturation differed in absence of 5HT2BR. Specifically, the outer aprismatic enamel border was 1.5- to 2-fold larger in KO compared to WT mice, together with a decreased etching pattern. Finally, although no noticeable difference was observed in dentin, the micro-CT three-dimensional pulp reconstruction evidenced a decrease in both length and width of dentin formation in the root canals of the KO versus WT mice. These data provide evidence that 5HT2BR-mediated signaling pathways are involved in enamel formation and dentinogenesis.

Primary functional and aesthetic restoration of the fingernail in distal fingertip amputations with the eponychial flap

Fingertip injuries often result in fingernail defects. Reconstruction of this structure is important for adequate functional and aesthetic results. This study evaluates the eponychial flap reconstruction technique in 45 fingertip amputations with loss of more than half the fingernail. In 33 cases the procedure was performed in combination with a palmar island flap for pulp reconstruction. Average follow up was 5 months. All eponychial flaps healed uneventfully. In 44 cases, the pulp volume was restored without nail growth disturbance. Five complications (9%) were observed (pain, soft nail, and nail deformity). Only one hook nail deformity required reoperation. All patients were satisfied with the aesthetic and functional outcome. We found eponychial flap fingernail reconstruction effective even for injuries proximal to the lunula and have extended the indication for this technique to very proximal fingernail defects. Eponychial flap reconstruction is a simple, safe, and time-effective technique without donor site morbidity. Simultaneous reconstruction of dorsal and palmar injuries should both be performed primarily resulting in the restoration of a satisfying fingertip.

A technique for the non-microsurgical reconstruction of thumb tip amputations

This article aims to present a technique for thumb tip amputations using a homodigital soft-tissue/periosteum flap and a portion of the amputated digit. Eight patients (aged 21-53 years) with avulsion thumb tip amputations were reviewed. We report a new technique in which a bone and nailbed composite graft was taken from the amputated portion of the thumb and a dorsoulnar flap combined with periosteum was harvested from the first metacarpal and designed to cover the volar bone. Patients were evaluated 6 months after surgery for functional and cosmetic outcomes. The radiographic evaluation showed bone healing in all of the patients 5 weeks postoperatively. With regard to pulp reconstruction, there was good recovery of static two-point discrimination. For both the reconstructed area and the donor site, the final results were good in terms of reliability and coverage as well as from a cosmetic perspective. This technique was found to be safe and effective. It is a good option for the non-microsurgical reconstruction of crushed and avulsed amputations of the distal thumb.

Digital Pulp Reconstruction with Free Neurovascular Toe Flaps

Finger pulp defects are commonly encountered in clinical settings and their treatment remains a consistent challenge for plastic and hand surgeons. Reconstruction should restore, as much as possible, the contour of the pulp as well as discriminating sensibility. Following the prime reconstructive principle of replacing "like with like," the free neurovascular toe pulp flap seems to be the optimal choice for digital pulp reconstruction because of the natural similarity of the digital pulp both anatomically and physically. However, after about 30 years of experience with this procedure, it is still controversial because it is technically demanding, involves donor site morbidity, and its reliability is questionable. With other small free flaps available, the application of this flap has been challenged and reconsidered. In this review we specifically focus on the reconstruction of soft tissue defects of digital pulp using the free neurovascular toe flap, aiming to investigate its advantages and drawbacks and obtain a comprehensive understanding of this procedure. The latest reconstruction concerns and technical refinements are also discussed. This journal requires that authors assign a level of evidence to each article.

Finger pulp reconstruction with free flaps from the upper extremity

Although never exceeding a few square centimeters, finger pulp defects are reconstructive challenges due to their special requirements and lack of neighboring tissue reserve. Local flaps are the common choice in the management of this injury. However, the development of microsurgery and clinical practice have greatly boosted the application of different free flaps for finger pulp reconstruction with excellent results, especially when local flaps are unsuitable or impossible for the coverage of large pulp defects. These flaps are all located in the same operation field and can be performed under one tourniquet; therefore, they are more convenient with better patients' compliance in clinical setting. Nonetheless, there is still no consensus about which type of these flaps should be preferred among various finger pulp reconstructive options. In this article, we attempt to review articles describing finger pulp reconstruction using free flaps from the upper extremity from the literature. We summarize the clinical applications of these free flaps and detail their advantages and drawbacks, respectively. The algorithm of flap selection for finger pulp reconstruction based on our experience and literature review is also discussed.

