eau-ebu update series 5 (2007) 179187

available at www.sciencedirect.com
journal homepage: www.europeanurology.com

Oral Mucosa Harvest: An Overview of Anatomic and Biologic

Considerations
Michael R. Markiewicz a,*, Joseph E. Margarone IIIb, Guido Barbagli c, Frank A. Scannapieco d
a

University at Buffalo, School of Dental Medicine, Buffalo, NY, Harvard School of Public Health, Boston, MA, and Center for Applied Clinical
Investigation, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA, USA
b
Department of Oral and Maxillofacial Surgery, School of Dental Medicine, University at Buffalo, Buffalo, NY, and Private Practice,
Williamsville, NY, USA
c
Center for Reconstructive Urethral Surgery, Arezzo, Italy
d
Department of Oral Biology, School of Dental Medicine, University at Buffalo, Buffalo, NY, USA

Article info

Abstract

Keywords:
Buccal mucosa graft
Hypospadias/epispadias
Oral mucosa graft
Transplants
Urethral stricture
Urethroplasty

Objectives: The authors review the biologic characteristics of the oral

mucosa. In addition, the authors report a contemporary harvesting technique of the oral mucosa for urethral transplantation, using biologically
sound principles, modified by current literature.
Methods: We reviewed pertinent English literature from January 1966
through January 1, 2007 regarding the biologic properties of the oral mucosa.
Results: The oral mucosa is made up of a thick, nonkeratinized, squamous
cell epithelium, overlying a thin lamina propia. It hosts a number of microorganisms, yet, the tissues inflammatory response to these organisms is
minimal. There are multiple immunologic processes intrinsic to the oral
mucosa that makes it impervious to native oral flora colonization. Histologic
studies have demonstrated that the oral mucosa is highly compatible with
the urethral recipient site, at times being indistinguishable from the surrounding tissue. The harvesting surgeon should closely inspect the oral
mucosa for any abnormalities prior to considering harvest. Wound healing
in the oral mucosa is ameliorated by sound surgical principles, yet is
mediated by biologic processes beyond the surgeons control. When harvesting oral mucosa, the surgeon is advised to stay well away from pertinent
anatomic landmarks to defer any aesthetic or functional defect to the donor
site.
Conclusions: Success of the oral mucosa graft for urethral surgery can be
partially attributed to the tissues biologic properties. When harvesting the
tissue, anatomic landmarks should be considered to provide the best
possible treatment for the patient while minimizing morbidity to the donor
site.
# 2007 European Association of Urology and European Board of Urology.
Published by Elsevier B.V. All rights reserved.
* Corresponding author. 6490 Main Street, Suite 3, Williamsville, NY 14221, USA.
Tel. +1 716 563 5574; Fax: +1 716 631 2814.
E-mail address: michaelmarkiewicz@gmail.com (M.R. Markiewicz).

1871-2592/$ see front matter # 2007 European Association of Urology and European Board of Urology. doi:10.1016/j.eeus.2007.05.002
Published by Elsevier B.V. All rights reserved.

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1.

eau-ebu update series 5 (2007) 179187

Introduction

It has been widely suggested that oral mucosa is

now the preeminent donor tissue for the reconstruction of urethral defects [1]. Its versatility is
confirmed by the vast use of the tissue for the
reconstruction of a variety of urethral defects such
as hypospadias [2], epispadias [3], and stricture [4]
among others. Although Humby reported the first
use of oral mucosa for urethroplastic repair [5], it
was not until a report by Burger et al. [6], closely
followed by a report from Dessanti et al. [7], that use
of the oral mucosa in reconstructive urology came
into widespread use.
The purpose of this overview is to provide the
reader with an understanding of the biologic traits of
the oral mucosa and its anatomic features that make
it such a versatile tissue for urethral reconstruction.
A secondary objective is to report a novel technique
for oral mucosa harvest modified by using sound
biologic principles identified through a review of the
literature.
2.

 Thick nonkeratinized stratified squamous avascular epithelium

 Slightly vascular underlying lamina propia [12]
These properties contrast the bladder mucosa
and the penile skin, both of which have a thin epithelium and a thick lamina propria [12].

Take Home Message:

The oral mucosa is architecturally similar to the stratified squamous epithelium of the penile and glanular
urethra, making it exceptionally adaptable for urethral
substitution.

