Rapid Healing of Palatal Necrosis with Active Oxygen Gel: A Case Report and Management Strategy

Introduction

Rehabilitation of the anterior maxilla poses significant challenges in implantology and prosthodontics, necessitating a delicate balance between stability and aesthetics while ensuring a minimal volume of bone and keratinized tissue surrounding the implant for optimal outcomes [1]. Guided bone and tissue regeneration techniques have emerged as effective strategies to modify the peri-implant region, offering predictable success in creating a conducive environment for rehabilitation [2].

Diverse techniques have been described in the literature to address deficiencies in the anterior maxilla, including ridge expansion through the split crest technique or ridge augmentation using autogenous or allogenic grafts [3–5]. Nonetheless, the choice of a suitable method depends on a careful assessment of anatomical features and implant placement time [6].

The nasopalatine canal is the most prominent anatomical structure in the anterior maxilla, and it serves as a conduit for neurovascular structures and plays a pivotal role in surgical interventions in this region [6,7]. In specific cases, preemptive measures such as nervus lateralization are warranted to mitigate postoperative pain and sensitivity following implantation procedures, while in other instances deflation of the neurovascular bundles is advocated [3,8]. Nervus deflation, as pioneered by Scher and Misch, involves the meticulous removal of neurovascular bundles followed by the placement of a bone graft within the incisive canal using particulate graft material and a membrane for augmentation and stabilization. This technique aims to optimize the osseointegration process and enhance long-term implant success by creating a favorable environment for tissue healing and regeneration [9].

Despite its reported successes, complications such as hypoesthesia, impaired osseointegration, and sensory disturbances are well-documented, presenting significant challenges for dental practitioners [10,11]. To address these issues, the use of topical oral oxygen therapy (TOOT) has gained attention for its antibacterial and regenerative properties, as well as its ability to accelerate wound healing [12,13]. Recent research highlights the potential of active oxygen in alleviating postoperative pain and inflammation following oral surgeries, offering promising strategies to enhance patient outcomes and mitigate complications [14,15]. TOOT provides substantial benefits in wound healing and tissue regeneration by improving local oxygen levels, which facilitates neovascularization and accelerates cellular metabolism, thus supporting effective tissue repair. Furthermore, active oxygen is pivotal in stimulating collagen synthesis and angiogenesis, which are essential for effective tissue regeneration. Its antimicrobial properties further contribute to reducing postoperative infection risks, fostering a favorable healing environment. Consequently, TOOT is a promising adjunctive therapy for optimizing post-surgical recovery [16]. A case study illustrated the advantageous use of an active oxygen gel in managing jaw osteonecrosis, showing significant improvement after 2 years of follow-up [17]. Based on that, this report presents the case of a 33-year-old man with postoperative palatal necrosis successfully treated with a TOOT formulation oxygen-active gel blue®m (composition: Aqua, Alcohol, Glycerin, Silica, Sodium Saccharin, Sodium Perborate, Citric Acid, PEG-32, Sodium Gluconate, Lactoferrin, Xanthan Gum, Cellulose Gum).

Case Report

A 33-year-old male patient was referred to our specialty clinic for rehabilitation of the anterior maxillary region, specifically to address an edentulous area resulting from trauma sustained at the age of 20, in preparation for dental implant placement. Initial physical examination revealed a deficient maxillary ridge. Cone beam computed tomography (CBCT) further delineated significant alveolar bone loss and the proximity of the defect to an enlarged incisive foramen, precluding immediate implant placement (Figure 1).

A comprehensive treatment plan was formulated, recommending nasopalatine nerve deflation in conjunction with guided bone regeneration to facilitate osseous augmentation and posterior implant placement. Local anesthesia was achieved using 4% articaine, administered at the major palatine and nasopalatine foramen sites, with less than 1 cartridge being required to achieve effective anesthesia of the major palatine and incisive canal. During the procedure, an incision was made to expose the underlying structures (Figure 2A, 2B), and the neurovascular bundle was meticulously excised using manual instruments and rotary handpieces under copious saline irrigation (Figure 2C). This was followed by placement of an alloplastic biomaterial (Blue-Bone®-Regener Biomateriais Co, Curitiba, Brazil) within the incisive canal, which was then covered with a collagen membrane (Green Membrane®-Regener Biomateriais Co, Curitiba, Brazil) (Figure 2D, 2E). To ensure primary wound closure, the flap was released via periosteal incision and subsequently sutured using 5/0 monofilament sutures (Figure 2F). Postoperatively, the patient was prescribed amoxicillin to be taken every 8 hours for 7 days, a non-steroidal anti-inflammatory drug taken every 8 hours for 5 days, and an analgesic regimen over the same duration.

Seven days following surgery, the patient presented for suture removal, reporting minimal pain; however, examination revealed the presence of a necrotic slough indicative of localized necrosis (Figure 3A). The necrotic tissue and any contaminated biomaterial were delicately removed without anesthesia (Figure 3B–3F). The site was then irrigated with saline solution and treated with a topical application of oxygenating gel (blue®m), applied thickly to the palatal lesion (Figure 3G, 3H).

