Use of Pedicied Buccal Fat Pad in the Closure of Oroantral Communication: Analysis of 75 Cases

Surgery

Use of pedicied buccal fat pad in the closure of oroantral communication: Analysis of 75 cases

Dogan Dolanmaz. DDS. PhD^/Hakan Tuz. DDS. PhDVSerhat Bayraktar. Murat Metin, DDS, PhD^/Erdal Erdem, DDS, PhD^/Timucin Baykul, DDS,

Objective: This report evaiuates the use of pedicied buccal fat pad for closure of oroantral communica- tJofts. Method and materials; Sevenly-frve patients were treated with pedicied buccal fat pad. Ffly-two were treated immediately after lootfi extradions. The remaining 23 had chronic oroantral communicaBon and were treated amilarly after Irrigation of tfie maxillafy sinus wiîfi saline for 7 days. Results: The 6-monlfi follow-up revealed unev^tful fiealing in aJI of tfie patiente. Tfiougfi partial necrosis of tfie flap was observed in three patients, this did not effect tfie final healing. Total necrosis of the fiap was not noted. Conclusion: The use of pecJided buccal fat pad is an acceptable and reliable alfemative in acute or chronic oroanlra! communications management and may even be used as a first treatment choice by ex- penenced surgeons. (Quintessence Int 2004;35:241-246)

Key words: con^jlication, hypertrophy, maxillaiy sinus, oroantral communication, partial necrosis, pecfided buccal fat pad

/"Vroantra! communications (OAC) may occur dur- Different local flap configurations or their combina- Vîng extractions of the maxillar>' teeth and also as tions are the most preferable treatment methods in a result of operations in the masilla. If the patient has minor perforations.^" Distant flap and graft materials a healthy sinus, an OAC less than 4 to 5 mm in diame- are used in cases of larger perforations and in cases ter will most likely heal spontaneously. In larger perfo- where there is inadequate adjacent soft tissue.*-* in ad- rations, surgery becomes the choice of treatment for dition to rare use of gold foil. pol^Tnethylmethacrylate prevention of chronic and irreversible changes in the and fibrin sealants in the closure of oroantral openings maxillary' sinus.' have been reported.'""- The treatment methods for OACs include the use of The huccal fat pad (BFP) as an anatomic element local flaps, distant flaps, and pafting procedures.- was first mentioned by Heister in 1732 and was de- scrihed by Bichat in 1802.'^ The BFP had some degree 'Assistant Professor. DEpatment of Oral and ManDoâcial Suigery. FaaAy of clinical importance for many years and was usually of Oenfeliy, IMvasft/al SEICI*, Konya. TiBkey. considered a surgical complication because of its unin- íteÉlanl Proíessor. Oepaitmenl of Ola and l>(axBotactal Sugeiy. Faculty tentional encounter either during different operations al DeiCsby, IMveisiy ol lOnkkale. Kinkkaie, Tiutey. in the pterygomaxiUari' space or after injuries of the ^leseanii Assäart, Depaibnenl ol Ora and Madoboal Surgery, Faculty maxill of acial region.*"' Egj'edi'^ was the earliest to re- of DerriÊtry, University of Arkara, Ankara, Tivtey. port of the use of BFP for oral reconstruction. In his 'AssÊtaM PmlesEor, Deferbnent oJ Oral arxl MaxOolaciail Surger)^ Faculty study, BFP was used in the form of a pedicied graft for ol DEnfetry. UrmeisBy oj Ordohic Mayis. Samsui, Tintey. the closure of postsurgicai ma.\illari' defects in four ^Professor, Department of Oral and Maxillofacial Surgery. Faculty of cases. Coverage of the exposed BFP with a skin graft Dentiary, Urmetsiy olArkara. Ankara. Tistey. also was suggested. Neder^^ reported post-traumatic Âs^tant Prolessor. Oepartmer« ol Oral and Madofaoal Sugery. Faculty scar tissue formation in two cases in which free fat ai DerAstry, University of Siêyman Demrd, Ispaita, TiBkey. grafts were used, «ith the BFP as the donor site. The Reinit requests: Or Oogan Oolanmaz, Sekuk Universitesj. Dis Hetômligi VB Ccnahisi AD. 42079 Kampus. Konya. Turkey E-mail: first broad study describing in detail the anatomy of

