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Pedicled buccal fat pad in the management of oroantral fistula: a clinical study of 15 cases
Int. J. Oral Maxillofac. Surg. 2012; 41: 1025–1029 doi:10.1016/j.ijom.2012.02.014, available online at http://www.sciencedirect.com
Clinical Paper Oral Surgery
Pedicled buccal fat pad in the management of oroantral fistula: a clinical study of 15 cases
M. K. Jain1, C. Ramesh2, K. Sankar3, K. T. Lokesh Babu1 1
Department of Oral and Maxillofacial Surgery, Sri Hasanamba Dental College and Hospital, Vidyanagar, Hassan 573201, Karnataka, India; 2Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Science, Puducherry, India; 3 Department of Oral and Maxillofacial Surgery, Mahatma Gandhi Postgraduate Institute of Dental Sciences (MGPGI), Puducherry, India
M. K. Jain, C. Ramesh, K. Sankar, K. T. Lokesh Babu: Pedicled buccal fat pad in the management of oroantral fistula: a clinical study of 15 cases. Int. J. Oral Maxillofac. Surg. 2012; 41: 1025–1029. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. This study evaluated the long term effectiveness of pedicled buccal fat pad (BFP) with or without buccal advancement flap in the closure of oroantral fistula (OAF). A prospective clinical study involving 15 patients with chronic OAF was carried out. All cases were managed with pedicled BFP as the primary or secondary procedure. Cases with doubtful outcome were closed in two layers using BFP along with buccal advancement flap. Cases were followed for 3 months (1, 4, 8 and 12 weeks) to evaluate any postoperative complications such as wound dehiscence, necrosis or infection. Females (66.7%) in their third to fourth decade were commonly affected in the right posterior region (75%). Dental extraction (73.3%) followed by maxillofacial pathology was the most common causes for developing OAF. Only 2 of 15 cases were closed in two layers. Complete epithelialisation of all the cases was observed with no postoperative complications. Pedicled BFP is an effective and reliable flap for the repair of OAF. Cases of larger oral defects with doubtful outcome can be closed in two layers using BFP along with buccal advancement flap.
An oroantral fistula (OAF) may develop as a complication of dental extractions, as a result of infection, or as sequelae of radiation therapy, trauma, and removal of maxillary cysts or tumours. The commonest aetiology of OAF is as a complication following extraction of maxillary posterior teeth.1,2 Treatment modalities to repair OAFs following any cause include local and distant soft tissue flaps, autogenous bone grafts, allogenous materials, xenografts, 0901-5027/0801025 + 05 $36.00/0
synthetic metals and other techniques.3–5 Regardless of the technique, two principles must be observed. First, the sinus must be rendered free of infection with adequate drainage and the use of appropriate sinus antibiotics in addition to topical or systemic decongestants. Second, tension free closure of a broad base, well vascularized soft tissue flap.3 Some traditional methods used in the repair of OAF include buccal advancement flaps, palatal rotation and palatal
Key words: oroantral fistula; buccal fat pad; oral reconstruction; buccal advancement flap. Accepted for publication 20 February 2012 Available online 21 March 2012
transposition flaps, tongue flaps, and nasolabial flaps.1–3,5 Recently, because of various advantages, buccal fat pad (BFP) is increasingly being employed in the repair of OAF and other oral defects worldwide.6–11 BFP was first described by Heister (1732), who thought the structure was glandular and termed it the ‘glandula molaris’.7–9,11–17 Bichat is credited with recognizing the true nature of the BFP. Therefore, it is commonly referred to as
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1026
Jain et al. The quick epithelialisation of the uncovered fat is a characteristic feature of the pedicled BFP flap and is histologically proven.7,10,12 The layer above the originally uncovered BFP consists of stratified squamous epithelium migrating from the adjacent mucosal regions. The aim of this paper is to evaluate the long term effectiveness of pedicled BFP with or without buccal advancement flap in the closure of OAF. Materials and methods
Fig. 1. The main body of the buccal fat pad and its extensions and relations with important adjacent structures.
