ANKH Polymorphisms and Clicking of the Temporomandibular Joint in Dental Residents

Aim

This study aimed to carry out a case-control research study to assess occurrence of clicking of the temporomandibular joint (TMJ) in order to establish the relationship between TMJ clicking and the genotype of “ANKH inorganic pyrophosphate transport regulator” (ANKH) polymorphisms.

Materials and Method

A sample of 41 first-year dental residents was selected. Each was examined using standard clinical procedures and genotyping techniques.

Results

The participation rate was 91.8 %. The prevalence of TMJ clicking was 51.2 % (95 % CI: 35.7–66.7 %). Occurrence of TMJ clicking was not related to age, gender and genotypes of ANKH-OR as well as ANKH-TR polymorphisms (p ≥ 0.165).

Conclusion

A similar distribution of ANKH genotypes in TMJ clicking and asymptomatic individuals has been demonstrated by this study. A high percentage of TMJ clicking has been confirmed. Future investigations are indicated.     

Comparative Analysis of the Anesthetic Efficacy of 0.5 and 0.75?% Ropivacaine for Inferior Alveolar Nerve Block in Surgical Removal of Impacted Mandibular Third Molars

Introduction

Ropivacaine belongs to pipecoloxylidide group of local anesthetics. There are reports supporting the use of ropivacaine as a long acting local anesthetic in oral and maxillofacial surgical procedures, with variable data on the concentration that is clinically suitable.

Materials and Methods

A prospective randomized double-blind study protocol was undertaken to assess the efficacy of 0.5 and 0.75 % ropivacaine for inferior alveolar nerve block in surgical extraction of impacted mandibular third molars. A total of 60 procedures were performed, of which thirty patients received 0.5 % and thirty received 0.75 % concentration of the study drug.

Results

All the patients in both the study groups reported subjective numbness of lip and tongue. The time of onset was longer for 0.5 % ropivacaine when compared to 0.75 % solution. 90 % of the study patients in 0.5 % ropivacaine group reported pain corresponding to VAS ≥3 during bone guttering and 93.3 % patients reported pain corresponding to VAS >4 during tooth elevation. None of the patients in 0.75 % ropivacaine group reported VAS >3 at any stage of the surgical procedure. The duration of soft tissue anesthesia recorded with 0.75 % ropivacaine was average 287.57 ± 42.0 min.

Conclusion

0.75 % ropivacaine was found suitable for inferior alveolar nerve blocks in surgical extraction of impacted mandibular third molars.     

Evaluation of Mandibular Wing Osteotomy in Obstructive Sleep Apnea Cases with Retrognathia

Objective

The aim of this study is to evaluate the efficacy of wing osteotomy for treating obstructive sleep apnea (OSA).

Materials and Methods

We performed mandibular wing osteotomy in subjects who had an apnea-hypopnea index (AHI) of more than 15, a previous unresponsive conservative treatment for the OSA, moderate to severe retrognathia and no suggested conventional orthognathic surgery because of dentition or lack of willingness. The subjects were evaluated using the Epworth Sleepiness Scale (ESS), AHI and posterior airway space (PAS) before and 1 year after surgery.

Results

We evaluated 10 subjects (4 males, 6 females) who underwent wing mandibular osteotomy. The mean age of the subjects was 37.8 ± 7.26 years. Analysis of the data demonstrated a significant change in ESS and AHI 1 year after operation. However, PAS was not changed 1 year after surgery. Results did not show any correlation between age, ESS and AHI before and 1 year after surgery.

Conclusion

Mandibular wing osteotomy is a novel procedure that improves signs of OSA. It may be a surgical option in retrognathic patients with OSA who are not candidates for conventional maxillomandibular advancement.     

Dental age assessment of Western Saudi children and adolescents

Aim

The aim of this study was to evaluate the use of the London Atlas of Human Tooth Development and Eruption for age estimation in Saudi Arabian children and adolescents (aged 2–20 years), for forensic odontology application.

Materials and methods

This cross-sectional survey analyzed orthopantomograms (OPGs) of the complete dentition (including root development) to estimate the deviation from chronological age. Each OPG was de-identified and analyzed individually and classified into age-groups by the lead author, using the methods of the Atlas of Tooth Development.

