Ridge augmentation planning, wound healing evaluation, and peri-implant tissue phenotype assessment with ultrasonography: A case report

BACKGROUND

Ridge regeneration for implant therapy requires comprehensive site evaluation and wound healing monitoring. This case report aimed to demonstrate ultrasound (US) can image soft and hard tissues for surgical planning and assess longitudinal outcomes.

METHODS AND RESULTS

US was used in a patient planned for ridge augmentation to evaluate soft tissue thickness, location of muscle attachment, and hard tissue defect features presurgically. US were obtained at 1, 2.5, and 5 months afterward to assess tissue healing. Preoperatively, US showed ∼2.5 mm and ∼0.8 mm soft tissue thickness on the facial and lingual sides, respectively. The crestal bone width was ∼2 mm, with severe facial bone deficiency and high muscle attachment. US showed wound approximation and ridge width gain to 4.5 and 4.0 mm at 1 and 5 months, respectively. US tissue perfusion increased to ∼two-fold and ∼4-fold at 1 and 2.5 months and reduced below the baseline at 5 months. An implant with simultaneous bone augmentation was performed accordingly. Tissue phenotype around the implant was measured on US images at 1-year visit.

CONCLUSIONS

This case report demonstrated that US parameters could be valuable for planning and wound healing outcome assessment of ridge augmentation in clinical as well as research settings.

KEY POINTS

Why is this case new information? Novel high-resolution, chairside ultrasound was proposed to facilitate treatment planning and wound healing outcome assessment of ridge augmentation in clinical as well as research settings. What are the keys to successful use of this technology? Proper training in imaging acquisition and interpretation Adhere to high-level disinfection protocol Patient education and explanation What are the primary limitations to success in using this technology? Investment in this technology Learning curve in imaging acquisition and reading Insurance reimbursement strategy.

Comparison between the Flapless Surgical Approach and a Novel Single Incision Access in Terms of Recovery Time and Comfort after Extraction of Impacted Inferior Third Molars: A Randomised, Blinded, Split-Mouth Controlled Clinical Trial

The recent attention to quality of life and oral health care procedures reflects a renewed 'patient-based' approach to dealing with non-life-threatening conditions. In the current study, we proposed a novel surgical approach to the extraction of impacted inferior third molars (iMs3) through a randomised, blinded, split-mouth controlled clinical trial following the CONSORT guidelines. The novel surgical procedure, hereinafter referred to as single incision access (SIA), will be compared with our previously described flapless surgical approach (FSA). The predictor variable was the novel SIA approach, involving access through a single incision without removal of soft tissue, on the impacted iMs3. The primary endpoint was the acceleration of the iMs3 extraction healing time. The secondary endpoints were the incidences of pain and oedema as well as gum health (pocket probing depth and attached gingiva). The study was carried out on 84 teeth of 42 patients with both iMs3 impacted. The cohort was composed of 42% Caucasian males and 58% Caucasian females, aged 23.8 ± 7.9 (17-49) years. We observed faster recovery/wound-healing on the SIA side (33.6 ± 4.3 days) than at the FSA side (42.1 ± 5.4 days; p < 0.05). The FSA approach confirmed the evidence previously detected concerning early post-surgery improvement in terms of attached gingiva and reduced oedema and pain, with respect to the traditional envelope flap. The novel SIA approach follows the early positive post-surgery FSA results.

[Application value of CTA combined with digital technology in the design of anterolateral thigh flap in repairing operative defect of head, neck and maxillofacial tumor resection]