A comparative study of finger pulp reconstruction using arterialised venous sensate flap and insensate flap from forearm

The aim of this study was to investigate the feasibility of finger pulp reconstruction using arterialised venous flaps from forearm and compare the outcomes of arterialised venous sensate flap and insensate flap. Twenty-seven arterialised venous flaps were reviewed retrospectively in the reconstruction of finger pulp defects in 23 patients, including 15 sensate flaps (sensate group) and 12 insensate flaps (insensate group). Nine flaps in this series were harvested from the dorsal aspect of the forearm and the other 18 were harvested from the volar aspect. Standardised assessment of outcomes in terms of objective sensory recovery, pinch power of the reconstructed digits, cold intolerance and time of returning to work was completed. All flaps survived completely. Twenty-six flaps were available for follow-up of more than 9 months (mean, 15.4 months). Almost all the flaps in the sensate group obtained normal sensation, while most cases of the insensate group only achieved protective sensation. Cold intolerance was present in most cases of the insensate group in comparison with the sensate group with only one case suffering from slight cold intolerance. There was no significant difference of pinch power between the two groups. All the patients were contented with the aesthetic outcomes of the surgery. The arterialised venous sensate flap from forearm is a practical alternative for finger pulp reconstruction with satisfactory functional and aesthetic outcomes. The forearm region can be an acceptable donor site for arterialised venous sensate flap in the reconstruction of larger finger pulp defect.

Finger Pulp Reconstruction with Free Dorsoulnar Artery Perforator (DUAP) Flap

Finger pulp is a common site for hand injuries, and pulp reconstruction is significantly important for optimal handling and sensation. Ideal substitute must provide matching texture, tenacity, and slim subcutaneous fat. This article presents six cases in which fingertip and finger pulp reconstruction were performed via free dorsoulnar artery perforator (DUAP) flap. All flaps survived and all patients healed uneventfully without any complications by the end of at least 3 months follow-up. Free DUAP flap has proved to be a suitable substitute for pulp reconstruction with its thin structure, minimally morbid donor site which is also close to the trauma zone, and possibility for neurotization. It can be especially favorable when splitting the surgical team for a glabrous flap harvest from the foot is not possible.

Foucher First Dorsal Metacarpal Artery Flap Versus Littler Heterodigital Neurovascular Flap in Resurfacing Thumb Pulp Loss Defects

Our study aims to illustrate the advantages and disadvantages of Foucher's first dorsal metacarpal artery flap and Littler's heterodigital neurovascular flap in thumb pulp reconstruction, by assessing wound healing of donor and recipient sites, sensibility, and functional outcome of the reconstructed thumb. Fourteen male patients were reconstructed either with Foucher (n = 8) or Littler flap (n = 6). Dissection of Foucher's flap was faster than that of Littler's flap. All Littler flaps survived completely, but we experienced 1 partial Foucher flap necrosis. Thumb motility and stability was optimal in all patients. Wound healing of donor sites was achieved in both groups. Two patients reconstructed with Littler flap developed scar contractures and presented a reduced range of motion of donor finger and first webspace, respectively. Although Littler flap resulted in better sensibility and tactile gnosis of the reconstructed thumb-pulp, Foucher flap ensured negligible donor site morbidity, complete cortical reorientation, and better overall hand function.

Reply: Randomized Prospective Study Comparing Reverse and Direct Flow Island Flaps in Digital Pulp Reconstruction of the Fingers

Reply: Randomized Prospective Study Comparing Reverse and Direct Flow Island Flaps in Digital Pulp Reconstruction of the Fingers

Randomized Prospective Study Comparing Reverse and Direct Flow Island Flaps in Digital Pulp Reconstruction of the Fingers

Randomized Prospective Study Comparing Reverse and Direct Flow Island Flaps in Digital Pulp Reconstruction of the Fingers

The outcome of direct-flow neurovascular island flaps in pulp defects

In this study we aimed to evaluate the results of the direct-flow neurovascular island flap (NIF) transfers in pulp defects. We reviewed the records of 96 patients with 115 NIF transfers performed for pulp defect reconstruction. The injury mechanism was crush type injury in 70 patients (72.9%). Ninety-three patients (97%) were emergency cases. Pulp reconstruction was performed by means of pedicled island flap transfer. The results were evaluated with proximal interphalangeal joint range of motion, the Semmes Weinstein monofilament test, static two-point discrimination and cold intolerance assessments. The relations between the injury mechanism, patient satisfaction, cold intolerance and scar problems were analyzed. Also, the association between skin grafting and hook nail deformity was investigated. The level of significance was set at p<0.05. All flaps survived. The mean follow-up time was 41±20.3 (range: 12-108) months. We observed proximal interphalangeal joint flexion contracture in 11 (9.5%) cases. In seven of these, the limitation was less than 10 degrees. Hook nail deformity was seen in 8 fingers (7%). Cold intolerance was found in 16 (17%) cases. Semmes Weinstein monofilament and static-two point discrimination tests of flaps revealed satisfactory results. There was no relation between the injury mechanism and cold intolerance, patient satisfaction and scar problems (p>0.05). Among patients, 91.7% were satisfied with their results. The transfer of direct-flow island flaps, from the same finger, causes minimal morbidity on the donor site and appears to be a safe method, providing satisfactory functional and aesthetic results in the reconstruction of pulp defects.