Cyst Formation After Subepithelial Connective Tissue Grafting: Management and Review.

Lesion formation after soft tissue gingival grafting is a rare but challenging clinical scenario to manage. This report presents a unique case of cyst formation after connective tissue grafting. All previously reported cases are confined to the mandibular labial lateral-canine space, whereas the present case is the first found in the maxilla. These cysts manifest clinically 9 months to 1.5 years after grafting and may communicate with the surface, as evidenced by sinus tract or cystic discharge. Because of the unique nature of these lesions with respect to clinical history, appearance, symptoms, and location, the differential diagnosis should be limited. The treatment recommendation is complete surgical excision, which should eliminate the risk of recurrence. In this report, a novel case is presented, and the literature is reviewed to discuss etiology and provide treatment recommendations. Int J Periodontics Restorative Dent 2023;43:257-263. doi: 10.11607/prd.5300.

Evaluation of complete-arch implant scanning with 5 different intraoral scanners in terms of trueness and operator experience.

STATEMENT OF PROBLEM: The intraoral scanning of the edentulous arch might be challenging for an inexperienced operator because of the large mucosal area and the use of scan bodies. PURPOSE: The purpose of this ex vivo study was to compare the trueness of 5 intraoral scanners in replicating implant scan bodies and soft tissues in an edentulous maxilla and to investigate the effects of operator experience. MATERIAL AND METHODS: The maxilla was resected from a fresh cadaver, 5 implants placed, and a reference scan made. Eight scans were made by experienced operators and 8 by an inexperienced operator with each scanner (iTero Element 2, Medit i500, Primescan, TRIOS 3, TRIOS 4). The implant platform deviation was measured after complete surface alignment and after scan body alignment. Deviation data were analyzed with a generalized linear mixed model (α=.05). RESULTS: After complete surface alignment, the mean ±standard deviation implant platform deviation was higher for the inexperienced operator (421 ±25 µm) than for experienced ones (191 ±12 µm, P<.001) for all scanners. After scan body alignment, no significant differences were found between operators for Element 2, Primescan, and TRIOS 3. The experienced operators produced a lower deviation for TRIOS 4 (35 ±3.3 µm versus 54 ±3.1 µm, P<.001), but higher deviation for i500 (68 ±4.1 µm versus 57 ±3.6 µm, P<.05). The scanner ranking was Element 2 (63 ±4.1 µm), i500 (57 ±3.6 µm, P=.443), TRIOS 4 (54 ±3.1 µm, P=.591), TRIOS 3 (40 ±3.1 µm, P<.01), Primescan (27 ±1.6 µm, P<.001) for the inexperienced operator and i500 (68 ±4.1 µm), Element 2 (58 ±4.0 µm, P=.141), TRIOS 3 (41 ±2.8 µm, P<.001), TRIOS 4 (35 ±3.3 µm, P=.205), Primescan (28 ±1.8 µm, P=.141) for the experienced operators. CONCLUSIONS: Mucosal alignment greatly overestimated the platform deviation. The intraoral scanners showed different trueness during the complete-arch implant scanning. The operator experience improved the trueness of the edentulous mucosa but not implant platform deviation.

Evaluation of the trueness and precision of complete arch digital impressions on a human maxilla using seven different intraoral digital impression systems and a laboratory scanner.

OBJECTIVES: An impression accuracy study using a cadaver maxilla was performed using both prepared and intact teeth as well as palatal tissue. MATERIALS AND METHODS: Three crown preparations were performed on a cadaver maxilla. Seven different digital impression systems along with polyvinylsiloxane impressions were used to create digital models of the maxilla. Three-dimensional (3D) files of the experimental models were compared to a master model. The 3D files were overlaid and analyzed using a comparison software to create color coded figures that were measured for deviations between the master and experimental models. RESULTS: For scanning tooth structure, only the Planscan was significantly less accurate than the rest of impression techniques. No significant differences in accuracy were found between models created using digital impressions and those created from traditional vinyl polysiloxane impressions with cross arch deviations ranging from 18 to 39 µm for each. CONCLUSIONS: Impressions taken using all digital impression systems, save for the Planscan, were able to accurately replicate the tissues of a complete arch human maxilla. CLINICAL SIGNIFICANCE: Studies examining accuracy of digital impression systems have generally been performed on materials other than dental tissues. Optically, materials such as plastic and metal have properties different from enamel and dentin. This study evaluates accuracy of digital impression systems on human dentin, enamel, and soft tissues.