the boule de Bichat or bolle graisseusse in French; it is called wangenfettpfropf or Wangenfettpolster (Wangen = Cheek + fett = fat, polster = pad-cheek, fat, pad) in German, and the sucking pad, sucking cushion, masticatory fat pad, or buccal pad of fat in English.18 The BFP is a simple lobulated mass consisting of a central body and four extensions: buccal, pterygoid, pterygopalatine, and temporal (Fig. 1). The main body is situated deeply along the posterior maxilla and upper fibres of the buccinator, covered with a thin capsule. The buccal extension lies superficially within the cheek and is partially responsible for cheek contour. The buccal extension and main body together constitute 55–70% of total weight. The pterygopalatine extension of fat tissue extends to the pterygopalatine fossa and inferior orbital fissure. The pterygoid extension is a posterior extension that generally stays in the pterygomandibular space and packs the mandibular neurovascular bundle and lingual nerve. The temporal extension can be divided further into superficial and deep. The superficial part of the temporal process of the BFP stays between the deep temporal fascia, temporalis muscle, and tendon. The anterior end of it turns around the anterior rim of the temporalis muscle, and continues with the deep part. The deep part of the temporal process lies behind the lateral orbital wall and frontal process of the zygoma and turns backward into the infratemporal space. Each process has its own
capsule and is anchored to the surrounding structures by ligaments. The size of the pterygoid and temporal extension is inconsistent, but is usually smaller than either body or buccal extension.4,11,17,19 The superficial temporal fat situated between two layers of deep temporal fascia is a separate fat pad and differs in appearance, has a separate vascular supply, and is anatomically distinct from the BFP.11 The parotid duct courses with the buccal branches of the facial nerve anteriorly (superficial), and on the lateral surface of the BFP, it penetrates the buccinator muscles, entering the oral cavity opposite the second molar. The facial vessels are in the same plane and mark the anterior extent of the BFP.4,11,17,19 The BFP derives its blood supply from the buccal and deep temporal branches of the maxillary artery, transverses facial branches of the superficial temporal artery, and branches of the facial artery. The branches from different sources form the lobar subcapsular plexus by freely anastomosing with each other. Owing to its rich blood supply, it can be considered as a pedicled graft with an axial pattern. The rich blood supply may explain the high success rate with this flap. It may also be one reason for the quick epithelialisation of the fat.4,11,17,19 The average volume of fat is 9.6 ml (range 8.33–11.9 ml).4,11,17,19 The size of the BFP is fairly constant regardless of overall body weight and fat distribution; even cachectic patients have BFPs of normal weight and volume.11,20
After obtaining ethics and research committee approval, a prospective observational clinical study involving patients requiring closure of oroantral communication (OAC)/chronic OAF was done in the Departments of Oral Surgery at Puducherry and Hassan. The study was carried out for 2 years from May 2008 to April 2010. The patients were all told about the procedure of using pedicled BFP for closure, its complications and the other options available for management including their advantages and disadvantages. Patients opting for BFP and willing to be followed up were included. Patients were excluded if they were above ASA 2, required radiation therapy following surgery or were immunocompromised. Fifteen cases were included and managed using pedicled BFP as the primary or secondary procedure (previous surgery had already been carried out unsuccessfully using another method to close the fistula) under local anaesthesia using lignocaine 2% with 1:80,000 adrenaline (except for one case that was carried out under general anaesthesia). Seven of the patients with chronic sinusitis and infection were treated using the Caldwell-Luc operation with OAF closure being performed at the same time. Cases with doubtful outcome were closed in two layers using BFP and buccal advancement flap. The patients gave informed consent and were given amoxicillin 500 mg with clavulanic acid 125 mg three times daily (augmentin 625 mg) 2 days before the surgery. After obtaining adequate anaesthesia, excision of the fistulous tract and freshening of the wound edges was carried out. The upper vestibular horizontal incision, depending on the side involved, was made posterior to the second premolar and extended to the posterior margin of the fistula to expose the BFP. Careful manipulation and blunt dissection was carried out to mobilize and advance the flap to the recipient site (Fig. 2). The flap was sutured in place with simple interrupted 3/0 polygalactin 910 sutures. The incision was closed over the bridge segment of the flap
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Pedicled buccal fat pad in oroantral fistula management
1 cm vertical incision was made in the reflected periosteum posterior to the zygomatic buttress to allow exposure and advancement of the BFP over the bony defect where it was sutured to the palatal mucosa (Fig. 3) followed by second layer closure with buccal advancement flap. Follow up lasted for 3 months, at intervals of 1, 4, 8 and 12 weeks to evaluate any postoperative complications such as wound dehiscence, necrosis or infection. Results Fig. 2. Harvesting BFP using vestibular approach.
Fig. 3. Two layered closure of OAF using buccal advancement flap and pedicled BFP.
with sutures. Patients were warned against blowing their noses for 2 weeks. The preoperative antibiotic regimen was continued for the next 5 days. The antral triad of decongestant, antihistamine and analgesic was prescribed for 5 days.