Methods

We reviewed the English literature using the databases

MEDLINE/PubMed (January 1966 through January 1, 2007),
the Cochrane Database of Systematic Reviews (CDSR), the
Cochrane Central Register of Controlled Trials (CENTRAL), and
Embase Drugs and Pharmacology (January 1974 through
January 1, 2007). The Medical Subjects Headings (MeSH): oral
mucosa graft and buccal mucosa graft were used to search these
databases for abstracts that reported the anatomic, histologic,
and biologic features, as well as novel tissue engineering
methods and harvesting techniques of the oral mucosa. The
bibliographies of pertinent articles were examined for additional references.

3.

oral mucosa transplantation in the oral cavity [8,10].

Furthermore, nonkeratinized mucosa contains
more elastic fibers than keratinized mucosa [11].
Anatomically, the oral mucosa is located between
the mucosal lining of the gastrointestinal tract and
the skin of the outer face displaying properties of
both tissues. As shown in Fig. 1, it consists of a:

Oral epithelial cells are infused with polymicrobial intracellular and extracellular flora, mainly
streptococci, yet include other species such as
[13]:









Actinobacillus actinomycetemcomitans
Porphyromonas gingivalis
Tannerella forsythensis
Fusobacterium nucleatum
Prevotella intermedia
Oral Campylobacter species
Eikenella corrodens
Treponema denticola

Results

3.1.

The Biology of the oral mucosa

3.1.1.

Characteristics common to labial and buccal mucosa

The two most common sites of oral mucosa harvest

for urethral repair are the:
 Mandibular (lower jaw) labial alveolar mucosa.
 Mucosa of inner cheekthe buccal mucosa.
Oral mucosa is approximately 500 mm in depth
[8]. Mucosal thickness is directly associated with
male gender and indirectly associated with age [9].
Nonkeratinized mucosa is significantly thicker then
keratinized mucosa and successfully withstands the
rigorous shearing forces of a prosthesis following

Despite these harsh exposures, inflammatory

infiltrate is rarely witnessed under histologic examination of oral mucosa in healthy individuals [13].
Reasons for this are:
 The intracellular suppressing activity mediated
between polymicrobial flora
 Production of antimicrobial peptides by the
epithelia (defensins, cytokines, etc).
 Mucosal epithelial cells of the oral cavity limit
microflora colonization by continued exfoliation
[14] and by a specialized immune system, the
mucosa-associated lymphoid tissue (MALT).
The lamina propria of a well-defatted oral mucosa
graft can be considered a secondary barrier

eau-ebu update series 5 (2007) 179187

181

Fig. 1 Buccal and labial mucosa harvest sites displaying anatomic landmarks, important accessory organs adjacent to the
harvest sites, and innervation and blood supply. Adjacent photomicrograph of the buccal mucosa displays a thick stratified
squamous cell epithelium overlying a thin lamina propria where a blood vessel can be visualized. Photomicrograph of the
inner labial mucosa is not shown due to similarity with the buccal mucosa.

preventing microorganisms from entering adjacent

tissue layers and exhibits noteworthy antimicrobial
properties including:






Immunoglobulin-synthesizing plasma cells

Lymphocytes
Polymorphonuclear neutrophils
Monocytes/macrophages
Mast cells

Sebaceous glands, when present, are located in

the lamina propria and are more prevalent in labial
than buccal mucosa. Immunohistochemical staining demonstrates that blood vessels and nerve fibers
from the submucosa infiltrate into the lamina propria [12] and therefore provide a mechanism for

angiogenesis and revascularization of the tissue

when grafting.
Frequently exposed to compression, stretching,
and shearing forces, the oral mucosa is highly
resilient. This can be partially attributed to the
lamina propria-oral epithelium interface, which
consists of extensive projections of connective
tissue into the epithelial layer [15], increasing the
surface area of the epithelial-lamina propria interface, and providing the oral mucosas ability to resist
overlying forces.
In comparison to the mucosa of the gastrointestinal tract, the oral mucosa has no muscularis
mucosae layer between its epithelium and lamina
propria layers. Minor salivary glands, found in the
submucosa, are primarily mucous secreting and are

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eau-ebu update series 5 (2007) 179187

more prevalently found in the labial mucosa. Thus,

it is nearly impossible to harvest a labial mucosa
graft without interfering with salivary secretion.
3.1.2.

