Measurement of volume changes of sinus floor augmentationcovered with buccal fat pad: A case series studyAli Hassani, DMD, MS,a Arash Khojasteh, DMD, MS,b Marzieh Alikhasi, DDS, MS,c andHamed Vaziri, DDS,d Tehran, IranAZAD UNIVERSITY OF MEDICAL SCIENCES, BEHESHTI UNIVERSITY OF MEDICAL SCIENCES, TEHRANUNIVERSITY OF MEDICAL SCIENCES

Objectives. The purpose of this study was to evaluate the volumetric changes of the maxillary sinus graft inconjunction with buccal fat pad (BFP) covering the lateral sinus wall.Study design. In this article, the radiographic results are presented on 11 consecutively treated patients using an equalmixture of the autogenous bone harvested from the tuberosity and natural bone mineral (Bio-Oss) used to augment themaxillary sinus. Buccal fat pad was used over the lateral sinus wall in all cases as a membrane to cover theaugmentation material. The mean initial bone height (IBH) was 3.82 mm as measured in the posterior maxilla. Threemonths after sinus elevation, radiographic evaluation was performed for the patients and secondary bone height wasmeasured (SBH1). Fifty-two implants were placed in augmented sinuses. Prosthetic rehabilitation of the patients wasdone 4 months after inserting the implants. Radiographs were taken 6 months after implant placement and secondarybone height was measured (SBH2).Results. Of 52 implants, 51 (98%) were considered clinically successful. One implant was removed because ofmobility at the time of surgical exposure. Clinically, no complications were observed, and all implants wereconsidered clinically osseointegrated after 6 months. Mean bone height was measured as 3.82 mm before sinusgrafting. SBH1 and SBH2 were measured as 12.22 mm and 10.5 mm respectively.Conclusion. The clinical findings suggested that BFP might be a substitute for bioresorbable collagen membranes in

maxillary and sinus floor bone grafts. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:369-374)

Ridge resorption and sinus pneumatization in the pos-terior maxilla, compounded with a poor quality of bone,can compromise implant rehabilitation of the patient.1

The procedure of choice to restore this anatomic defi-ciency is maxillary sinus floor elevation (sinus lift),which is one of the most common preprosthetic surger-ies performed in dentistry today.1 The procedure can beaccomplished by using 1- or 2-stage surgical proce-dures, and different grafting materials can be used to fillthe space created between the superiorly repositionedlateral sinus wall and the alveolar crest.2 Successfulresults of sinus lifting surgeries for the placement ofimplants have been well documented by several stud-

aAssistant Professor, Department of Oral and Maxillofacial Surgery,Azad University of Medical Sciences, Tehran, Iran.bChief Resident, Department of Oral and Maxillofacial Surgery,Taleghani Hospital, Beheshti University of Medical Sciences, Teh-ran, Iran.cAssistant Professor, Department of Fixed Prosthodontics and DentalResearch Center, School of Dentistry, Medical Sciences/Universityof Tehran, Tehran, Iran.dDentist, Tehran University of Medical Sciences, Tehran, Iran.Received for publication Apr 24, 2008; returned for revision Aug 20,2008; accepted for publication Aug 31, 2008.1079-2104/$ - see front matter© 2009 Mosby, Inc. All rights reserved.

doi:10.1016/j.tripleo.2008.08.022

ies.3 The grafting materials, which are derived from orcomposed of tissue involved in the growth or repair ofbone, could encourage bone formation in soft tissues orstimulate quicker bone growth in bone implant sites.4