Cases with larger oral defects, those with an already raised trapezoidal flap, and patients with doubtful outcome were closed in two layers using BFP along with buccal advancement flap. After raising the trapezoidal buccal mucoperiosteal flap, a
Fifteen patients were reviewed. Females (n = 10, 66.7%) n the third to fourth decade were commonly affected in the right posterior region (n = 12, 80%). Dental extraction (n = 11, 73.3%) followed by maxillofacial pathology was the most common reasons for developing OAF. Among extractions, OAF was more often a complication following removal of the maxillary first molar (63.3%) than the second molar. The length of time the OAF had been present ranged from nil to 30 months (Table 1). The size of the bony defect found after raising a flap ranged from 6 mm to 6.1 cm. Two of 15 cases were managed using pedicled BFP as a secondary procedure where buccal advancement flap was unsuccessfully used as primary procedure for closure of OAC immediately following extraction (Table 1). Only 2 of 15 cases were closed in two layers and one of these was managed under general anaesthesia. These cases were closed in two layers to provide tension free closure as the defect was large
Table 1. Demographic variables, aetiology, size, site, length of time OAF/OAC present and their follow up findings following treatment using BFP. Sl. no. of the Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Age/ gender 42 24 51 46 37 21 57 62 38 61 34 41 42 33 51
yrs/M yrs/M yrs/F yrs/F yrs/M yrs/F yrs/F yrs/F yrs/F yrs/F yrs/F yrs/M yrs/F yrs/F yrs/F
Aetiology
Size and site of the defect
Extraction* Extraction* Extraction Cyst Extraction Tumour Infection Extraction Cyst Extraction Extraction Extraction Extraction Extraction Extraction
2.2 cm, right maxillary posterior (16, 17 region) 1.5 cm, right maxillary posterior (16, 17 region) 1.2 cm, Left maxillary posterior (16 region) 2.1 cm, right maxillary posterior (14, 15 region) 1.6 cm, right maxillary posterior (17, 18 region) 6.1 cm 1.5 cm, right maxillary posterior (14–18 region)z 1 cm, right maxillary posterior (17 region) 6 mm, right maxillary posterior (16 region) 3.1 cm, left maxillary posterior (15–18 region) 1.1 cm, right maxillary posterior (17 region) 7 mm, right maxillary posterior (16 region) 1.2 cm, right maxillary posterior (16 region) 1.2 cm, right maxillary posterior (16 region) 8 mm, Left maxillary posterior (26 region)z 9 mm, right maxillary posterior (16 region)
Length of time OAC/OAF present 30 months 18 months 12 months Nil 14 months Nil 8 months Nil Nil 5 months 1 month 7 months 3 months Nil 1 month
Follow up (3 months) NSy NS NS NS NS NSô NS NS NS NS NS NS NS NS NS
* Cases managed using pedicled BFP as secondary procedure where buccal advancement flap was unsuccessfully used as primary procedure for closure of OAC immediately following extraction. y NS: not significant. z Cases managed by BFP and buccal flap. ô Excessive granulation and hypertrophy was noted which reached normal size spontaneously.
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Jain et al. postoperative complications at the 3month follow up visit (Fig. 6).
Discussion
Fig. 4. Extensive tumour (cemento ossifying tumour) which after excision was reconstructed by BFP.
Fig. 5. Defect following excision of the tumour in Fig. 4 reconstructed in two layers using buccal advancement flap and pedicled BFP.
(6.1 cm 1.5 cm) due to excision of extensive tumour (Figs 4 and 5) in one case and because a trapezoidal flap was already raised in another case for transalveolar extraction. Excessive granulation and hypertrophy was noted in one case but it returned to a normal size spontaneously following secondary healing over time. Table 1 gives the demographic variables, the site and size of the defect, the length of time OAF/OAC had been present and the postoperative follow up findings. In most cases, 3 days postoperatively, the exposed BFP is red round the gingival edges, with a light yellow colour in the central portion. At 7 days, the BFP has almost changed to a yellowish pink colour. At 14 days the BFP has changed into a granulation-like tissue with slight contraction. At 21 days, complete epithelialisa-
tion is observed in the grafted area. At 2 months, there is complete healing of the operative site. Complete epithelialisation occurred in all cases and there were no
Successful closure of OAF with BFP is widely reported in the literature.6,10– 12,20,21 Dolanmaz et al.14 in their series of 75 cases reported a favourable healing course in all the patients and the wounds were epithelialized 3–4 weeks after surgery. Excessive granulation and hypertrophy were noticed in nine cases. In six of these, the BFP near the mucosal border was reduced with scissors to prevent the risk of dental trauma while chewing. In another three patients, such an operation was not needed, and there were no significant healing differences between these cases. The BFP that was left hypertrophic reached an almost normal level by completing secondary epithelialisation. Excessive granulation and hypertrophy was noticed in one case but returned to a normal size through secondary healing in time. The difference between levels eventually disappeared completely. In another report by el-Hakim and el-Fakharany16 the use of pedicled BFP was compared with palatal rotation flap in the closure of oroantral communication and palatal defects resulting from tumour resection. They found BFP to be consistently successful, preserving the normal anatomical architecture of the oral mucosa. No denuded area requiring secondary granulation was required as in the case of palatal flaps. Complications in large series range from 3.1 to 6.9%6,7,12 and include partial necrosis, infection, excessive scarring, excessive granulation, and sulcus obliteration. No such complications were observed in the present cases. Pedicled BFP had been successfully employed in the coverage of 7 cm 4 cm 3 cm defects.21 Overenthusiastic use of BFP in covering very large defects should be avoided.10,21
Fig. 6. Complete epithelialisation of BFP 3 months after surgery.