Ountessence Irtterrtabonal 241 Doianmaz et ai the BFP, its vascular supply, the operative technique, fore the divergent cuts were done. A mucoperiosteal and the clinical results from the use of the BFP in 12 flap was reflected from the alveolar process and laters^ cases of reconstruction of surgical defects in the oral wail of the maxilla. A 1-cm vertical incision was made cavity was reported by Tideman et al."* They also re- on the periosteum dissected from the posterior aspea ported on the idea of using the BFP as a pedicled graft of the zygomatic buttress in the second molar region. and its complete epithelization without the use of skin The BFP was seen through a blunt minor dissection^ graft. After these studies, pedicled BFP gained popu- No aspiration was performed in order to protect the larity, and various encouraging clinical results have tbin capsule of the BFP, Buccal fat tissue then was ad- since been reported.'^'^•' vanced gently to the osseous defect area and sutured In tbis article, outcomes and treatment protocol of with 4.0 vicryl to palatal mucosa without tension. The 75 OAC patients managed by pedicled BFP are pre- mucoperiosteal flap was brought to its original posi- setited. tion and sutured. Fat tissue in the perforation area was left exposed to the oral cavity. No surgical splint or dressing was used. METHOD AND MATERIALS If the roots that pushed into the sinus were un- reachable, they were removed by saline irrigation per- This study was conducted in four different oral and formed tbrough the perforations. When a Caldweil- maxillofacial surgery centers from 1995 to date by sur- Luc procedure was done, the anterior vertical incision geons wbo bave undergone the same specialty train- was extended horizontally to the canine region. ing. Seventy-five patients (53 male and 22 female) All patients were given oral penicillin and decon- who bad acute and ebronic OACs larger than 5 mm in gestant nasal drops and were instructed to avoiij diameter were included in the study. Ages ranged be- smoking, strong sneezing, and to use a pipette while tween 17 and 61 years. Preoperatively, routine radi- drinking, and were given a soft diet. All the patients ograpbs were taken of all patients to examine tbe were followed weekly during the first month and then antrum and the OAC region. Fifty-two of the cases controlled monthly for 6 months. Six of the patients were acute OACs, which occurred after maxillary did not show up after the third control month. molar teeth extractions. Most of these extractions were performed in other clinics and referred to the authors for closure of the acute OAC. In seven of these cases, a tooth root pushed into the maxillary sinus was RESULTS found. Some of the patients had palatal or buccal mucosal injuries related to traumatic tootb extractions. Each of the 75 cases had a favorable healing course Tbe remaining 23 patients bad chronic oroantral following the operation, and the wounds became suc- openings that occurred after dental extractions. Six of cessfully epitbelized in 3 to 4 weeks postoperatively. these patients had a history of previous unsuccessful Clinically, in the typical course, tbe surface of the attempts of fistula closure in different clinics where orally exposed fat became yellowisb-white in 3 days, other methods were employed. The patients with and then gradually became red within 1 week, which acute OAC underwent operations immediately. was likely due to the formation of young granulation Chronic OACs were treated after irrigation with saline tissue. This changed into a firmer granulation tissue solution through the fistula path for 1 week (three during the second week, and it became completely ep- times daiiy). Preoperative oral antibiotics were pre- ithelized with a slight contraction of the wound by 3 scribed if required. In three patients, an additional weeks after the operation, Postoperatively, the de- Caldwell-Luc procedure without intranasal antros- crease in the depth of the vestibular sulcus gradually tomy was required. improved and was restored almost to the preoperative form about 2 months after the operation {Figs 1 and 2). The authors detected a partial necrosis of the flap Surgical method in three cases with no clinical repercussion and achieved a complete epithelization later. Total necrosis All of the operations were performed under local of the flap was not discovered in any of the patients. anesthesia. In the acute OAC cases, a gingival incision Excessive granulation and hypertrophy in nine cases was made, and two divergent cuts were then made was noticed. In six of these, the BFP near the mucosal from each end of the gingival incision extending into border was reduced with scissors to reduce the risk of the vestibule. In the patients who had clironic OAC, a dental trauma while chewing. In another three pa- circular incision with a 3-mm margin was made tients, such an operation was not needed, and no sig- around the fistula to excise completely the epithelial nificant healing differences existed between these tract and inflammatory tissue within the opening be- cases. The BFP that was left hypertrophie reached an

242 Voiume 35, Number 3, 2004 ' Ddanmaz et al

Fig1 Managament of acute OAC fa; View of Itte extraction socket fö) bony defect larger öisn 5 mm; (c) exposure and removal of BFP; (d) tiermetic chjsore of OAC wtih pedicled BFP; (e) suturing the mucoperiosteal flap to ils original position: (¡) tiypeiplastic , -j' ; ffaKrfabon tissue (g) irr^iregnation of opposite denWion oo tfie hyperplastic gfan.L,i-i: :- fesue Oi) reduction ai Ihe fiypetplastic tissue and bleeding due to nch vascularily c5 jl£p 0) mdirect view of the firmer granulaöon tissue in second vieek and fKrtial necrosis of «fie fbp on palatal side;