Objective:To explore the value of computed tomography angiography （CTA） combined with digital technology in the vascular anatomy of the anterior thigh flap in patients with operative defects after head, neck and maxillofacial tumor operation, and in the design of preoperative and intraoperative flaps. Methods:Twenty-five cases of patients with postoperative defect after head, neck and maxillofacial tumor surgery admitted to our hospital from April 2018 to April 2019 were selected. Preoperative CTA and digital technology were used to clarify vascular anatomy and other related conditions, and the operation was carried out. Consistency analysis was applied to evaluate the value of CTA, digital technology and CTA combined digital technology in the localization of anterolateral thigh perforator flap with operative defects after head, neck and maxillofacial tumor resection, and the diagnostic efficacy of the three methods was compared. Results:The preoperative CTA examination revealed that there were 26 intermuscular perforators with a diameter greater than 0.8 mm in the flap donor site, and 17 musculocutaneous perforators with a diameter greater than 1.0 mm. During the operation, it was actually found that there were 27 intermuscular perforators with a diameter greater than 0.8 mm and 17 musculocutaneous perforators with a diameter greater than 1.0 mm. The accuracy rates of Pre-operative examination were 96.29% and 100.00%, respectively.In addition, the lateral femoral circumflex artery determined by digital technology. The starting position of the descending branch, the diameter of the vessel, the direction of the perforating vessel, and the maximum length of the pedicle that can be cut were consistent with the actual observation during the operation. All the patients in the group successfully underwent flap removal and repair. After the operation, 2 skin flaps suffered from vascular crisis, and survived under the managements of anticoagulation, lifting of restraint, and massage. The rest of the flaps survived smoothly. The patients were followed up for 3-12 months postoperatively. Twenty-four cases of skin flaps had good appearance. One case had swollen wound And the appearance of the skin flap was satisfactory after elective secondary thinning. Among the 25 patients with head and neck defects, in the perforator location examination, 18 cases were detected by CTA, with a sensitivity of 90.0%, a specificity of 60.0%, an accuracy of 84.0%, and Kappa=0.500. 19 cases was detected by digital technology, with a sensitivity of 86.36%, a specificity of 66.67%, a accuracy rate of 84.00%, and Kappa=0.412. 21 cases was detected by CTA combined with digital technology,with a sensitivity of 95.45%, a specificity of 66.67%, a accuracy of 92.00%, and Kappa=0.621. The accuracy of CTA combined with digital technology in the perforator positioning of patients with head and neck tumor defects was significantly higher than that of the single method（P<0.05）. Conclusion:CTA has good application value in the positioning of perforator in patients with head, neck and maxillofacial tumor defects. In addition, the combination of CTA and digital technology can improve the accuracy of the vascular anatomy of the anterior thighflap and the design of the preoperative and intraoperative flaps, which is beneficial to surgery clinical implementation.

Flapless Surgical Approach to Extract Impacted Inferior Third Molars: A Retrospective Clinical Study

This study aimed to compare a flapless surgical approach (FSA) with a traditional envelope flap (traditional approach (TA)). Every patient was treated with two approaches: TA and FSA. The primary outcome variables were both the discomfort during the post-operative convalescence and the correct final recovery of the impacted area. The secondary outcome variable was the average duration of the surgery. Post-operative pain and oedema were recorded. The measurements of soft tissue interface toward the distobuccal edge of the second molar were taken by periodontal probe before surgery (baseline) and 8 weeks after surgery. Statistical software was used to evaluate the data; a p-value < 0.05 was considered statistically significant. Twenty-four teeth of 12 patients (six Caucasian males and six Caucasian females, aged 23 ± 4 (17-30) years) with both lower impacted third molars (Ms3) were analysed. Considering an alpha error 0.05 that sample size allows power from 0.80 to 0.90, depending on the variable evaluated. Concerning attached gingiva, oedema and pain, the linear mixed model resulted in a statistically significant difference between the TA and FSA (p = 0.003; p < 0.01; and p = 0.018, respectively). Conversely, the model did not show a difference (p = 0.322) if pocket probing depth was considered. The FSA procedure was faster (p < 0.05) than the TA procedure (17 min and 8 s (±6 s) vs. 28 min and 6 s (±4 s), respectively). The results suggest that the FSA could be a suitable option for improving the surgical removal of lower Ms3. However, additional randomized controlled trial studies are necessary to confirm the reliability of our procedure and to verify its suitability in more complex Ms3 classifications.

Envelope or triangular flap for surgical removal of third molars? A systematic review and meta-analysis

The aim of this systematic review was to compare the triangular and envelope flaps in mandibular third molar surgery with regard to pain, oedema, and trismus. Secondary outcomes assessed were dehiscence, ecchymosis, alveolar osteitis, periodontal condition, and surgical time. The PRISMA guidelines and recommendations in the Cochrane Handbook were followed, and the review was registered before commencement (PROSPERO; CRD42018112373). The literature search was conducted in the Web of Science, PubMed, Virtual Health Library, Cochrane Library, and Scopus databases and in the grey literature; randomized clinical trials, indexed through November 2018 were included. Three reviewers independently examined the studies. Twenty studies were included in the qualitative analysis, of which 18 were included in the meta-analyses. The flap design did not influence pain, oedema, trismus, dehiscence, or osteitis. The triangular flap was associated with a greater occurrence of postoperative ecchymosis (odds ratio 4.58, 95% confidence interval 1.34 to 15.91, I²=0) and lower periodontal probing depth on day 7 postoperative (standardized mean difference -1.36, 95% confidence interval -2.68 to -0.03, I²=88%) when compared to the envelope flap in mandibular third molar surgeries.