Results

OPGs from a total of 252 patients [110 (44%) males, 142 (56%) females] aged 2–20 years (24–240 months) were examined in this study. The average estimated and chronological ages of subjects differed significantly p < 0.001 (143 ± 55.4 vs. 145 ± 57.9 months). Most (65.5%) estimates were within 12 months of subjects’ chronological ages; 19% overestimated and 15.5% underestimated age by >12 months.

Conclusion

This study, conducted in a sub-population of different origin than the UK sample used for the development of the London Atlas, identified variation in age estimates that may have significant impacts on results. The establishment of a composite international repository of atlas-based data for diverse ethnic sub-populations would be of great value to clinicians across the globe.     

Ramus Condyle Unit Reconstruction Using Vertical Ramus Osteotomy in Temporomandibular Joint Ankylosis

Introduction

Treatment of bony Temporomandibular Joint (TMJ) Ankylosis includes release of the ankylosis and creation of a gap with or without insertion of interposing material and complete reconstruction of the joint using e.g. costochondral, autogenous coronoid/ankylosed mass, sternoclavicular, clavicular bone grafts etc. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry, deviated mouth opening and reankylosis. The authors have applied the method of vertical ramus osteotomy (VRO) on the posterior border of the mandibular ramus for reconstruction of the ramus condyle unit (RCU) as a pedicled graft along with Myofascial Temporalis Interposition for the correction of TMJ Ankylosis.

Materials and methods

Ten patients of TMJ Ankylosis were included in this study. All ten patients were treated using VRO for the RCU reconstruction with posterior border of mandibular ramus after Gap Arthroplasty. Temporalis myofascial flap was used as an interpositional material in all patients. Patients were followed from 20 to 30 months (mean 24 months).

Results

As a result of successful procedure the post-operative maximal mouth opening of 32–45 mm (mean 37 mm) was achieved. No patient experienced pain and infection at surgical site. None of the patients had graft rejection and reankylosis at follow-up.

Conclusion

The results showed that VRO on the posterior border of the mandibular ramus seems to be an alternative and promising method for RCU reconstruction in patients with TMJ Ankylosis.     

Management of Extra-Capsular Temporo-Mandibular Joint Ankylosis: Does Conservative Approach to Treatment Have a Role?

Background

The conventional management of fibrous extracapsular temporo-mandibular joint (TMJ) ankylosis, a debilitating disease, is associated with surgical complications and financial burden on the patients.

Objective

To assess the outcome of conservative approach to the management of fibrous extracapsular TMJ ankylosis.

Patients and methods

This is a prospective study of patients who presented at the Dental and Maxillofacial Surgery Clinic of the University of Calabar Teaching Hospital, Nigeria, during the period from January 1999 to December 2012 with a history of inability to open the mouth diagnosed as fibrous extracapsular TMJ ankylosis.

Results

Twenty-one subjects were treated and their ages ranged from 11 to 22 years with mean at 15.0 years. There were 13 (61.9 %) males and 8 (38.1 %) females with male: female ratio of 1.6:1. The aetiological factor that predisposed to formation of extracapsular TMJ ankylosis was facial trauma. There was no facial asymmetry and the side distribution of the affliction showed that 1 (4.8 %) was bilateral while 20 (95.2 %) were unilateral. Eight cases (38.1 %) were incomplete ankylosis while the rest (n = 13, 61.9 %) were complete. The shorter the duration of fibrous ankylosis and the greater the initial inter-incisal distance before treatment, the better the treatment outcome.

Conclusion

The outcome of treatment suggests that the conservative approach to management of this condition was beneficial to these patients because they presented early. However, randomized controlled clinical trials are needed to validate this treatment option.     

Comparison of Efficacy of Methylprednisolone Injection into Masseter Muscle Versus Gluteal Muscle for Surgical Removal of Impacted Lower Third Molar

Purpose

To compare the efficacy, advantages and disadvantages of the use of preoperative injection of methylprednisolone into masseter muscle versus gluteal muscle to minimize postoperative swelling after the surgical removal of lower third molar.

Materials and Methods

A prospective randomized study was planned comprising of 10 subjects, undergoing elective surgery for bilateral impacted lower third molar removal with similar severity index. The subjects were randomly assigned into two groups—group I who received intrabuccal masseteric injection and group II who received gluteal injection of 40 mg of methylprednisolone after inferior alveolar nerve and long buccal nerve block (prior to the surgical removal of the impacted lower third molars). We evaluated the postoperative pain, trismus, swelling, advantages and disadvantages of the injection techniques. Statistical analysis was done using student t test.