The success of sinus grafting is dependent primarily onthe neovascularization of the graft mass, which is re-ported to derive mainly from the sinus floor.5 Wong6

found that blood supply was 30% higher within 5 mmnear the sinus floor compared with the other parts.Wong6 also showed that by using buccal fat pad (BFP)for additional and immediate blood and nutritional sup-ply and protection of the graft, the quality of bone couldbe improved as other parts as well. Similarly, otherstudies have shown that the greatest amount of newbone formation occurred in regions closest to the sinusfloor, independent of the materials used,7-9 whichshows the importance of early blood supply. The use ofthe buccal fat pad has increased in popularity in recentyears because of its reliability, ease of harvesting, andlow complication rate.10,11 The BFP is an encapsulated,rounded, biconvex fatty structure located between thebuccinator medially, and the anterior margin of themasseter muscle and the mandibular ramus and zygo-matic arch laterally.5,12 It was first described byEgyedi13 as a pedicled graft for closure of oral defects.There have been several reports demonstrated success-

ful use of the BFP as a pedicled graft in reconstructing

369

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small to medium-sized maxillary defects after resectionof a tumor.14-20 It has been used as a pedicled graft infacial augmentation procedure,21 for the repair of per-sistent oroantral fistulas after dental extractions,22 andin treatment of oral submucous fibrosis.23 Neder24 re-ported the use of BFP as a free graft. Tideman et al.25

described the use of the uncovered BFP as a pedicledgraft in mouth, and showed that healing occurredwithin 2 to 3 weeks, leaving a good mucosal surface.Liversedge and Wong5 used BFP in sinus floor graftingof severely atrophic maxilla before implant placementand demonstrated better protection and early bloodsupply to maxillary and sinus bone grafts, and did notfind any complications among patients. By placing theBFP between fast-growing fibrous tissue and the defectitself, slow-growing osseoprogenitor cells can migrateinto the bone defect and lead to the reossification of thisarea.26 Despite these articles, there are very few fatpad-related articles that relate to sinus grafting. In thisstudy, the authors performed sinus augmentation with amixture of autogenous bone and natural bone mineral,covered the lateral sinus wall with BFP, and performedradiographic measurement of volumetric changes.

MATERIALS AND METHODSPatient Selection

The study population was composed of patients witha loss of height in the posterior maxilla that requiredapplication of a sinus lift technique to allow rehabili-tation with a fixed implant-supported prosthesis. Im-mune system disorders, uncontrolled diabetes, ongoingchemotherapy or radiation, drug abuse, history of para-functional habits, and chronic sinus pathology were thecriteria of exclusion. All patients were informed aboutthe surgery, risks, and complications. Eleven patientswere selected for the study, 6 males and 5 females, whoall signed the informed consent. The study protocol wasapproved by the Human Subject Review Committee atAzad University of Medical Sciences, Tehran, Iran.Smokers were not excluded from the study. Panoramicradiographs were performed to evaluate the initial boneheight of the posterior maxillary alveolar bone (IBH).

Surgical proceduresPatients received 1 g of amoxicillin 1 hour before the

surgery and 7 days postsurgically (500 mg/8 h). Allpatients underwent surgery under local anesthesia with1/100,000 vasoconstrictor. The decision to place simul-taneous implants during the sinus floor elevation or at alater date depended on whether the crest had sufficientresidual bone height to ensure primary stability of theimplant. The minimum amount to indicate immediateimplantation was 5 mm.27 Based on this criterion, 10

sinuses were selected to receive 32 implants (Zimmer

Dental, Carlsbad, CA) during sinus lift surgery,whereas the implantation was deferred in 7 (total of 20Zimmer implants) sinuses until 4 months after sinusgrafting.