Anatomy of the labial mucosa

The mandibular labial mucosal upper and lower

borders are designated by the vermillion border of
the lower lip and the vestibular fold between the
lower lip and the anterior border of the mandible,
respectively.
The lateral borders are a made up by the outer
commissures of the lower lip (Fig. 1).
The mandibular labial alveolar mucosa is innervated by the mental nerve, a terminal branch of the
inferior alveolar nerve of the mandibular division of
the trigeminal nerve (CN V3). The mental nerve exits
the mandible between the first and second premolar
teeth through the mental foreman [16]. The surgeon
should plan the incision for a labial mucosa harvest
medial to the middle of the canines to avoid
damaging the mental nerve and compromising
sensation to the lower lip.
The mandibular labial alveolar mucosa receives
its blood supply from the inferior labial artery (a
branch of the facial artery), the mental artery (a
continuation of the inferior alveolar artery), as well
as anastomoses from the buccal artery. The mental
and buccal arteries are both branches of the
maxillary artery. Both the facial artery and the
maxillary artery are divisions of the external carotid
artery [16].
Take Home Message:
Failure to operate away from the vermillion border of the
lip may result in cosmetic, muscular, and neurosensory
defects to the orbicularis oris muscle leading to a difficulty in smiling and a decrease in mobility of the lips. In
addition, if the graft is harvested beyond the vestibule
vertically, toward the teeth, the surgeon may encroach
on the masticatory mucosa, which may create periodontal defects.

3.1.3.

Anatomy of the buccal mucosa

The buccal mucosa is bordered vertically by the

maxillary and mandibular vestibular folds, whereas
its anterior and posterior borders are formed by the
outer commissure of the lips and the anterior
tonsillar pillar, respectively. The buccal mucosa is
primarily innervated by the long buccal nerve (CN
V3), and by the anterior, middle, and posterior
superior alveolar nerves of the second division of
the trigeminal nerve (CN V2). Additionally there is
limited sensory innervation from the facial nerve [16].

The blood supply of the buccal mucosa originates

primarily from:
 The buccal arterya branch of the maxillary
artery
 The anterior superior alveolar artery of the
infraorbital arterya branch of the third part of
the maxillary artery
 The middle and posterior superior alveolar
arteriesbranches of the maxillary artery
 Accessory vessels from the transverse facial
arterya branch of the superficial temporal artery
[16].
The harvesting surgeon must continually be aware
of the parotid (Stensen) duct. This duct originates
from the parotid gland, travels across the body of the
masseter muscle, turns medially at the anterior
border of the masseter, crosses the buccal fat pad,
pierces the buccinator muscle, and finally terminates
at its orifice. This orifice is clinically visible by a
papilla located on the mucosa of the inner aspect of
the cheek adjacent to the maxillary second molar.
The anatomic buccal space located lateral to the
buccinator muscle consists of:







Adipose tissue (buccal fat pad)

Stensens duct
The facial artery and vein
Lymphatic vessels
Minor salivary glands
Branches of CN VII and CN IX

The surgeon must be aware of these structures as

well as the underlying buccinator muscle as the
graft is dissected from the underlying fat pad.
Failure to leave the buccinator muscle intact could
result in poor wound closure at the donor site and
dysfunction of the buccinator muscle, which serves
as a muscle of facial expression.
3.2.

Histologic and animal studies

Iizuka et al conducted an experiment in a canine

population in which a longitudinal incision in the
urethra was repaired either by primary closure
(control group) or by oral mucosa [17]. Histologically,
the oral mucosa group displayed a urethral lumen
completely lined by squamous epithelium with a
submucosa abundant in blood vessels and smooth
muscle essentially identical to the control group.
Oral mucosa grafts (OMGs) exhibited a thinner
lamina propria and a thicker squamous epithelium
compared to penile skin [18]. Filipas et al. [19]
histologically compared healing of full-thickness

eau-ebu update series 5 (2007) 179187

skin grafts and OMGs on implantation in the

bladders of mini-pigs. Full-thickness skin grafts
exhibited significantly greater inflammatory cell
infiltration, necrosis, and graft ulceration than
OMGs on visual examination. El-Sherbiny used a
canine model to compare the histologic outcomes of
two different grafting procedures (tube vs. onlay),
and three types of grafts (full-thickness skin graft,
bladder mucosa, and oral mucosa) [20]. OMGs had an
average shrinkage rate of 10%, whereas bladder
mucosa and full-thickness grafts had shrunk 2040%
of their original size following transplantation.
Histologically, no difference in the degree of
neovascularization of the three graft tissues was
observed, yet an increase in inflammation and
fibrosis was more associated with the full-thickness
grafts, especially in the area of hair follicles. Bladder
and oral mucosa showed a more uniform graft
thickness in comparison to full-thickness skin,
which demonstrated an irregularity in graft thickness. Interestingly, the structural integrity of oral
mucosa remained intact following transplantation
to distant sites [21].
3.3.