Pedicled buccal fat pad in oroantral fistula management A defect of about 6.1 cm 1.5 cm was covered successfully in the present study. Complete epithelialisation of the BFP was observed after 4–6 weeks of inset. This is in agreement with the literature.7,10,12 Egyedi15 recommended coverage of the exposed BFP with a skin graft, but the present case confirmed other previous reports that epithelialisation of the flap takes place without split skin graft cover after 3–4 weeks of inset.4,10,21 Histology of healed tissue at graft sites has confirmed that epithelialisation does take place, although the origin of this epithelium is not clear.7,10,12 Histological evaluation of healed tissue was not carried out in the present study. Information on the use of BFP along with buccal advancement flap is scarce in the literature.9,11,18 In the authors’ opinion, defects larger than 5 cm 1 cm can be managed better using BFP and buccal advancement flap. It provides more stability, tension free closure, can be used to cover BFP and provides additional tissue for closure where there is deficient BFP. Buccal flap need not be sutured to palatal tissue to avoid obliteration of the vestibule. It can be sutured to BFP at the desired site so that vestibular depth is not greatly altered. BFP has been used for procedures other than closure of OAF because of its numeradvantages and encouraging ous results.6,11 The location of the BFP allows it to be harvested with ease and minimal dissection. Other advantages are its simplicity, versatility, excellent blood supply, low rate of complications, minimal to no donor site morbidity, quick surgical technique because it is located in the same surgical field as the defects to be covered, good rate of epithelialisation and because it allows for replacement of the mucoperiosteal flap without loss of vestibular depth.6,11,14 The possibility of harvesting under local anaesthesia can be considered as an added advantage6,11 and this advantage was utilized in the present study. To conclude, pedicled BFP is an effective and reliable flap for the repair of OAF with various advantages. Cases of larger oral defects with doubtful outcome can be closed in two layers using BFP along with buccal advancement flap. It can also be
considered as a reliable back-up procedure in the event of failure of other techniques. Competing interests
12.
None declared. Funding
13.
None. 14.
Ethical approval
Required and obtained. References 1. Seward GR, Harris M, McGowan DA. Sinusitis, oroantral fistula and removal of tooth or root from the maxillary sinus in Killey and Kay’s Outline of oral surgery, Part 1. 2nd ed. Bristol: IOP Publishing Ltd.; 1987. p. 241–7. 2. Yilmaz T, Suslu AE, Gursel B. Treatment of oroantral fistula: experience with 27 cases. Am J Otolaryngol 2003;24:221–3. 3. Lazow SK. Surgical management of the oroantral fistula: flap procedures. Oper Tech Otolaryngol Head Neck Surg 1999;10: 148–52. 4. Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA. The anatomy and clinical applications of the buccal pad of fat. Plast Reconstr Surg 1990;85:29–37. 5. Susan H, Visscher SH, van Minnen B, Bos RR. Closure of oroantral communications: a review of literature. J Oral Maxillofac Surg 2010;68:1384–91. 6. Adeyemo WL, Ogunlewe MO, Ladeinde AL, James O. Closure of oroantral fistula with pedicled buccal fat pad. A case report and review of literature. Afr J Oral Health 2004;1:42–6. 7. Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg 2000;58:389–92. 8. Marzano UG. Lorenz Heister’s molar gland. Plast Reconstr Surg 2005;115:1389–93. 9. Pandolfi PJ, Yavuzer R, Jackson IT. Three layer closure of an oroantralcutaneous defect. Int J Oral Maxillofac Surg 2000;29:24–6. 10. Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22:2–6. 11. Singh J, Prasad K, Lalitha RM, Ranganath K. Buccal pad of fat and its applications in oral and maxillofacial surgery: a review of
15.
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21.
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published literature (February) 2004 to (July) 2009. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:698– 705. Chao CK, Chang LC, Liu SY, Wang JJ. Histologic examination of pedicled buccal fat pad in oral submucous fibrosis. J Oral Maxillofac Surg 2002;60:1131–4. Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad in oral reconstruction. Head Neck 2001;23:383–8. Dolanmaz D, Tuz H, Bayraktar S, Metin M, Erdem E, Baykul T. Use of pedicled buccal fat pad in the closure of oroantral communication: analysis of 75 cases. Quintessence Int 2004;35:241–6. Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J Maxillofac Surg 1977;5: 241–4. el-Hakim IE, el-Fakharany AM. The use of the pedicled buccal fat pad (BFP) and palatal rotating flaps in closure of oroantral communication and palatal defects. J Laryngol Otol 1999;113:834–8. Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1999;103:2059–60. Batra H, Jindal G, Kaur S. Evaluation of different treatment modalities for closure of oro-antral communications and formulation of a rational approach. J Maxillofac Oral Surg 2010;9:13–8. Zhang HM, Yan YP, Qi KM, Wang JQ, Lui ZF. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg 2002;109:2509–18. Tideman H, Bosanquet A, Scott A. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986;44:435–40. Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction of oral defects: review of the literature and report of 15 cases. J Oral Maxillofac Surg 2000;58: 158–63.