(3untessence International 243 Dolanmaz et al

Fig 2 Management ot chronic OAC, (a) The root pushed into lett maxillary antrum, (b) surgieal side aíler Caicweii-Luc operation without antrostomy, (c) view of surgical side afler operation; (d) linai healing; (e) indirect oooiusal view of final liealing

almost normal level by completing secondary epithe- passes down and back to lay on the lateral surface of lization. The difference between levels eventually dis- the pterygoid plates. The temporal extension passes appeared completely. upward, below the zygomatic arch and comprises the deep and superficial portions. The deep part lies di- rectly on the temporalis muscle and its tendon, sepa- DiSCUSSiON rating the muscle from the zygomatic arch. The blood supply is from the buccal and deep temporal branches The BFP is a mass of adipose tissue that extends pos- of the maxillary artery, the superficial temporary teriorly for 2 cm through the mucosa and fibers of the artery {transverse facial artery), and a small branch of buccinator muscle. The anatomy of the BFP is com- the facial artery.^''^^'" plex. It rests on the periosteum that covers the poste- Unlike subcutaneous fat, the BFP changes very lit- rior aspect of the maxiila and is bounded by buccina- tle in terms of size and weight, even in cases of ex- tor muscle medially, masseter muscle and mandibular treme weight loss or gain of the patient. In this way it ramus laterally, and the lateral pterygoid muscle supe- is similar to orbital fat, which appears to have a differ- riorly. It consists of a main body and four extensions: ent rhythm of lipolysis.'"-^^ There is great variety in the the buccal, the pterygoid, and the superficial and deep size of the BFP among different individuals and be- temporal extensions. The main body lies above the tween one side and the contralateral side." However, parotid duct on the anterior border of the masseter no significant differences in size between hoth sides in muscle and extends deeply to lay on the posterior each individual has been reported.'' The amount of fat maxilla and forward along the buccal vestibule. The in the BFP is not proportional to total body fat.'^.^^ buccal extension is the most superficial and enters the BFP as a pedicled graft initially used to reconstruct cheek below the parotid duct. The pterygoid extension posterior maxillary defects and oroantral openings