Wound healing in the oral mucosa

Age and female status are associated with prolonged

wound healing in the oral mucosa [22]. In contrast to
the healing of keratinized oral mucosa whereby the
process of wound healing is more complex [23], the
healing of nonkeratinized mucosa is less complicated and is much more predictable.
Take Home Message:
The three primary clinical factors responsible for successful healing of the oral mucosa wound are:
1. Close proximity of wound edges during primary
healing
2. Minimal development of granulation tissue during
secondary healing [23]
3. Properly defatting and removing all excess submucosal tissue, fat, and muscle encouraging revascularization of the graft [24,25]

These variables can be ameliorated by using

sound harvesting techniques and by the patients
cooperation with postoperative and oral hygiene
instructions from the harvesting surgeon. Healing
by secondary intention was associated with less
postoperative pain, discomfort, and dysfunction to
patient [26].

3.4.

183

Tissue engineering

Previous dental procedures, tissue trauma, infection,

malignancy, or prior OMG harvest may make donor
sites less than adequate for harvest. In fact, a wellknown shortcoming of oral mucosa as a donor tissue
is the limited quantity available compared with skin
[27]. Bhargava et al developed a technique to increase
the amount of tissue available for harvest called
tissue-engineered buccal mucosa (TEBM) [28]. To
assess graft tensile strength, the graft was exposed to
shear mechanical and catheterization forces.

Take Home Message:

Histologic examination revealed that full-thickness
TEBM was well integrated at the epidermal-dermal junction and was suitable to withstand catheterization forces
without substantial epithelial changes [28].

Lauer et al described a technique facilitating

primary closure of the oral mucosa harvest site [29].
Tissue grafts were engineered and resized to fit
corresponding intraoral defects left by OMG harvest
and were then sutured to the surrounding native
mucosa. Clinical assessment of maximum jaw
opening revealed that all 12 patients returned to
preoperative maximum jaw opening measurements. The grafted/native mucosa interface could
not be differentiated clinically 3 mo following
harvest.
3.5.

Surgical procedures for oral mucosa harvest

To facilitate access to the oral cavity, nasal endotracheal intubation is the preferred method of
airway control by the harvesting surgeon [30]. When
oral endotracheal intubation is used, special precautions should be taken to maintain proper tube
placement during the entire harvesting procedure.
This is particularly important when the urethral
defect requires bilateral buccal mucosa harvests.
Two separate sterile surgical instrument tables,
instrument setups, prepping and draping should be
used to minimize cross-contamination of the oral
and urologic wounds.
3.5.1.

The two-team approach

The exaggerated lithotomy position has well-documented potential complications that are proportional to the length of time in surgery. By reducing
the patients time in the lithotomy position, a

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eau-ebu update series 5 (2007) 179187

Table 1 Normal and pathologic oral conditions

Normal oral conditions [37]
Ephelis (cutaneous freckle)
Fordyce granules (ectopic sebaceous glands)
Linea alba buccalis (white streak on buccal
mucosa following the occlusal plane)
Morsicatio buccarum (cheek chewing)

Pathologic oral conditions

Leukemia [35]
Leukoedema [35]
Mucositis associated with head and neck radiation therapy,
chemotherapy, and cancer surgery [34]
Pemphigus vulgaris
Mucous membrane pemphigoid
Erythema multiforme
Leukoedema [37]
Oral lichen planus
Recurrent aphthous stomatitis (canker sores) [36]

The first column list oral conditions that may necessitate the need to delay oral mucosa harvest until site conditions improve. The second
column lists oral conditions that would be strict contraindications for oral mucosa harvesting.

reduction in sequelae such as neurapraxia, compartment syndrome, myoglobinuria, and renal failure can be achieved [31]. When the lithotomy
position is used by the reconstructive urologist, a
two-team approach with separate and concurrent
operating teams at the urologic and oral sites
reduces lithotomy and general anesthesia time.
Furthermore, it allows the transplantation team to
solely concentrate on urethral reconstruction [30].
When a single operator performs both the harvesting and urethroplasty procedures, the patients legs
should be put down, out of the lithotomy position
during harvest to prevent any unpleasant complications.
3.5.2.