Results

Ten patients of mean age 27 ± 6 years were selected for the study including six males and four females. The mean age was 27 years (SD 6). The differences in measurements of preoperative and postoperative pain, swelling and mouth opening between group I and group II were not statistically significant.

Conclusion

The study evidently proves that there is no statistically significant difference between the intrabuccal approach of masseteric injection and gluteal injection of methylprednisolone in terms of pain, swelling and trismus following surgical removal of impacted lower third molars. However, the intrabuccal approach of masseteric injection was found to be more convenient when compared to gluteal injection, for the surgeon as well as the patient. It also has an additional advantage of being a painless steroidal injection on an anesthetized injection site.     

Costochondral Graft as Interpositional material for TMJ Ankylosis in Children: A Clinical Study

Abstract

TMJ ankylosis is one of the most disruptive anomaly that affects the masticatory system. The inability to move the mandible has significant functional ramification, such as the inability to eat a normal diet. Additionally, speech is affected, making it difficult for some individuals to communicate and express themselves to others. As there are several biologic and anatomic similarities to the mandibular condyles, autogenous costochondral grafts have been considered to be the most acceptable tissue for temporomandibular joint reconstruction. In addition donor site complications are infrequent and regeneration of the rib usually occurs within a year post operatively in children.

Aim

The aim of this study was to evaluate the function of costochondral grafts to replace the mandibular condyles and to assess the position, growth, overgrowth, function, success, failure and resorption of costochondral grafts.

Materials and Methods

Ten TMJ ankylosis patients were operated in the Department of Oral and Maxillofacial Surgery at Institute of Dental Sciences, Bareilly. Out of the 10 cases 6 were male patients and 4 female patients in age group of ≤14 years; of which 8 patients were of unilateral TMJ ankylosis and 2 were of bilateral TMJ ankylosis. All ten patients underwent interpositional gap arthroplasty with reconstruction of the condyle by costochondral graft.

Results

All patients with costochondral grafts had improved mandibular symmetry and growth with adequate mouth opening.

Conclusion

This study indicates that using costochondral grafts to reconstruct TMJ ankylosis in children provides a good result.     

The Use of Sodium Tetradecyl Sulphate for the Treatment of Venous Malformations of the Head and Neck

Introduction

Vascular malformations have devastating cosmetic effects in addition to being associated with pain and bleeding. Sclerotherapy has been used as an effective therapeutic modality for the management of vascular malformations. The purpose of this case series is to describe our clinical experience of using sodium tetradecyl sulphate (STS) 3 % in the treatment of venous malformation lesions of head and neck.

Materials and Methods

Thirteen patients were included in this study (three male and ten female; age range between 8 months and 54 years; mean age 18.2 years, ±SD 15.71). The patients were treated by 3 % STS intralesional injections. Of the thirteen patients treated, complete resolution occurred in four patients (28.57 %), a good response occurred in five patients (35.7 %), a moderate response in two patients (14.28 %), a mild response in two patients (14.28 %) and no response in one patient (7.14 %). The side effects encountered in all patients were pain and edema after injection which was controlled by oral analgesics and an intramuscular injection of dexamethasone. In addition, two patients developed a superficial ulceration (11.76 %) which healed uneventfully, and one patient developed ecchymosis after injection (5.88 %).

Conclusion

Sclerotherapy with 3 % STS is a simple, safe, and effective modality for the treatment of venous malformations.     

The Need for Lateral Piriform Rim Augmentation in Patients with Unilateral Cleft Lip/Palate During Alveolar Cleft Bone Grafting

Background

Alveolar bone grafting in unilateral cleft lip/palate (CLP) patients can improve nasal symmetry and facial esthetic. In some cases lateral piriform hypoplasia cannot be compensated by soft tissue thickness of the face, necessitating onlay bone grafting. This study was designed to estimate the proportion of patients among unilateral CLP patients requiring this procedure.

Materials and Methods

In a retrospective study, unilateral CLP patients with severe paranasal deficiency, who were managed by paranasal augmentation with cortico-cancellous bone graft during the alveolar cleft bone grafting, were included.