244 Voiume 35, Number 3, 2004 ' Dolanmaz el a!

was later used in the reconstruction of the buccal area, Potential complications of tising pedicled BFP are soft palate, retromolar trigone. lateral pharyngeal H-all. minimal, although hematoma, infection, and e\'en fa- and even in palatal cleft repair.'*^'«-3"-^"5 There are cial ner\'e injury have been reported. These can be also some reports regarding the successful use of it to avoided by careful incision in the buccinator fascia prepare a vascular hed for bone grafts placed in the and limited dissection within the masticatory spaces.^ posterior maxilla and mandibie.^^-^ Its flexible nature Additionally, partial necrosis and excessive scar tissue allowed it to be useful in managing oral submucous fi- formation may be seen on the healing side. Rapidis et brosis patients.^ Additionally, ¿ere is an indication of al^ reviewed complications that occtirred after using use in midface atigmentation for esthetic ptirposes.'' pedicled BFP and reported that complication rates Histologie studies investigating intraoral recon- were rather low {partial necrosis 7.9''o, infection 0.6"«, structions using pedicled BFP showed that the fat tis- excessive scarring 3.4'^o, other 2.4%). The use of the sue became granulation tissue in the short term and fi- pedicled BFP is not recommended in patients with brous tissue in the long term. It is claimed that the malar hypopiasia or patients n-ith thin cheeks, as this stirface of this tissue is covered hy an epithelial cell may accentuate a gaunt appearance, producing hol- loaing within the cheek. .•Uso it is not recommended migration from adjacent areas.'^^^^-^ for patients with Down s s\Tidrome.^*^' In patients requiring postoperative radiation ther- apy, it was obser\'ed that the healing process in recon- This muiticentered study of the use of pedicled BFP struction areas «as tineventful, and this situation was in acute or chronic OAC has the largest case group in explained with a rich vascular supply of BFR'*^'^-'*' the literature, and all of the cases were successM. No Although Fujimura et al^ treated a case successfully postoperative esthetic deformitj'. limitation of maximal after radiotherapy and chemotherapy, Rapidis et aK interincisal opening, infection in sinus or in fat tissue, reported a complete failure in their two OAC patients or sigitiËcant narrowing of vestibular sulcus in the who had chemotherapy and radiotherapy because of long-term period was obser\'ed ciinically. It also was nasophar>Tigeal carcinoma preoperatively. They re- conciuded that age, sex, and body weight have no im- ported that the use of the BFP in the reconstruction of pact on healing- previotisly irradiated oral soft tissues is not indicated. A^Tien comparing the pedicled BFP technique with Removal of the BFP has heen done with open frequently used orthodox methods- it can he said that lipectomi" or liposuction as methods of contotiring the no vestibular sutcus narrowing that may be seen in facial esthetic lines, particularly' in patients with buccal advancement flap cases occurs- Moreover, chuhby cheeks.^^* But it is suggested that when the while this technique allows healing of oral mucosa, it large part of buccal fat tissue is tised for reconstructive also protects its normal anatomic architecttire- Thus, procedtires- no asymmetric deformities occur in the fa- the need for futtire operations could he eliminated in cial region-^^^-*^*-*" This is a controversial procedure, patients who may tjse a removable prosthesis. Unlike and in order to establish objective criteria, more stud- palatal flap cases, there are no secondary healing ies are needed. In the current study, no esthetic defor- areas that require a long and painfui healing period. ntities were found in the patients postoperativety, Additionally, it may be suggested that this is an easier prohabiy due to the minimal BFP usage to close method when the operator has equal experience and oroantral openings. skills with this technique as «ith other techniques. in reviewing the literature. 95 OAC cases were found in which patients, «ith the exception of the irradiated patients in Rapidis et al.^ were treated with CONCLUSION pedicled BFP following dental extractions.^"^^^ All of these cases were reported as successful. The largest It is suggested to place the BFP hermetically in the de- patient group helongs to Stajcic.^ Stajcic stated that fect cavity,- not to use surgical suctions during surgery pedicled BFP was a good alternative in cases where that cotild damage the fat tissue capsule, and to suture hticcal or palatal mucosa were damaged and other without tension,^' When considering the reports pub- techniques failed- el-Hakim and el-Fakharany^* hshed and the current results, it may be concluded showed that the healing potential of pedicled BFP was that the use of pedicled BFP in management of acute superior to the palatal flap. or chronic OAC is an acceptable and reliable alterna- Several advantages were reported for the BFP tive and can be used as a first treatment choice hy ex- method that is used for the clostire of oroantral fistula: perienced stirgeons. wide applicability, in most cases; minimal incidence of failure when properly performed: the simplici^' of the procedure; no need for additional tooth or bone removal; and minimal discomfort for patients.-'