Coronally advanced flap and envelope type of flap plus acellular dermal matrix graft for the treatment of thin phenotype multiple recession defects. A randomized clinical trial

INTRODUCTION

The aim of this randomized clinical trial was to assess the aesthetical and clinical outcomes of acellular dermal matrix graft (ADMG) plus coronally advanced flap (CAF) with vertical incisions or the envelope flap in the treatment of thin phenotype, multiple-recession defects.

MATERIAL AND METHODS

Twenty-two participants with 55 class recession type 1 (RT1) with a depth of ≥3 mm were investigated. Control group was treated with ADMG plus conventional CAF with vertical releasing incisions, whereas test group received the envelope flap with ADMG. Primary outcome variables were complete root coverage (CRC), root coverage aesthetic score and patient satisfaction.

RESULTS

Tooth-based CRC was observed in 23 of the 28 recession defects in mCAF + ADMG group (82.1%), whereas in 19 of the 27 recession defects in CAF + ADMG group (70.37%), with no inter-group difference (p > .05). CRC was observed in 9 of the 11 patients in mCAF + ADMG group (81.8%). On the other hand, in CAF + ADMG group, CRC was achieved in 8 of the 11 patients (72.7%). Results were similar between the groups (p > .05).

CONCLUSIONS

Both techniques were successful in the management of multiple recessions; however, superior results regarding patient's satisfaction were achieved with mCAF + ADMG.

[Effect of triangular flap design and healing procedure on the sequelae after extraction of impacted lower third molars]

OBJECTIVE

To evaluate the effect of different triangular flap design and healing procedure on the sequelae after extraction of impacted lower third molars.

METHODS

In this prospective, split-mouth study, 60 healthy patients with bilateral, symmetrically fully impacted lower third molars (LM3) were included, of whom 30 patients with totally bony impacted LM3 were allocated into group A, while the other patients with partially bony impacted LM3 were allocated into group B. All the teeth were extracted by the same surgeon. Triangular flap was used on one side, and the wound was primarily closed with two sutures (TF-P). On the other side, modified triangular flap was used with a triangular region of mucosa posterior to LM2 removed during operation, and a triangular soft tissue defect was left for drainage after suture (MTF-S). The patients were followed up on postoperative days 1, 3 and 7. Clinical parameters included postoperative pain, swelling, and trismus. Distal probing depth of adjacent second molar was assessed 6 months after extraction. Doctors responsible for the evaluation did not know the group and flap design. Paired sample t test was used to analyze the differences of postoperative sequelae between the two strategies.

RESULTS

In group A, MTF-S strategy could reduce postoperative pain, ibuprofen consumption, and swelling significantly compared with TF-P strategy on the postoperative 1st and 3rd days (P<0.05). Besides, the trismus in the patients with TF-P strategy was more serious than that with MTF-S strategy on the postoperative 1st, 3rd and 7th days (P<0.05). However, statistic difference between the two strategies in pain, swelling and trismus was not detected in group B. Additionally, the VAS score in the patients with MTF-S strategy in group B increased slightly on the postoperative 4th day. The probing depth of the adjacent second molar was evaluated 6 months after extraction. Statistic difference was not detected between MTF-S strategy and TF-P strategy in the both groups.

CONCLUSION

Modified triangular flap with secondary healing procedure could effectively reduce the postoperative complications of totally bony impacted LM3. However, the difference between the two strategies in the probing depth of the adjacent second molar was not statically significant 6 months after extraction.

Design of skin islands for a myocutaneous serratus anterior free flap-An anatomical study and clinical implication for pharyngeal reconstruction after laryngopharyngectomy

Objectives

The main purpose of this study was to evaluate flap size and flap design of skin islands in myocutaneous serratus anterior free flaps (SAFFs) in fresh cadavers and to further investigate whether myocutaneous SAFFs are suitable flaps for pharyngeal reconstruction after laryngopharyngectomy.

Methods

Dissection and injection of methylene blue were performed in 20 hemithoraces of 13 fresh cadavers to evaluate flap size and location of skin islands. Based on these pre‐clinical data, we performed pharyngeal reconstruction with myocutaneous SAFF in five patients after laryngopharyngectomy.