Retraction

Several methods have been proposed to stabilize the

dissection plane in oral mucosa harvest. One group
has advocated use of the Steinhauser mucosa
stretcher [30,32], which is designed to retract and
provide hemostasis to the donor bed providing
improved access and ease of harvest for the surgeon.
Similar devices, initially designed for cleft palate
surgery, have proven useful in oral mucosa harvest
by adding the benefit of tongue and cheek retraction
thereby increasing operator visibility and access to
the harvest site [33].
3.5.3.

Site conditions contraindicating oral mucosa harvest

A thorough head and neck examination should be

undertaken to avoid potential transplantation of
diseased tissue to the recipient site. There are
several conditions in the oral cavity that would
contraindicate oral mucosa harvest (Table 1) [3436].
Immunocompromised patients have a higher susceptibility to all these conditions. These conditions
must not be confused with variations of normal oral
mucosa (Table 1) [37].
Alterations in normal mucosal anatomy
increase in prevalence as one increases in age

[38,39]. Functional changes increasing with age

are a decreased nerve response to thermal,
chemical, and mechanical stimuli and an
increased susceptibility to chronic irritation, such
as that caused by a removable prosthesis. This is
most likely due to arteriosclerotic changes of the
oral mucosa that cause a decrease in perfusion to
the tissue.
A thorough social history must also be elicited
from the patient. Ethanol abuse increases the
permeability of the oral mucosa [40] by altering
the lipid composition of oral mucosa cells [41]. In
addition, chronic exposure to alcohol may induce
dysplastic change in the oral mucosa, contraindicating its harvest [42]. A social history positive for
heavy smoking warrants careful examination of the
oral mucosa for dysplastic change because smoking
is more associated with malignancy than alcohol
abuse. Although smoking and periodontal disease in
unison may be contraindications for oral mucosa
harvest, when combined these patient-oriented
factors increase the prevalence of pathogens in
the tissues possibly leading to a poor outcome at the
recipient site [43].
Medications, whether prescription or over the
counter, herbal supplements, or vitamins, can affect
the condition of the oral mucosa [44]. Patients on
anticoagulants, antithrombotic therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal
supplements such as ginger, gingko biloba, and
garlic are at risk for increased bleeding at the harvest
site. Commonly used medications directly affecting
the oral mucosa causing erythema multiforme or
lichenoid lesions include clindamycin, Ibuprofen,
barbiturates, and Captopril among others. In addition, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, and NSAIDs
have been associated with angioedema of the oral
mucosa. Both of these conditions would contraindicate oral mucosa harvest.

eau-ebu update series 5 (2007) 179187

3.5.4.

Graft harvest

Similar surgical procedures should be undertaken

when harvesting from both labial and buccal sites.
In the operating room, the patient is prepped and
draped in a fashion typical for oral and maxillofacial
surgical procedures: a pharyngeal throat screen is
placed, and beta-iodine solution is used to cleanse
the oral cavity.
Once the urologist determines the quantity of
graft needed, either by preoperative urethrography
examination or by measuring the defect intraoperatively, a surgical marking pen is used to outline the
extent and shape of the graft, staying several
millimeters inferior to the papilla of the Stensen
duct orifice in the buccal harvest site. The outline
should compensate for predicted shrinkage of the
graft because one group reported that OMGs shrink
up to 20% of their original size at harvest [29].
Anatomic variations such as extensive frenal (muscle) attachments extending toward the vermillion
border of the lip and poor periodontal status
contraindicate labial mucosa harvest, whereas
variations such as an unusually inferiorly located
Stensens duct or anteriorly located anterior pillar
and tonsillar tissue contradict buccal mucosa
harvest. The graft can be outlined as an elliptical
shape (Fig. 1). This design allows for ease in primary
closure of the anterior and posterior aspects of the
donor site without compromising graft size or
viability [26].
Local anesthetic (1% lidocaine with 1:100,000
epinephrine) is injected at the periphery of the
marked outline and deep into the central area of
the donor site to help elevate and hydro-dissect the
oral mucosa from the underlying soft tissues. After
an interval of 57 min to allow for maximum
epinephrine vasoconstriction effect, an initial
incision at the anterior apex of the outline is made
with a steel blade or Bovie needle tip on cut mode.
The incision is limited to the full thickness of the
mucosa only, and a dissection plane is created above
the submucosal adipose layer superficial to the
buccinator muscle containing as little of the buccal
fat pad as possible. Atraumatic forceps are used to
handle and grasp the tissue on the submucosal side
of the graft with particular care directed at avoiding
trauma to the external mucosal surface of the graft.
Metzenbaum scissors may be used for both sharp
and blunt dissection staying above the submucosal
plane, which is performed somewhat past the entire
marked outline to the posterior apex of the graft.
When dissecting the graft from the buccinator
muscle of the buccal site, adipose tissue should be
spared on the buccinator surface. Sharp and blunt
submucosal dissection is then extended at least