Address: Manoj Kumar Jain Department of Oral and Maxillofacial Surgery Sri Hasanamba Dental College and Hospital Vidyanagar Hassan 573201 Karnataka India Tel: +91 9972643973 E-mail: [email protected]
Clinical Paper Oral Surgery
Pedicled buccal fat pad in the management of oroantral fistula: a clinical study of 15 cases
M. K. Jain1, C. Ramesh2, K. Sankar3, K. T. Lokesh Babu1 1
Department of Oral and Maxillofacial Surgery, Sri Hasanamba Dental College and Hospital, Vidyanagar, Hassan 573201, Karnataka, India; 2Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Science, Puducherry, India; 3 Department of Oral and Maxillofacial Surgery, Mahatma Gandhi Postgraduate Institute of Dental Sciences (MGPGI), Puducherry, India
M. K. Jain, C. Ramesh, K. Sankar, K. T. Lokesh Babu: Pedicled buccal fat pad in the management of oroantral fistula: a clinical study of 15 cases. Int. J. Oral Maxillofac. Surg. 2012; 41: 1025–1029. # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Abstract. This study evaluated the long term effectiveness of pedicled buccal fat pad (BFP) with or without buccal advancement flap in the closure of oroantral fistula (OAF). A prospective clinical study involving 15 patients with chronic OAF was carried out. All cases were managed with pedicled BFP as the primary or secondary procedure. Cases with doubtful outcome were closed in two layers using BFP along with buccal advancement flap. Cases were followed for 3 months (1, 4, 8 and 12 weeks) to evaluate any postoperative complications such as wound dehiscence, necrosis or infection. Females (66.7%) in their third to fourth decade were commonly affected in the right posterior region (75%). Dental extraction (73.3%) followed by maxillofacial pathology was the most common causes for developing OAF. Only 2 of 15 cases were closed in two layers. Complete epithelialisation of all the cases was observed with no postoperative complications. Pedicled BFP is an effective and reliable flap for the repair of OAF. Cases of larger oral defects with doubtful outcome can be closed in two layers using BFP along with buccal advancement flap.
An oroantral fistula (OAF) may develop as a complication of dental extractions, as a result of infection, or as sequelae of radiation therapy, trauma, and removal of maxillary cysts or tumours. The commonest aetiology of OAF is as a complication following extraction of maxillary posterior teeth.1,2 Treatment modalities to repair OAFs following any cause include local and distant soft tissue flaps, autogenous bone grafts, allogenous materials, xenografts, 0901-5027/0801025 + 05 $36.00/0
synthetic metals and other techniques.3–5 Regardless of the technique, two principles must be observed. First, the sinus must be rendered free of infection with adequate drainage and the use of appropriate sinus antibiotics in addition to topical or systemic decongestants. Second, tension free closure of a broad base, well vascularized soft tissue flap.3 Some traditional methods used in the repair of OAF include buccal advancement flaps, palatal rotation and palatal
Key words: oroantral fistula; buccal fat pad; oral reconstruction; buccal advancement flap. Accepted for publication 20 February 2012 Available online 21 March 2012
transposition flaps, tongue flaps, and nasolabial flaps.1–3,5 Recently, because of various advantages, buccal fat pad (BFP) is increasingly being employed in the repair of OAF and other oral defects worldwide.6–11 BFP was first described by Heister (1732), who thought the structure was glandular and termed it the ‘glandula molaris’.7–9,11–17 Bichat is credited with recognizing the true nature of the BFP. Therefore, it is commonly referred to as
# 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1026
Jain et al. The quick epithelialisation of the uncovered fat is a characteristic feature of the pedicled BFP flap and is histologically proven.7,10,12 The layer above the originally uncovered BFP consists of stratified squamous epithelium migrating from the adjacent mucosal regions. The aim of this paper is to evaluate the long term effectiveness of pedicled BFP with or without buccal advancement flap in the closure of OAF. Materials and methods
Fig. 1. The main body of the buccal fat pad and its extensions and relations with important adjacent structures.