Evaluation of the effect scan pattern has on the trueness and precision of six intraoral digital impression systems.

OBJECTIVE: Clinicians have been slow to adopt digital impression technologies due possibly to perceived technique sensitivities involved in data acquisition. This research has two aims: determine whether scan pattern and sequence affects the accuracy of the three-dimensional (3D) model created from this digital impression and to compare the 5 imaging systems with regards to their scanning accuracy for sextant impressions. MATERIALS AND METHODS: Six digital intraoral impression systems were used to scan a typodont sextant with optical properties similar to natural teeth. The impressions were taken using five different scan patterns and the resulting digital models were overlayed on a master digital model to determine the accuracy of each scanner performing each scan pattern. Furthermore, regardless of scan pattern, each digital impression system was evaluated for accuracy to the other systems in this same manner. RESULTS: No differences of significance were noted in the accuracy of 3D models created using six distinct scan patterns with one exception involving the CEREC Omnicam. Planmeca Planscan was determined to be the truest scanner while 3Shape Trios was determined to be the most precise for sextant impression making. CONCLUSIONS: Scan pattern does not significantly affect the accuracy of the resulting digital model for sextant scanning. CLINICAL SIGNIFICANCE: Companies who make digital impression systems often recommend a scan pattern specific for their system. However, every clinical scanning scenario is different and may require a different approach. Knowing how important scan pattern is with regards to accuracy would be helpful for guiding a growing number of practitioners who are utilizing this technology.

Anatomic Customization of Root-Analog Dental Implants With Cone-Beam CT and CAD/CAM Fabrication: A Cadaver-Based Pilot Evaluation.

Existing root-analog dental implant systems have no standardized protocols regarding retentive design, surface manipulation, or prosthetic attachment design relative to the site's unique anatomy. Historically, existing systems made those design choices arbitrarily. For this report, strategies were developed that deliberately reference the adjacent anatomy, implant and restorable path of draw, and bone density for implant and retentive design. For proof of concept, dentate arches from human cadavers were scanned using cone-beam computed tomography and then digitally modeled. Teeth of interest were virtually extracted and manipulated via computer-aided design to generate root-analog implants from zirconium. We created a stepwise protocol for analyzing and developing the implant sites, implant design and retention, and prosthetic emergence and connection all from the pre-op cone-beam data. Root-analog implants were placed at the time of extraction and examined radiographically and mechanically concerning ideal fit and stability. This study provides proof of concept that retentive root-analog implants can be produced from cone-beam data while improving fit, retention, safety, esthetics, and restorability when compared to the existing protocols. These advancements may provide the critical steps necessary for clinical relevance and success of immediately placed root-analog implants. Additional studies are necessary to validate the model prior to clinical trial.

A novel technique for reference point generation to aid in intraoral scan alignment.

OBJECTIVE: When using a completely digital workflow on larger prosthetic cases it is often difficult to communicate to the laboratory or chairside Computer Aided Design and Computer Aided Manufacturing system the provisional prosthetic information. The problem arises when common hard tissue data points are limited or non-existent such as in complete arch cases in which the 3D model of the complete arch provisional restorations must be aligned perfectly with the 3D model of the complete arch preparations. In these instances, soft tissue is not enough to ensure an accurate automatic or manual alignment due to a lack of well-defined reference points. A new technique is proposed for the proper digital alignment of the 3D virtual model of the provisional prosthetic to the 3D virtual model of the prepared teeth in cases where common and coincident hard tissue data points are limited. Clinical considerations: A technique is described in which fiducial composite resin dots are temporarily placed on the intraoral keratinized tissue in strategic locations prior to final impressions. These fiducial dots provide coincident and clear 3D data points that when scanned into a digital impression allow superimposition of the 3D models. CONCLUSIONS: Composite resin dots on keratinized tissue were successful at allowing accurate merging of provisional restoration and post-preparation 3D models for the purpose of using the provisional restorations as a guide for final CLINICAL SIGNIFICANCE: Composite resin dots placed temporarily on attached tissue were successful at allowing accurate merging of the provisional restoration 3D models to the preparation 3D models for the purposes of using the provisional restorations as a guide for final restoration design and manufacturing. In this case, they allowed precise superimposition of the 3D models made in the absence of any other hard tissue reference points, resulting in the fabrication of ideal final restorations.