185

0.5 cm beyond the superior and inferior wound

edges to release tension during primary closure.
Primary closure is accomplished with a single layer
of 4-0 Polyglactin 910 sutures (Vicryl rapid, Ethicon
Inc, Somerville, NJ, USA) with an RB-1 tapered
needle to minimize mucosal tearing. Initially, two
or three interrupted sutures are equally placed along
the entire length of the incision to evenly segment
and properly align the wound margins. The remainder of the wound is then closed with multiple simple
interrupted sutures or a continuous horizontal
mattress suture.
The harvested tissue is then inspected and
measured. It is usually prepared by the harvesting
surgeon by vigilantly removing any muscle, salivary
gland, or subcutaneous adipose tissue remnants
from the underside of the graft using sharp scissors.
Care is taken to avoid accidental perforations and to
maintain uniformity of the thickness of the tissue
during this process. The graft is then placed on a
sponge, rolled up, and placed in 0.9% NaCl solution
and passed to the urology surgical table and stored
until needed for reconstruction. All patients should
be prescribed chlorhexidine oral rinses in the postoperative period to control microbiologic colonization. A second-generation cephalosporin (eg, cefotaxime) is typically administered intravenously by
the urologist following surgery. This coverage is
adequate to minimize incidence of infection at the
donor site.

4.

Conclusion

Since the initial papers by Burger et al and Dessanti

et al, numerous reports have detailed the biologic
reasoning for the success of the oral mucosa in
reconstructive urology. Innovative techniques are
being reported at a rapid pace. Paralleling the
clinical success of the oral mucosa, researchers
must understand the biologic basis for why one
technique works better than another. The translation of this information from the bench top to the
surgeons hands is necessary to move the field
forward.

Acknowledgments
The authors thank Mr. John Nyquist, MS, CMI,
University at Buffalo, for providing the illustration
in this manuscript. The authors are indebted to Dr.
Alfredo Aguirre, DDS, MS, School of Dental Medicine, University at Buffalo, for providing the photomicrograph in this manuscript.

186

eau-ebu update series 5 (2007) 179187

Conflict of interests
The authors report no conflict of interest or sources
of funding for this article.

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CME questions
Please visit www.eu-acme.org/europeanurology
to answer these CME questions on-line. The CME
credits will then be attributed automatically.
1. The oral mucosa is composed of:
A. A thin squamous cell epithelium and a thick
lamina propria
B. A thick squamous cell epithelium and a thin
lamina propria
C. A thin squamous cell epithelium and a thin
lamina propria
D. A thick squamous cell epithelium and a thick
lamina propria
2. The most abundant microorganism(s) indigenous
to the oral mucosa is (are):
A. Streptococci
B. Porphyromonas gingivalis
C. Fusobacterium nucleatum
D. Prevotella intermedia
3. The mandibular labial mucosa is innervated
primarily by the:
A. Mental nerve
B. Buccal nerve

C. Middle posterior alveolar nerve

D. Facial nerve
4. One of the primary patient-oriented factors found
to be directly associated with delayed wound
healing in the oral mucosa of an otherwise
healthy patient is:
A. Young age
B. Surgical harvest site (labial vs. buccal)
C. Race
D. Female gender status
5. Normal features of the oral mucosa may include:
A. Leukoedema
B. Linea alba buccalis
C. Pemphigus vulgaris
D. Aphthous ulcer
6. Medications that may cause erythema multiforme or lichenoid lesions of the oral mucosa
include:
A. Sertraline
B. Loratadine
C. Acetylsalicylic acid
D. Ibuprofen