the boule de Bichat or bolle graisseusse in French; it is called wangenfettpfropf or Wangenfettpolster (Wangen = Cheek + fett = fat, polster = pad-cheek, fat, pad) in German, and the sucking pad, sucking cushion, masticatory fat pad, or buccal pad of fat in English.18 The BFP is a simple lobulated mass consisting of a central body and four extensions: buccal, pterygoid, pterygopalatine, and temporal (Fig. 1). The main body is situated deeply along the posterior maxilla and upper fibres of the buccinator, covered with a thin capsule. The buccal extension lies superficially within the cheek and is partially responsible for cheek contour. The buccal extension and main body together constitute 55–70% of total weight. The pterygopalatine extension of fat tissue extends to the pterygopalatine fossa and inferior orbital fissure. The pterygoid extension is a posterior extension that generally stays in the pterygomandibular space and packs the mandibular neurovascular bundle and lingual nerve. The temporal extension can be divided further into superficial and deep. The superficial part of the temporal process of the BFP stays between the deep temporal fascia, temporalis muscle, and tendon. The anterior end of it turns around the anterior rim of the temporalis muscle, and continues with the deep part. The deep part of the temporal process lies behind the lateral orbital wall and frontal process of the zygoma and turns backward into the infratemporal space. Each process has its own
capsule and is anchored to the surrounding structures by ligaments. The size of the pterygoid and temporal extension is inconsistent, but is usually smaller than either body or buccal extension.4,11,17,19 The superficial temporal fat situated between two layers of deep temporal fascia is a separate fat pad and differs in appearance, has a separate vascular supply, and is anatomically distinct from the BFP.11 The parotid duct courses with the buccal branches of the facial nerve anteriorly (superficial), and on the lateral surface of the BFP, it penetrates the buccinator muscles, entering the oral cavity opposite the second molar. The facial vessels are in the same plane and mark the anterior extent of the BFP.4,11,17,19 The BFP derives its blood supply from the buccal and deep temporal branches of the maxillary artery, transverses facial branches of the superficial temporal artery, and branches of the facial artery. The branches from different sources form the lobar subcapsular plexus by freely anastomosing with each other. Owing to its rich blood supply, it can be considered as a pedicled graft with an axial pattern. The rich blood supply may explain the high success rate with this flap. It may also be one reason for the quick epithelialisation of the fat.4,11,17,19 The average volume of fat is 9.6 ml (range 8.33–11.9 ml).4,11,17,19 The size of the BFP is fairly constant regardless of overall body weight and fat distribution; even cachectic patients have BFPs of normal weight and volume.11,20
After obtaining ethics and research committee approval, a prospective observational clinical study involving patients requiring closure of oroantral communication (OAC)/chronic OAF was done in the Departments of Oral Surgery at Puducherry and Hassan. The study was carried out for 2 years from May 2008 to April 2010. The patients were all told about the procedure of using pedicled BFP for closure, its complications and the other options available for management including their advantages and disadvantages. Patients opting for BFP and willing to be followed up were included. Patients were excluded if they were above ASA 2, required radiation therapy following surgery or were immunocompromised. Fifteen cases were included and managed using pedicled BFP as the primary or secondary procedure (previous surgery had already been carried out unsuccessfully using another method to close the fistula) under local anaesthesia using lignocaine 2% with 1:80,000 adrenaline (except for one case that was carried out under general anaesthesia). Seven of the patients with chronic sinusitis and infection were treated using the Caldwell-Luc operation with OAF closure being performed at the same time. Cases with doubtful outcome were closed in two layers using BFP and buccal advancement flap. The patients gave informed consent and were given amoxicillin 500 mg with clavulanic acid 125 mg three times daily (augmentin 625 mg) 2 days before the surgery. After obtaining adequate anaesthesia, excision of the fistulous tract and freshening of the wound edges was carried out. The upper vestibular horizontal incision, depending on the side involved, was made posterior to the second premolar and extended to the posterior margin of the fistula to expose the BFP. Careful manipulation and blunt dissection was carried out to mobilize and advance the flap to the recipient site (Fig. 2). The flap was sutured in place with simple interrupted 3/0 polygalactin 910 sutures. The incision was closed over the bridge segment of the flap
1027
Pedicled buccal fat pad in oroantral fistula management
1 cm vertical incision was made in the reflected periosteum posterior to the zygomatic buttress to allow exposure and advancement of the BFP over the bony defect where it was sutured to the palatal mucosa (Fig. 3) followed by second layer closure with buccal advancement flap. Follow up lasted for 3 months, at intervals of 1, 4, 8 and 12 weeks to evaluate any postoperative complications such as wound dehiscence, necrosis or infection. Results Fig. 2. Harvesting BFP using vestibular approach.
Fig. 3. Two layered closure of OAF using buccal advancement flap and pedicled BFP.
with sutures. Patients were warned against blowing their noses for 2 weeks. The preoperative antibiotic regimen was continued for the next 5 days. The antral triad of decongestant, antihistamine and analgesic was prescribed for 5 days.