Mitochondrial uncoupling protein 2 induces cell cycle arrest and necrotic cell death.

Uncoupling protein 2 (UCP2) is a mitochondrial membrane protein that regulates energy metabolism and reactive oxygen species (ROS) production. We generated mouse carboxy- and amino-terminal green fluorescent protein (GFP)-tagged UCP2 constructs to investigate the effect of UCP2 expression on cell proliferation and viability. UCP2-transfected Hepa 1-6 cells did not show reduced cellular adenosine triphosphate (ATP) but showed increased levels of glutathione. Flow cytometry analysis indicated that transfected cells were less proliferative than nontransfected controls, with most cells blocked at the G1 phase. The effect of UCP2 on cell cycle arrest could not be reversed by providing exogenous ATP or oxidant supply, and was not affected by the chemical uncoupler carbonyl cyanide-p-trifluoromethoxyphenylhydrazone (FCCP). However, this effect of UCP2 was augmented by treatment with genistein, a tyrosine kinase inhibitor, which by itself did not affect cell proliferation on control hepatocytes. Western blotting analysis revealed decreased expression levels of CDK6 but not CDK2 and D-type cyclins. Examination of cell viability in UCP2-transfected cells with Trypan Blue and Annexin-V staining revealed that UCP2 transfection led to significantly increased cell death. However, characteristics of apoptosis were absent in UCP2-transfected Hepa 1-6 cells, including lack of oligonucleosomal fragmentation (laddering) of chromosomal DNA, release of cytochrome c from mitochondria, and cleavage of caspase-3. In conclusion, our results indicate that UCP2 induces cell cycle arrest at G1 phase and causes nonapoptotic cell death, suggesting that UCP2 may act as a powerful influence on hepatic regeneration and cell death in the steatotic liver.

Cerulenin blockade of fatty acid synthase reverses hepatic steatosis in ob/ob mice.

Fatty liver or hepatic steatosis is a common health problem associated with abnormal liver function and increased susceptibility to ischemia/reperfusion injury. The objective of this study was to investigate the effect of the fatty acid synthase inhibitor cerulenin on hepatic function in steatotic ob/ob mice. Different dosages of cerulenin were administered intraperitoneally to ob/ob mice for 2 to 7 days. Body weight, serum AST/ALT, hepatic energy state, and gene expression patterns in ob/ob mice were examined. We found that cerulenin treatment markedly improved hepatic function in ob/ob mice. Serum AST/ALT levels were significantly decreased and hepatic ATP levels increased in treated obese mice compared to obese controls, accompanied by fat depletion in the hepatocyte. Expression of peroxisome proliferator-activated receptors α and γ and uncoupling protein 2 were suppressed with cerulenin treatment and paralleled changes in AST/ALT levels. Hepatic glutathione content were increased in some cases and apoptotic activity in the steatotic livers was minimally changed with cerulenin treatment. In conclusion, these results demonstrate that fatty acid synthase blockade constitutes a novel therapeutic strategy for altering hepatic steatosis at non-stressed states in obese livers.

Methamphetamine abuse and oral health: a pilot study of "meth mouth".

Abuse of methamphetamine (meth), a potent central nervous system stimulant, has been associated with significant dental disease. Current descriptions of "meth mouth" are limited in their scope and fail to illuminate the potential pathogenic mechanisms of meth for oral disease. The purpose of this pilot study was to characterize the oral health of subjects with a history of meth abuse as compared to nonabusing control subjects. A total of 28 meth abusers and 16 control subjects were enrolled. Interviews and surveys regarding meth abuse, dental history, oral hygiene, and diet were collected. A comprehensive oral cavity examination including salivary characterization was completed. We observed significantly higher rates of decayed surfaces, missing teeth, tooth wear, plaque, and calculus among meth abusers. No significant difference in salivary flow rates were noted, yet results showed significant trends for lower pH and decreased buffering capacity. These findings suggest that salivary quality may play a more important role in meth mouth than previously considered. Salivary analysis may be useful when managing a dental patient with history of methamphetamine abuse.