Results

From 85 unilateral CLP patients treated from 2005 to 2011 in the Oral and Maxillofacial Surgery Department, Mashhad University of Medical Sciences, fourteen patients were treated with lateral piriform augmentation technique. Mean age of the patients at the time of operation was 16 ± 4.8 years. Follow-up period was 2–6 years.

Conclusion

Concomitant alveolar bone grafting and lateral piriform augmentation is needed at least in 16.5 % of unilateral CLP patients.     

The Local Effect of Alendronate with Intra-alveolar Collagen Sponges on Post Extraction Alveolar ridge Resorption: A Clinical Trial

Introduction

Extraction of teeth is followed by resorption of the residual alveolar ridge that continues throughout life resulting in loss of alveolar height and width. Of the numerous techniques that have been used to arrest post extraction alveoloar ridge resorption, the placement of a graft material inside the socket immediately after extraction has been mostly followed. Type 1 collagen is one of the commonly used graft material that prevent resorption by providing dimensional stability to the socket. Bisphosphonates are an anti-osteoclastic drug that prevent resorption by disrupting the membrane ruffling of the osteoclasts. Alendronate a bisphosphonate, is primarily used in diseases with bone loss. It has been used to reduce active bone resorption significantly without interfering with bone mineralization and quality. The need for the study is to examine the inhibitory effect of alendronate on residual ridge resorption when applied locally in combination with type I collagen on alveolar bone immediately following tooth extraction.

Materials and Methods

Twenty patients with age between 30 and 65 years were selected from the out patient department of The Oxford Dental College and Hospital. The patients were divided into two groups. In the first group after extraction of teeth from premolar to midline the sockets were irrigated with saline and sutured. On the left side type I collagen sponge was placed and sutured. In the other group the right side was treated the same way after extraction as in first group where as in the left side sockets type I collagen soaked in 20 mg/ml of alendronate was placed and sutured. Patients were evaluated clinically for any local irritation as well as radiologically with orthopantomograph X-rays were taken immediately after the extraction, 1 month after extraction and 4 months after extraction to determine the amount of bone loss prevented.

Results

The statistically significant bone loss prevented by the collagen alone was 22.8 % and in collagen with alendronate group was 44.38 % at the end of 4 months.

Conclusion

Type I collagen soaked with alendronate when placed in the socket immediately after extraction of teeth prevents post-extraction alveolar ridge resorption.     

Treatment of Oral Submucous Fibrosis Using Split Skin Graft and a Polyethylene Stent: A Prospective Study

Aim

Aim of this study was to evaluate the split skin graft held in place with a polyethylene stent for the treatment of oral submucous fibrosis.

Methods

Fifteen prospective patients diagnosed clinically with oral submucous fibrosis, from June 2011 to 12 December 2012, were recruited for this study. All patients were treated surgically using the same surgical technique of fibrotomy followed by split skin graft along with a polyethylene stent. Preoperative and postoperative mouth opening measurements at 1 week and after a minimum of 6 months were evaluated by measuring the inter incisal distance.

Results

Mean follow up was 9.8 months with a minimum of 6 months. Mean preoperative mouth opening was 12.9 mm (6–20 mm). Intraoperatively mean mouth opening was 37.9 mm (36–41 mm). After 1 week mean mouth opening was 35.8 mm (31–40 mm). At 6 months follow up, mean mouth opening was 33 mm (20–40 mm).

Conclusion

Fibrotomy followed by split skin graft along with a polyethylene sheet stent and sufficient postoperative physiotherapy is a simple, cost effective and viable treatment modality for oral submucous fibrosis.     

Skeletal Relapse Following Sagittal Split Ramus Osteotomy Advancement

Background

Sagittal split ramus osteotomy (SSRO) is an accepted and standard procedure to address mandibular corpus deficiency. The relapse following the mandibular advancement has a negative impact both on clinician and patient.

Purpose

To analyse the hard tissue changes and to investigate relapse following SSRO advancement procedure.

Materials and Methods

A retrospective review of 21 patients treated by bilateral SSRO advancement at our institute was conducted. Lateral cephalograms obtained at pre-treatment (T1), pre-surgery (T2), 2 months (T3) and 2 years post-surgery (T4) were evaluated by an independent investigator. The data T2–T3 revealed immediate postoperative changes, and T3–T4 revealed skeletal relapse following surgery after 2 years.