Cases with larger oral defects, those with an already raised trapezoidal flap, and patients with doubtful outcome were closed in two layers using BFP along with buccal advancement flap. After raising the trapezoidal buccal mucoperiosteal flap, a
Fifteen patients were reviewed. Females (n = 10, 66.7%) n the third to fourth decade were commonly affected in the right posterior region (n = 12, 80%). Dental extraction (n = 11, 73.3%) followed by maxillofacial pathology was the most common reasons for developing OAF. Among extractions, OAF was more often a complication following removal of the maxillary first molar (63.3%) than the second molar. The length of time the OAF had been present ranged from nil to 30 months (Table 1). The size of the bony defect found after raising a flap ranged from 6 mm to 6.1 cm. Two of 15 cases were managed using pedicled BFP as a secondary procedure where buccal advancement flap was unsuccessfully used as primary procedure for closure of OAC immediately following extraction (Table 1). Only 2 of 15 cases were closed in two layers and one of these was managed under general anaesthesia. These cases were closed in two layers to provide tension free closure as the defect was large
Table 1. Demographic variables, aetiology, size, site, length of time OAF/OAC present and their follow up findings following treatment using BFP. Sl. no. of the Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Age/ gender 42 24 51 46 37 21 57 62 38 61 34 41 42 33 51
yrs/M yrs/M yrs/F yrs/F yrs/M yrs/F yrs/F yrs/F yrs/F yrs/F yrs/F yrs/M yrs/F yrs/F yrs/F
Aetiology
Size and site of the defect
Extraction* Extraction* Extraction Cyst Extraction Tumour Infection Extraction Cyst Extraction Extraction Extraction Extraction Extraction Extraction
2.2 cm, right maxillary posterior (16, 17 region) 1.5 cm, right maxillary posterior (16, 17 region) 1.2 cm, Left maxillary posterior (16 region) 2.1 cm, right maxillary posterior (14, 15 region) 1.6 cm, right maxillary posterior (17, 18 region) 6.1 cm 1.5 cm, right maxillary posterior (14–18 region)z 1 cm, right maxillary posterior (17 region) 6 mm, right maxillary posterior (16 region) 3.1 cm, left maxillary posterior (15–18 region) 1.1 cm, right maxillary posterior (17 region) 7 mm, right maxillary posterior (16 region) 1.2 cm, right maxillary posterior (16 region) 1.2 cm, right maxillary posterior (16 region) 8 mm, Left maxillary posterior (26 region)z 9 mm, right maxillary posterior (16 region)
Length of time OAC/OAF present 30 months 18 months 12 months Nil 14 months Nil 8 months Nil Nil 5 months 1 month 7 months 3 months Nil 1 month
Follow up (3 months) NSy NS NS NS NS NSô NS NS NS NS NS NS NS NS NS
* Cases managed using pedicled BFP as secondary procedure where buccal advancement flap was unsuccessfully used as primary procedure for closure of OAC immediately following extraction. y NS: not significant. z Cases managed by BFP and buccal flap. ô Excessive granulation and hypertrophy was noted which reached normal size spontaneously.
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Jain et al. postoperative complications at the 3month follow up visit (Fig. 6).
Discussion
Fig. 4. Extensive tumour (cemento ossifying tumour) which after excision was reconstructed by BFP.
Fig. 5. Defect following excision of the tumour in Fig. 4 reconstructed in two layers using buccal advancement flap and pedicled BFP.
(6.1 cm 1.5 cm) due to excision of extensive tumour (Figs 4 and 5) in one case and because a trapezoidal flap was already raised in another case for transalveolar extraction. Excessive granulation and hypertrophy was noted in one case but it returned to a normal size spontaneously following secondary healing over time. Table 1 gives the demographic variables, the site and size of the defect, the length of time OAF/OAC had been present and the postoperative follow up findings. In most cases, 3 days postoperatively, the exposed BFP is red round the gingival edges, with a light yellow colour in the central portion. At 7 days, the BFP has almost changed to a yellowish pink colour. At 14 days the BFP has changed into a granulation-like tissue with slight contraction. At 21 days, complete epithelialisa-
tion is observed in the grafted area. At 2 months, there is complete healing of the operative site. Complete epithelialisation occurred in all cases and there were no
Successful closure of OAF with BFP is widely reported in the literature.6,10– 12,20,21 Dolanmaz et al.14 in their series of 75 cases reported a favourable healing course in all the patients and the wounds were epithelialized 3–4 weeks after surgery. Excessive granulation and hypertrophy were noticed in nine cases. In six of these, the BFP near the mucosal border was reduced with scissors to prevent the risk of dental trauma while chewing. In another three patients, such an operation was not needed, and there were no significant healing differences between these cases. The BFP that was left hypertrophic reached an almost normal level by completing secondary epithelialisation. Excessive granulation and hypertrophy was noticed in one case but returned to a normal size through secondary healing in time. The difference between levels eventually disappeared completely. In another report by el-Hakim and el-Fakharany16 the use of pedicled BFP was compared with palatal rotation flap in the closure of oroantral communication and palatal defects resulting from tumour resection. They found BFP to be consistently successful, preserving the normal anatomical architecture of the oral mucosa. No denuded area requiring secondary granulation was required as in the case of palatal flaps. Complications in large series range from 3.1 to 6.9%6,7,12 and include partial necrosis, infection, excessive scarring, excessive granulation, and sulcus obliteration. No such complications were observed in the present cases. Pedicled BFP had been successfully employed in the coverage of 7 cm 4 cm 3 cm defects.21 Overenthusiastic use of BFP in covering very large defects should be avoided.10,21
Fig. 6. Complete epithelialisation of BFP 3 months after surgery.