Mitochondrial uncoupling protein-2 deficiency protects steatotic mouse hepatocytes from hypoxia/reoxygenation.

Steatotic livers are sensitive to ischemic events and associated ATP depletion. Hepatocellular necrosis following these events may result from mitochondrial uncoupling protein-2 (UCP2) expression. To test this hypothesis, we developed a model of in vitro steatosis using primary hepatocytes from wild-type (WT) and UCP2 knockout (KO) mice and subjected them to hypoxia/reoxygenation (H/R). Using cultured hepatocytes treated with emulsified fatty acids for 24 h, generating a steatotic phenotype (i.e., microvesicular and broad-spectrum fatty acid accumulation), we found that the phenotype of the WT and UCP2 KO were the same; however, cellular viability was increased in the steatotic KO hepatocytes following 4 h of hypoxia and 24 h of reoxygenation; Hepatocellular ATP levels decreased during hypoxia and recovered after reoxygenation in the control and UCP2 KO steatotic hepatocytes but not in the WT steatotic hepatocytes; mitochondrial membrane potential in WT and UCP2 KO steatotic groups was less than control groups but higher than UCP2 KO hepatocytes. Following reoxygenation, lipid peroxidation, as measured by thiobarbituric acid reactive substances, increased in all groups but to a greater extent in the steatotic hepatocytes, regardless of UCP2 expression. These results demonstrate that UCP2 sensitizes steatotic hepatocytes to H/R through mitochondrial depolarization and ATP depletion but not lipid peroxidation.

Toll-like receptor 4 knockout mice are protected from endothelial overactivation in the absence of Kupffer cells after total hepatic ischemia/reperfusion.

Kupffer cells (KCs) have been shown to be critical mediators of ischemia/reperfusion (I/R) injury in the murine liver. Using liposomal clodronate (LC), we found that KCs were protective in models of total hepatic ischemia with bowel congestion. We investigated the role of toll-like receptor 4 (TLR4) in the damage that occurs after I/R in KC-depleted livers. We injected 8-week-old C57BL/10J mice and C57BL/10ScN [toll-like receptor 4 knockout (TLR4KO)] mice with LC 48 hours before 35 minutes of warm hepatic ischemia with bowel congestion, which was followed by either 6 or 24 hours of reperfusion. The KC-depleted animals had increased mortality as well as a 10-fold increase in their aminotransferase levels that correlated with increases in centrilobular necrosis. These changes were absent in the TLR4KO animals. Lipopolysaccharide was bound extensively to endothelial cells after I/R, and this binding was diminished in the TLR4KO animals. In conjunction with this, there was an up-regulation of endothelial cell adhesion molecules in the LC-treated animals that was absent in the TLR4KO animals. Finally, there was a dramatic increase in the proinflammatory cytokine levels of the LC-treated animals, and the TLR4KO animals were protected against this increase. In conclusion, TLR4 promotes endothelial overactivation after I/R in the absence of KCs.

Murine Kupffer cells are protective in total hepatic ischemia/reperfusion injury with bowel congestion through IL-10.

Kupffer cells (KCs) are thought to mediate hepatocyte injury via their production of proinflammatory cytokines and reactive oxygen species in response to stress. In this study, we depleted KCs from the liver to examine their role in total warm hepatic ischemia/reperfusion (I/R) injury with bowel congestion. We injected 8-wk-old C57BL/10J mice with liposome-encapsulated clodronate 48 h before 35 min of hepatic ischemia with bowel congestion, followed by 6 or 24 h of reperfusion. KC-depleted animals had a higher mortality rate than diluent-treated animals and a 10-fold elevation in transaminase levels that correlated with increases in centrilobular necrosis. There was extensive LPS binding to the endothelial cells, which correlated with an upregulation of endothelial adhesion molecules in the KC-depleted animals versus diluent-treated animals. There was an increase in the levels of proinflammatory cytokines in KC-depleted animals, and a concomitant decrease in IL-10 levels. When KC-depleted mice were treated with recombinant IL-10, their liver damage profile in response to I/R was similar to diluent-treated animals, and endothelial cell adhesion molecules and proinflammatory cytokine levels decreased. KCs are protective in the liver subjected to total I/R with associated bowel congestion and are not deleterious as previously thought. This protection appears to be due to KC secretion of the potent anti-inflammatory cytokine IL-10.