Results

Twelve females and nine males with age ranging from 16 to 24 years underwent mandibular advancement. The mean follow-up period was 2 years 7 months ± 4 months. The mean mandibular advancement at pogonion was 5.1 ± 1.25 mm with significant improvement in SNB, ANB, CoGn, maxillo-mandibular differential and SN:GoPg ratio following surgery. Comparison of the outcomes following surgery revealed that the mean relapse at pogonion was 0.2 ± 0.44 mm. B point, mandibular corpus length, anterior and posterior facial height remained stable with no significant relapse following mandibular advancement.

Conclusion

Sagittal split ramus osteotomy within the range of mandibular advancement is a stable procedure.     

Evaluation of Neurosensory Disturbance Following Orthognathic Surgery: A Prospective Study

Aim and Objectives

The prospective study was to evaluate the incidence, type of neurosensory disturbance (NSD), grade its severity and monitor its recovery occurring in the lower lip and chin due to damage to inferior alveolar nerve following orthognathic surgery involving mandible.

Materials and Methods

The study included 10 patients who have undergone sagittal split osteotomy, genioplasty, and anterior subapical osteotomy (ASO). All the patients examined preoperatively and post operatively 1 week, 1 and 6 months according to standardized test to clarify the subjective and objective neurosensory status of the injured nerve. Pin prick test, blunt test, two-point discrimator test, brush stoke direction, light touch test, warm and cold test were used bilaterally to lower lip and chin area.

Results

Seven patients underwent bilateral sagittal split osteotomy (BSSO) (70 %), one patient had BSSO with genioplasty (10 %), two patients had BSSO with ASO (20 %). During the operation none of the nerves were transectioned, in 60 % of patients nerve was not visible and in 40 % of patients nerve was seen in distal segment. 70 % of patients underwent setback, 30 % of patients underwent advancement. The subjective evaluation of the patients revealed the incidence of 90 % at 1 week, 30 % at 1 month, 20 % at 6 months and 10 % at 1 year post operatively. The altered sensation reported subjectively was hypoesthesia in 50 % of the patients, anaesthesia in 40 % of the patients. There was 100 % recovery in advancement cases and 93.5 % recovery in setback cases.

Conclusion

There is a high incidence of NSD of the lower lip and chin after BSSO related to advancement, setback, intraoperative nerve encounter and surgical skill. However, recovery of sensation occurs with increasing frequency during the follow-up period. The clinical neurosensory tests are effective guides to study the neurosensory deficit.     

Nebulisation Versus Spray-as-You-Go Airway Topical Anaesthesia in Patients with Temporomandibular Joint Ankylosis using 2?% Lignocaine

Study Design

This randomized, comparative clinical study was designed to compare 2 % lignocaine nebulization and 2 % lignocaine via spray-as-you-go technique for topical airway anaesthesia during or awake flexible fiberoptic intubation (AFOI) in temporomandibular joint (TMJ) ankylosis patients.

Methods

Sixty adult patients with TMJ ankylosis were randomly assigned to the following study groups using a computer generated random number table 2 % lignocaine nebulised (group A) and 2 % lignocaine via spray-as-you-go technique (group B). After airway anaesthesia, awake flexible fiberoptic nasotracheal intubation was performed. An independent investigator who did not participate in the study scored patients’ comfort during airway topical anaesthesia and patients’ reaction during awake FOI. Changes in haemodynamics during the airway manipulation were also observed.

Results

There were no statistically significant differences in the observed variables between the two groups.

Conclusions

Both 2 % lignocaine nebulization and 2 % lignocaine spray-as-you-go technique provided acceptable conditions for AFOI in TMJ patients.     

Combination of bone allograft,barrier membrane and doxycycline in the treatment of infrabony periodontal defects: A comparative trial

Aim

The purpose of the present study was to compare the regenerative potential of noncontained periodontal infrabony defects treated with decalcified freeze-dried bone allograft (DFDBA) and barrier membrane with or without local doxycycline.