The patient was instructed to apply oxygen-active gel blue®m (composition: Aqua, Alcohol, Glycerin, Silica, Sodium Saccharin, Sodium Perborate, Citric Acid, PEG-32, Sodium Gluconate, Lactoferrin, Xanthan Gum, Cellulose Gum) 3 times daily every 8 hours for 30 days, and to use blue®m mouthwash every 8 hours for 1 month. No antibiotics were prescribed after removal of necrotic tissue; however, a prescription-only analgesic (Tylenol 750 mg) was advised every 8 hours for 3 days.

Follow-up visits were scheduled every 2 days. By the 12th day after surgery, rapid healing and significant clinical improvement were noted (Figure 4A), with the patient reporting an absence of pain or sensitivity. By day 24, the lesion exhibited healthy tissue and favorable healing progression (Figure 4B). Complete closure and re-epithelialization of the lesion were achieved by day 34 (Figure 4C). After the healing process, the patient reported no further clinical symptoms. A follow-up CT scan was recommended 6 months later to evaluate the progress of bone regeneration and determine if additional intervention would be necessary.

Discussion

This case report details the management of palatal necrosis that occurred following nasopalatine deflation, highlighting the use of topical oxygen gel as an innovative treatment approach. The application of this gel, which enhances the healing process through its regenerative properties, was instrumental in treating the necrosis and promoting tissue recovery. The report provides insights into the effectiveness of this novel therapy and its potential benefits in post-surgical wound management.

Oxygen plays a critical role in wound healing by promoting revascularization, enhancing energy production necessary for reparative processes, and augmenting defense mechanisms against bacterial invasion [12,18]. Studies have demonstrated the effectiveness of hyperbaric oxygen therapy in improving outcomes for irradiated patients with tissue injuries, reducing the risk of osteoradionecrosis following tooth extractions in irradiated fields [19], and aiding the healing of nonhealing wounds [20]. Furthermore, topical oxygen therapies have been found to be beneficial in fostering the healing of chronic wounds [21]. In dental applications, oxygen therapy has shown promising results in treating osteoradionecrosis and necrosis induced by bisphosphonates [17,22]. Recent advancements have also introduced its use in orthodontic treatments, enhancing clinical outcomes [23].

The hypothesis for our case report posits that tissue hypoxia, resulting from nerve removal and vasoconstriction induced by anesthesia, compounded by possible suture dehiscence, led to the necrotic condition. Although the literature contains instances of complications associated with nervus deflation and lateralization [24], no studies have reported palatal necrosis under similar circumstances, thus supporting our hypothesis of compromised blood supply leading to the observed necrosis [1]. The decision to use topical oxygen gel was based on its ability to enhance tissue oxygen levels and support the complex processes of wound healing, which require significant cellular activity and adequate blood supply. Additionally, similar cases involving jaw osteonecrosis have reported favorable outcomes with this treatment, further supporting its potential efficacy in managing complex wound conditions [12,17].

Although the use of topical oxygen gel (blue®m) is relatively recent, with only a few in vivo and in vitro studies reported, comparative analyses have underscored its efficacy [13]. Notably, it has demonstrated superior performance in reducing red complex bacteria within biofilm models, outperforming established agents such as chlorhexidine [13]. Furthermore, a randomized clinical trial has indicated that blue®m gel is equally effective in treating residual pockets in patients with periodontitis when compared with subgingival instrumentation [15]. Additional case reports corroborate the gel’s effectiveness when integrated with standard treatments [25]. These reports detail complete resolution of mandibular cysts, significant reduction of post-surgical inflammatory pain, and successful outcomes in the management of periodontitis [17,25–27].

Notably, in our case, the rapid resolution of the tissue lesion, absence of pain postoperatively, and lack of need for additional treatments underscore the therapeutic potential of this approach. Such outcomes may largely be attributed to the stimulation of angiogenesis, a critical mechanism in wound healing [27]. Oxygen supplementation during healing processes is known to enhance oxidative bacterial killing, stimulate angiogenesis, accelerate extracellular matrix formation, and increase fibroblast proliferation and collagen deposition, collectively expediting the healing process [28]. The components in blue®m products, such as honey (enzyme glucose oxidase) and sodium perborate, generate a slow and continuous release of oxygen when in contact with tissue fluids, converting to H2O2 at low concentrations (0.003 to 0.15%), thereby offering healing and bactericidal benefits [27].

Despite these promising findings, a major limitation is the limited literature available on the clinical use of topical oxygen gel and the lack of robust scientific evidence supporting its efficacy. Most existing studies are primarily case reports, which provide valuable insights but do not offer the level of evidence required for widespread clinical endorsement. The need for more rigorous clinical trials and controlled studies is essential to substantiate the therapeutic benefits of topical oxygen gel and establish its efficacy as a standard treatment modality in clinical practice.

Within limitations, this case report showed complete resolution of palatal necrosis after nervus deflation using TOOT with active oxygen gel (blue®m), and this therapy seems to accelerate the healing process in this case.