Quintessence Inlematiooal 245 • Dolanmaz et al

REFERENCES 20. Ho KH. Excision of check leukoplakia and lining the defect with a pedicle buccal fat pad graft. Br Dent J 1989;166; 1. Gonty AA. Diagnosis and maLiagement of sinus disease. In: 455-456. Peterson LJ (ed]. Principles of Oral and Maxillofacial 21. Loh FC, Loh HS. Use of the buccal fat pad for correction of Surgery. Philadelphia; Lippineott-Raven, 1992:250. intraorai defects' Report of cases. I Oral Maxillofac Surg 2. Awang MN. Closure of oroantral fistula, lnt ) Oral Maxillo- 1991;49;413-416. fac Surg 1988;17:110-115. 22. Stajcic Z. The buccal fai pad in the closure of oro-antral 3. von VVowern N. Closure of oroantral fistula with buccal communications; A study of 56 cases, ] Craniomaxillofac flap; Rehrmann versus Moczar. Int ] Oral Surg X982;ll: Surg 1992;20;193-197. 156-165. 23. Samman N, Cheung LK, Tideman H. The buccai fat pad in 4. Skoglund LA, Pedersen SS, Hoist E. Surgical management oral reconstruction. Int | Oral Maxillofac Surg 1993¡22;2-5, of 85 perforations to the maxillary sinus. Int J Oral Surg 24. Hanazawa Y, Itoh K, Mabashi T, Sato K. Closure of 1983;12:l-5. oroantral communications using a pedicied buccal fat pad 5. Guven O. A clinical study on oroantral fistulae. J Cranio- graft, I Oral Maxillofac Surg 1995;53;771-775- maxillofac Surg 1998;26:267-271. 25. Martin-Granizo R, Naval L, Costas A, et al. Use of buccal 6. Car M, Juretic M. Treatment oí oroantral communications fat pad to repair intraorai defects; Review of 30 cases. Br J after tooth extraction. !s drainage into the nose necessary or Oral Maxillofac Surg 1997 ;35;81-84. not? Acta Otolaryngol 1998;118;844-846. 26. el-Hakim IE, el-Fakharany AM. The use of the pedicied 7. Yamazaki Y, Yamaoka M, Hirayama M, Shimada H. The buccal fat pad (BFP) and palatal rotating flaps in closure of submucosal island flap in the closure of oro-antral fistula, oroantral communication and palatai defects, ] Laryngol Br I Oral Maxillofac Surg 1985;23;259-263. Otol 1999:113:834-838. 8. Kim YK, Yco HH, Kim SG, Use of the tongue flap for intra- 27 Rapidis AD, Alexandridis CA, Eleftheriadis E, Angeiopoulos orai reconstruction: A report of 16 cases. J Oral Maxillofac AP. The use of the buccal fat pad for reconstruction of oral Surg 19g8;56:7I6-719. defects; Review of the literature and report of 15 cases. J 9. Godfrey PM. Sinus obliteration for chronic oro-antral fis- Oral Maxillofac Surg 2000 ;58; 158-163. tula; A case report. Br J Plast Surg 1993:46;341-342. 28. Baumann A, Ewers R. Application of Ihe buccai fat pad in 10. Mainous EG, Hammer DD Surgicai closure of oroantral oral reconstruction. I Oral Maxillofac Surg 2000;58: fistula using Ihe gold foil technique. J Oral Surg 1974;32: 389-392. 528-530. 29. Hao SP. Reconstruction of oral defects with the pedicied 11. Al-Sibahi A, Shanoon A. The use of soft polymethyl- buccal fat pad flap. Otolaryngol Head Neck Surg 200{);122: methacrylate in the closure of oro-antral fistula, J Oral 863-867. Maxillofae Surg 1982;4ü:165-166. 30. Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba 12. Staicic Z, Todorovic L|, Petrovic V. Tissucol in closure of M. The buccal fat pad flap in oral reconstruction. Head oroantral communication. A pilot study. Int J Oral Surg Neck2001;23;383-388. 1985; 14:444-446 31. Stuzin JM, Wagstrom L, Kawamoto HK, Baker T¡, Wolfe 13. Tostevin PM], Ellis H. The buccal fat of pad; A review. Clin SA. The anatomy and clinical applications of the buccal fat Anat 1995:8:403-406. pad. Plast Reconstr Surg 1990;85;29-33. 14. Brooke RI. Traumatic hemiation of buccai pad of fat (trau- 32. Matarasso A, Discussion. Anatomy of the buccal fat pad matic pseudolipoma). A review. Oral Surg Oral Med Oral and its clinical significance, Plast Reconstr Surg 1999;103: Pathol 1978;45:689-691. 2061-2063. 15. Wolford DG, Stapleford RG, Forte fiA, Heath M. Traumatic 33. Hudson JW, Anderson JG, Russell RM Jr, Anderson N, hemiation of the buccal fat pad: Report of a case. J Am Chambers K. Use of pedicied fat pad graft as an adjunct in Dent Assoc 1981;103;593-594. the reconstruction of palatal cleft defects. Oral Surg Oral 16. Egyedi P. Utilization of the buccal fat pad for closure of oro- Med Oral Pathol Oral Radioi Endod 1995;80;24-27 antral and/or oro-nasal communications, J Maxillofac Surg 34. Yeh CJ. Application of the buccal fat pad to the surgical 1977 ;5;241-244, treatment of oral submucous fibrosis. Int J Oral Maxillofac 17 Neder A. Use of buccal fat pad for grafts. Oral Surg Oral Surg 1996;25;130-133. Med Oral Pathol 1983;55;349-350. 35. Ramirez OM. Buccal fat pad pedicle flap for midface aug- 18. Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad mentation. Ann Plast Surg 1999;43:109-118. as a pedicied graft. | Oral Maxillofac Surg 1986 44' 36. Fujimura N, Nagura H, Enomoto S. Grafting of the buccal 435-440. fat pad into palatal defects, J Craniomaxillofac Sure 1990; 18:219-222. 19, Vuillemin T, Raveh ], Ramon Y. Reconstruction of the maxilla with bone grafts supported by the buccal fat pad, ] Oral 37 Matarasso A. Buccal fat pad excision; Aesthetic improve- Maxillofac Surg 1988;46:100-106. ment of the midface. Ann Plast Surg 1991;26;4Í3-418. 38. Newman ]. Removal of buccal fat pad by liposuction Plast Reconstr Surg 1990;86;385-386,

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