Methods

This study included 48 one- or two-wall infrabony defects from 24 patients (age: 30–65 years) seeking treatment for chronic periodontitis. Defects were randomly divided into two groups and were treated with a combination of DFDBA and barrier membrane, either alone (combined treatment group) or with local doxycycline (combined treatment + doxycycline group). At baseline (before surgery) and 3 and 6 months after surgery, the pocket probing depth (PPD), clinical attachment level (CAL), radiological bone fill (RBF), and alveolar height reduction (AHR) were recorded. Analysis of variance and the Newman–Keuls post hoc test were used for statistical analysis. A two-tailed p-value of less than 0.05 was considered to be statistically significant.

Results

In the combined treatment group, the PPD reduction was 2.00 ± 0.38 mm (32%), CAL gain was 1.25 ± 0.31 mm (17.9%), and RBF was 0.75 ± 0.31 mm (20.7%) after 6 months. In the combined treatment + doxycycline group, these values were 2.75 ± 0.37 mm (44%), 1.5 ± 0.27 mm (21.1%), and 1.13 ± 0.23 mm (28.1%), respectively. AHR values for the groups without and with doxycycline were 12.5% and 9.4%, respectively.

Conclusion

There was no significant difference in the regeneration of noncontained periodontal infrabony defects between groups treated with DFDBA and barrier membrane with or without doxycycline.     

A Prospective Study on Management of Mandibular Angle Fracture

Purpose

To evaluate the results of management of mandibular angle fracture by open reduction and internal fixation using single non compression miniplate via transbuccal, intraoral or extraoral approaches.

Patients and Methods

In this prospective study, 30 patients were randomly selected regardless of age, sex requiring open reduction and internal fixation of non comminuted angle fracture with/or without other associated fractures of the mandible. All the patients were operated under general anaesthesia following routine haematological, biochemical, general physical examination and routine radiographic examination. Patients were randomly distributed into 3 groups namely: (1) intraoral, (2) transbuccal, and (3) extraoral groups depending on the surgical approach used for open reduction and internal fixation of fracture of the angle of mandible. In the intraoral group (12 patients), angle fracture was approached through the intraoral vestibular incision similar to sagittal split incision. In the transbuccal group (8 patients), angle fracture was approached through the intraoral vestibular incision and transbuccal stab incision for screw fixation via trochar. In the extraoral group (10 patients), angle fracture was approached through the Risdon’s submandibular incision. In all the patients, fractures were reduced with upper and lower Erich’s arch bar fixation as means for IMF intraoperatively. In all the patients, fracture of the angle of the mandible was fixed with single non compression 2.5 mm, 4 holed with gap stainless steel miniplate and 6/8 mm monocortical screws. All patients were followed up for minimum of 6 months to maximum of 24 months.

Results

Complications were relatively minor such as paresthesia (on average 26.7 % first post-operative day which was gradually improved and on average after 1 month was 3.3 %), mild to moderate occlusal discrepancies (on average 36.7 %) which needed the post-operative intermaxillary fixation with elastics for 1–2 weeks, infection (20 % on average) was mild to moderate which was managed with antibiotic therapy and/or incision and drainage except in one case, plate removal was done under general anaesthesia (extraoral group) because of recurrent infection. Post-operative pain was mild to moderate (mean VAS score pre operative–6.17, post-operative 1 week–1.63) which was managed with analgesics. Mouth opening was recorded in all patients which was on average 20.98 mm preoperatively which improved to 40.57 mm after 1 month.

Conclusion

The use of a single non compression miniplate for fractures of the angle of the mandible is a simple, reliable technique with relatively rare major complications and few minor complications irrespective of the surgical approach used for the open reduction.     

Kapetansky-Juri Technique to Correct the Whistlers Lip in the Multiple Operated Cleft Patient

Purpose

One of the common sequels of a cleft lip repair may be “whistling lip deformity” but other deformities are also seen particularly in failed or multiple resurgery cases. This retrospective study was carried out to evaluate the usefulness of “Kapetansky-Juri” advancement flap technique to correct such deformities.

Methods

Ten patients of bilateral cleft lip with history of minimum five failed cleft lip surgeries and having residual lip deformity were operated using “Kapetansky-Juri” advancement flap technique and were followed up to minimum 36 months.

Results

All patients showed good tissue fullness and complete correction of the deformity. There was no contracture of surrounding skin or vermilion during follow-up period. In eight patients minimal scar formation was seen while two showed midline scar formation.

Conclusion

No tissue loss due to vascular insufficiency was observed. The technique gives good tissue distribution and minimal surface scar formation.