Toll-like receptor 4 is a key mediator of murine steatotic liver warm ischemia/reperfusion injury.

Steatotic donors are routinely rejected for transplantation because of their increased rate of primary nonfunction. These grafts are more sensitive to ischemia/reperfusion (I/R) during transplantation. Removal of endotoxin before reperfusion improves liver performance post-I/R. We hypothesize that the main modality of injury in steatotic livers is toll-like receptor 4 (TLR4) signaling. We fed 4-week-old control and TLR4-deficient (TLR4KO) mice a normal diet (ND) or a 60% high-fat diet (HFD) for 4 weeks to induce steatosis. Mice were subjected to total hepatic ischemia (35 minutes) and reperfusion (1 or 24 hours). Survival improved and liver pathology decreased at 24 hours in TLR4KO HFD animals compared to control HFD animals. An investigation of infiltrates showed that neutrophils and CD4+ cells were increased at 24 hours in control HFD animals, whereas TLR4KO HFD animals were similar to ND controls. Messenger RNA levels of interleukin 6 (IL-6), IL-12, and interferon gamma were elevated at 1 hour in control HFD animals, whereas TLR4KO HFD animals were similar to ND controls. IL-10 levels at 1 hour of reperfusion in control HFD and TLR4KO animals were decreased versus control ND animals. In conclusion, these improvements in liver function in TLR4KO HFD animals implicate TLR4 as a mediator of steatotic graft failure after I/R.

A rapid PCR-based method for the identification of ob mutant mice.

With increasing incidence of obesity, there is greater demand for suitable research and therapeutic models. The ob/ob mouse model develops obesity by 5 weeks of age. Previously, a method using DNA purification, PCR, and restriction digestion of products was devised to identify mice bearing the ob allele. Here, we describe a direct PCR method that requires no DNA purification. Wild-type and ob-specific primers are used under the same conditions in two separate and simultaneously run three-primer PCRs. Standard PCR using the wild-type primer mix produces 191 bp and 104 bp bands in +/+ and ob/+ and only the control 191 bp band in ob/ob animals. The ob-specific primer reaction produces 191 bp and 123 bp bands in ob/+ and ob/ob and only the control 191 bp band in +/+ animals. Phenotypic weight gain in offspring of heterozygous intercrosses was used to validate genotypes. This primer-specific PCR method allows simultaneous identification of +/+, ob/+, and ob/ob genotypes prior to breeding age to facilitate breeding and research studies in an important model of clinical obesity.

The use of the Papworth cocktail is detrimental to steatotic livers after ischemia-reperfusion injury.

BACKGROUND: Hormonal resuscitation, specifically administration of levothyroxine (T4) and methylprednisolone (steroid, i.e., the "T4 Protocol") in organ transplant donors, is becoming increasingly used. Previous studies have shown that this maximizes the number of usable organs by reducing metabolic disturbances post-brain death. However, anecdotal evidence has shown that steatotic livers are adversely affected by this protocol. Therefore, we sought to investigate the hypothesis that the use of T4 and steroid is detrimental to steatotic livers in a model of total hepatic warm ischemia-reperfusion (I/R). METHODS: We subjected 8- to -10-week-old male C57BL/6 and ob/ob mice to injections of T4 and steroid 48 hr before 15 min of total hepatic ischemia, followed by 24 hr of reperfusion. RESULTS: We saw a significant decrease in survival in ob/ob animals given T4 and steroid as compared with single-treated or vehicle-treated animals. This decrease in survival was accompanied by a dramatic increase in liver necrosis (as measured on a scale from 0 to 3) in these animals as compared with controls. Previous work in our lab has shown that uncoupling protein-2 is a major mediator of I/R in steatotic animals, as it upsets normal energy homeostasis. Following with this hypothesis, we see a dramatic increase in uncoupling protein-2 levels in the combination treated animals, which is accompanied by a concomitant decrease in ATP levels after reperfusion. CONCLUSIONS: The T4 protocol is detrimental to steatotic livers subjected to I/R, likely because of a decreased ability to recover after reperfusion caused by decreased ability to form ATP.

Mitochondrial uncoupling protein-2 mediates steatotic liver injury following ischemia/reperfusion.