Pedicled buccal fat pad in oroantral fistula management A defect of about 6.1 cm 1.5 cm was covered successfully in the present study. Complete epithelialisation of the BFP was observed after 4–6 weeks of inset. This is in agreement with the literature.7,10,12 Egyedi15 recommended coverage of the exposed BFP with a skin graft, but the present case confirmed other previous reports that epithelialisation of the flap takes place without split skin graft cover after 3–4 weeks of inset.4,10,21 Histology of healed tissue at graft sites has confirmed that epithelialisation does take place, although the origin of this epithelium is not clear.7,10,12 Histological evaluation of healed tissue was not carried out in the present study. Information on the use of BFP along with buccal advancement flap is scarce in the literature.9,11,18 In the authors’ opinion, defects larger than 5 cm 1 cm can be managed better using BFP and buccal advancement flap. It provides more stability, tension free closure, can be used to cover BFP and provides additional tissue for closure where there is deficient BFP. Buccal flap need not be sutured to palatal tissue to avoid obliteration of the vestibule. It can be sutured to BFP at the desired site so that vestibular depth is not greatly altered. BFP has been used for procedures other than closure of OAF because of its numeradvantages and encouraging ous results.6,11 The location of the BFP allows it to be harvested with ease and minimal dissection. Other advantages are its simplicity, versatility, excellent blood supply, low rate of complications, minimal to no donor site morbidity, quick surgical technique because it is located in the same surgical field as the defects to be covered, good rate of epithelialisation and because it allows for replacement of the mucoperiosteal flap without loss of vestibular depth.6,11,14 The possibility of harvesting under local anaesthesia can be considered as an added advantage6,11 and this advantage was utilized in the present study. To conclude, pedicled BFP is an effective and reliable flap for the repair of OAF with various advantages. Cases of larger oral defects with doubtful outcome can be closed in two layers using BFP along with buccal advancement flap. It can also be
considered as a reliable back-up procedure in the event of failure of other techniques. Competing interests
12.
None declared. Funding
13.
None. 14.
Ethical approval
Required and obtained. References 1. Seward GR, Harris M, McGowan DA. Sinusitis, oroantral fistula and removal of tooth or root from the maxillary sinus in Killey and Kay’s Outline of oral surgery, Part 1. 2nd ed. Bristol: IOP Publishing Ltd.; 1987. p. 241–7. 2. Yilmaz T, Suslu AE, Gursel B. Treatment of oroantral fistula: experience with 27 cases. Am J Otolaryngol 2003;24:221–3. 3. Lazow SK. Surgical management of the oroantral fistula: flap procedures. Oper Tech Otolaryngol Head Neck Surg 1999;10: 148–52. 4. Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA. The anatomy and clinical applications of the buccal pad of fat. Plast Reconstr Surg 1990;85:29–37. 5. Susan H, Visscher SH, van Minnen B, Bos RR. Closure of oroantral communications: a review of literature. J Oral Maxillofac Surg 2010;68:1384–91. 6. Adeyemo WL, Ogunlewe MO, Ladeinde AL, James O. Closure of oroantral fistula with pedicled buccal fat pad. A case report and review of literature. Afr J Oral Health 2004;1:42–6. 7. Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. J Oral Maxillofac Surg 2000;58:389–92. 8. Marzano UG. Lorenz Heister’s molar gland. Plast Reconstr Surg 2005;115:1389–93. 9. Pandolfi PJ, Yavuzer R, Jackson IT. Three layer closure of an oroantralcutaneous defect. Int J Oral Maxillofac Surg 2000;29:24–6. 10. Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22:2–6. 11. Singh J, Prasad K, Lalitha RM, Ranganath K. Buccal pad of fat and its applications in oral and maxillofacial surgery: a review of
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published literature (February) 2004 to (July) 2009. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:698– 705. Chao CK, Chang LC, Liu SY, Wang JJ. Histologic examination of pedicled buccal fat pad in oral submucous fibrosis. J Oral Maxillofac Surg 2002;60:1131–4. Dean A, Alamillos F, Garcia-Lopez A, Sanchez J, Penalba M. The buccal fat pad in oral reconstruction. Head Neck 2001;23:383–8. Dolanmaz D, Tuz H, Bayraktar S, Metin M, Erdem E, Baykul T. Use of pedicled buccal fat pad in the closure of oroantral communication: analysis of 75 cases. Quintessence Int 2004;35:241–6. Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro-nasal communications. J Maxillofac Surg 1977;5: 241–4. el-Hakim IE, el-Fakharany AM. The use of the pedicled buccal fat pad (BFP) and palatal rotating flaps in closure of oroantral communication and palatal defects. J Laryngol Otol 1999;113:834–8. Jackson IT. Anatomy of the buccal fat pad and its clinical significance. Plast Reconstr Surg 1999;103:2059–60. Batra H, Jindal G, Kaur S. Evaluation of different treatment modalities for closure of oro-antral communications and formulation of a rational approach. J Maxillofac Oral Surg 2010;9:13–8. Zhang HM, Yan YP, Qi KM, Wang JQ, Lui ZF. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg 2002;109:2509–18. Tideman H, Bosanquet A, Scott A. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surg 1986;44:435–40. Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of the buccal fat pad for reconstruction of oral defects: review of the literature and report of 15 cases. J Oral Maxillofac Surg 2000;58: 158–63.
Address: Manoj Kumar Jain Department of Oral and Maxillofacial Surgery Sri Hasanamba Dental College and Hospital Vidyanagar Hassan 573201 Karnataka India Tel: +91 9972643973 E-mail: [email protected]