Results

Perfused skin paddles were found in all specimens with a mean size of perfused skin islands of 85.6 ± 49.8 cm². Lengths and widths of skin islands ranged from 10‐21 cm and 6‐20.5 cm respectively. Flap size did not significantly differ between males and females (P = 0.998), left compared to right hemithoraces (P = 0.468) and between paired specimens (P = 0.915). All skin islands were found within the upper 29.3%‐51.7% of hemithorax (calculated from axilla to costal arch), and between latissimus dorsi muscle posteriorly and anterior axillary line anteriorly. Accordingly, myocutaneous SAFFs were used for pharyngeal reconstruction after laryngopharyngectomy in five patients with advanced hypopharyngeal carcinomas. Three patients had uneventful courses, while one patient developed immediate intraoperative flap loss and another patient developed partial necrosis of SAFF on postoperative day 7.

Conclusion

Skin islands of SAFF have reliable blood supply, which allow harvest of large myocutaneous SAFFs that can be used also for pharyngeal reconstruction after laryngopharyngectomy.

Evaluation of two flap designs on the mandibular second molar after third molar extractions

BACKGROUND

The extraction of third molars is associated with some clinical outcomes and periodontal problems. It is imperative to note that the type of incision used in the surgery for the removal of the impacted third molar is critical. The design of the flap influences the healing of the surgically created defect and damage to the distal periodontal area of the adjacent second molar. However, till date, there have been conflicting reports on the influence of different flap designs used for the surgical removal of impacted third molars.

AIM

The present study aimed to comparatively evaluate the clinical outcomes and periodontal status of the adjacent second molar, when two different flap designs, namely, the envelope and the modified triangular flap designs were used.

MATERIALS AND METHODS

Sixty female patients with bilateral impacted third molars completed the study with envelope flap on one side and modified triangular flap design on the other side of the mandible for third molar removal. Clinical parameters including pain, dehiscence and swelling were assessed postoperatively and periodontal probing depth (PPD) on the distal aspect of adjacent second molar were assessed both pre- and post-operatively.

RESULTS

The results were assessed on 1, 3 and 8 days for pain using visual analog scale. The subjective perception of swelling was evaluated on 3, 7 and 15 days postoperatively in a similar manner. The results of the periodontal parameters were evaluated both preoperatively and 3 months postoperatively, with cautious exploration using a University of North Carolina (UNC)-15 periodontal probe. The statistically significant results for swelling and PPD were noted for the two flap groups using the Chi-square test (P < 0.05).

CONCLUSION

The study revealed that the modified triangular flap had lesser postoperative PPDs and dehiscence. The envelope flap was better when swelling was analyzed. The pain scores, though slightly higher for the modified triangular flap group, were not statistically significant.

Anatomic and physiological fundamentals for autologous breast reconstruction

The success of autologous tissue transfer is reliant on adequate blood supply and as we endeavour to tailor our reconstructive options through our flap choices and design. Autologous breast reconstruction has made substantial progress over the years and the evolution of refinements over the last 30 years has allowed flaps to be based on specific perforators. The ultimate goal of breast reconstruction following mastectomy is to match optimal tissue replacement with minimal donor-site expenditure. In parallel surgeons will seek ways to ensure safe flap design and harvest while maintaining predictability and reliable tissue perfusion. Better understanding of the vascular anatomy and physiology of the cutaneous circulation of soft tissues, and that of patterns of blood flow from individual perforator has provided insight to advance perforator flap harvest and modifications in flap design. The aim of this article is to review the principles of blood supply and flap design exemplified through common flaps used in autologous breast reconstructive surgery, to better understand approaches for safe flap harvest and transfer of well perfused tissue.

Flap approaches in plastic periodontal and implant surgery: critical elements in design and execution

AIM

To identify critical elements in design and execution of coronally advanced flap, lateral positioned flap and their variations for the treatment of facial gingival recessions or peri-implant soft tissue dehiscences.

MATERIALS AND METHODS

Clinical studies were identified with both electronic and hand searches, and examined for the following aspects: flap design and incision techniques, flap elevation, root conditioning, flap mobility, flap stability and suturing. Moreover, prognostic factors for complete recession coverage were identified.

RESULTS

Some critical elements are evident in flap design and execution: the dimension and the thickness of tissue positioned over the denuded roots; the use on root surface of enamel matrix derivate; the stability and suturing of the flap in a position coronal to the cemento-enamel junction. The pre-determination of the clinical cemento-enamel junction, smoking status, operator surgical skills and the compliance to a supportive care programme have a role in obtaining and maintaining a complete root coverage.

CONCLUSIONS

Different flap approaches are available when performing periodontal plastic surgery, resulting in a great variability in clinical outcomes. The possibility of using pedicle flaps alone to achieve complete soft tissue coverage of facial implant dehiscence has not yet been investigated.