Steatotic livers are not used for transplantation because they have a reduced tolerance for ischemic events with reduced ATP levels and greater levels of cellular necrosis, which ultimately result in total organ failure. Mitochondrial uncoupling protein-2 (UCP2) is highly expressed in steatotic livers and may be responsible for liver sensitivity to ischemia through mitochondrial and ATP regulation. To test this hypothesis, experiments were conducted in lean and steatotic (ob/ob), wild-type, and UCP2 knock-out mice subjected to total warm hepatic ischemi-a/reperfusion. Although ob/ob UCP2 knock-out mice and ob/ob mice have a similar initial phenotype, ob/ob UCP2 knock-out animal survival was 83% when compared with 30% in ob/ob mice 24 h after reperfusion. Serum alanine aminotransferase concentrations and hepatocellular necrosis were decreased in the ob/ob UCP2 knock-out mice when compared with ob/ob mice subjected to ischemia. Liver ATP levels were increased in the ob/ob UCP2 knock-out animals after reperfusion when compared with the ob/ob mice but remained below the concentrations from lean livers. Lipid peroxidation (thiobarbituric acid-reactive substances) increased after reperfusion most significantly in the steatotic groups, but the increase was not affected by UCP2 deficiency. These results reveal that UCP2 expression is a critical factor, which sensitizes steatotic livers to ischemic injury, regulating liver ATP levels after ischemia and reperfusion.

Obesity alters rat abdominal flap survival.

Obesity presents a risk factor for flap-related complications in autologous tissue breast reconstruction. In this study, an animal model was developed to examine this phenomenon. Abdominal flaps based on a superficial inferior epigastric pedicle were elevated in an experimental group of obese Zucker (fa/fa) rats (n = 8; mean weight, 413 g) and in their lean littermates (n = 9; mean weight, 276 g). Flap tissue was harvested from a subset of both groups for baseline characterization, including histology, and assays for ATP and oxidative phosphorylation uncoupler, UCP-2. Flaps were then evaluated for survival by planimetry at 4 and 7 days postprocedure. Flap survival 7 days postoperatively was reduced in obese (42.0% +/- 8.6%) versus lean (70.3% +/- 6.7%) rats (P < 0.05). At baseline, flap tissue of obese animals had decreased ATP content relative to lean counterparts (0.12 +/- 0.12 nM/microg vs 0.36 +/- 0.23 nM/microg protein, P < 0.05), whereas UCP2 mRNA was higher in obese flap tissue versus lean. Reduced viability of obese flaps may be attributable to decreased baseline energy stores due to oxidative phosphorylation uncoupling by UCP-2. This study is the first to introduce a promising animal model for examining the effect of obesity on increased flap-related complications in breast reconstruction using autologous tissue.

Steatotic liver transplantation in the mouse: a model of primary nonfunction.

BACKGROUND: The number of potential donor organs deemed suboptimal for transplantation because of hepatic steatosis is rising as the obesity rate increases. However, no mouse transplant model has been described within the framework of hepatic steatosis. We describe the development of and our initial experience with a steatotic mouse orthotopic liver transplant model using the ob/ob mouse. This model is technically achievable and functionally mimics primary nonfunction. MATERIALS AND METHODS: Adapting techniques of a nonarterialized murine transplant model, C57BL6 ob/ob mice aged 5-7 weeks (26-35 g) and lean controls served as liver donors and recipients. Orthotopic liver transplantation (OLT) was performed using a two-cuff technique at the infrahepatic cava and portal vein. The suprahepatic cava was anastomosed end to end, and the bile duct was stented. The hepatic artery was not reconstructed. RESULTS: Lean-to-lean OLT was performed with 70% (n = 10) long-term survival. ob/ob-to-age-matched lean recipients had 0% (n = 10) survival because of size discrepancy. ob/ob livers were transplanted to size-matched lean recipients (>3 months old) with short-term survival of 30% (n = 10). These mice survived the operation, awakened, but expired within 24 h. Serum transaminases revealed a significantly higher injury profile in the recipients of the steatotic livers, and histology showed massive centrilobular coagulative necrosis with hemorrhage, the overall picture being that of primary nonfunction. CONCLUSIONS: This novel use of the ob/ob mouse for OLT provides us with a model for steatotic transplantation with primary nonfunction as the end point and may help to better understand the response of the steatotic liver to the insult of transplantation.