An incision was made in the palatal aspect of thealveolar crest in the edentulous area. A vertical releas-ing incision in the canine fossa helped to completereflection of the flap and also ensured soft tissue closureover the bone after surgery. The lateral wall of themaxilla was exposed by reflecting the mucoperiostealflap superiorly to the level of the malar buttress. A bonywindow was outlined with a round bur. Once the out-line was completed, a sinus elevator was used to pushthe bony wall inside gently. The sinus membrane wasdissected from the sinus floor by using elevators so thatit was completely free inferiorly and medially. If theresidual bone throughout the alveolar process was 5mm27 or more, the sequence of drills required for theplacement of implants was implemented, avoiding useof the final drill so the implant could be placed byexerting compression on the maxillary bone, favoringprimary stability. Subsequently, half of the graft wasplaced on the palatal wall of the sinus before placementof the implant, and the remainder was used to fill thesinus cavity once the implants were placed. Then au-togenous bone (harvested from the same maxillary tu-berosity area, zygomatic buttress, and trapped boneduring drilling) was mixed with organic Bio-Oss (Gei-stlich, Osteohealth Biomaterials, Bern, Switzerland) ina 1:1 ratio. The BFP was exposed by a 2-cm horizontalperiosteal incision lateral to the maxillary buttress ex-tending backward above the maxillary second molartooth. Blunt dissection through the buccinator and loosesurrounding fascia allowed the BFP to herniate into themouth. The body of the BFP and the buccal extensionwere gently mobilized by blunt dissection, taking carenot to disrupt the delicate capsule and vascular plexusand to preserve as wide a base as possible. Pressure onthe cheek helped to express the fat into the mouth. Afterthe pad had been dissected free from the surroundingtissues, it was grasped with vascular forceps, gentlyteased out, advanced, and expanded over the defects.The pad was sutured to the mucosal edges with syn-thetic resorbable suture (Vicryl; Ethicon, Somerville,MA) ensuring that it was not under excessive tension(Fig. 1).

Radiographic evaluationAll panoramic radiographs were taken with the same

Orthopantomograph (OP100D, Instrumentarium Ima-gin, Tuusula, Finland). Indistinct radiographs or thoseof unsuitable head positions were excluded from anal-ysis. A single manual tracing of the implant body,

alveolar crest, original sinus floor, and grafted sinus

OOOOEVolume 107, Number 3 Hassani et al. 371

floor was performed on tracing paper overlying theradiographs. This was undertaken by a single investi-gator who was not involved in the treatment of patients.Radiographs of the same patient were blinded accord-ing to time (Fig. 2). Panoramic images from a total of11 patients were used for morphometric measurements.Four variables were measured on the tracing paper withthe use of a digital ruler and recorded. To evaluate thechange in height of the grafted sinus floor for eachimplant, the variables were initial bone height (IBH),defined as the distance from the intraoral marginal boneto the lowest point of the original sinus floor; graftedsinus height (SBH1), defined as the distance from theintraoral marginal bone to the grafted sinus floor after 3months; and secondary bone height (SBH2), which wasmeasured after 6 months28,29 (Fig. 3).

RESULTSNo dental injuries or tears of Schneiderian membrane

were noted during the procedures. No adverse eventswere recorded during the healing period in any of thepatients, with no signs of infection. Only 1 implantfailed before loading because of lack of osseointegra-tion, which belonged to the group of the simultaneousimplantation. Of 52 implants, 51 (98%) were consid-ered clinically successful demonstrating complete bonecoverage of the implant, no mobility, and normal ra-

Fig. 1. A, Buccal window in sinus after elevation of a fullimplants placed. B, Sinus filled with Bio-Oss before closure.of surgical window with BFP.

diographic appearance at the time of insertion and 6

months postimplant exposure. One implant was re-moved because of mobility at the time of prostheticdevice installation.

Panoramic images from a total of 11 patients wereused for morphometric measurements (Table I). Themean of the initial bone height was 3.82 mm, initialgrafted sinus height (SBH1) was 12.22 mm, and sec-ondary bone height after 6 months (SBH2) was 10.5mm (Fig. 4).

DISCUSSIONOver the past decade, the success of sinus floor

augmentation with graft material for the placement ofimplants has increased significantly, and the procedurehas become an excellent choice for treating patientswith severely atrophic posterior maxilla.6 The success-ful osseous reconstruction of small and major maxillaryjaw defects by bone grafting is dependent on the earlyphysical protection of the graft from trauma and mi-cromotion, and the establishment of a blood supply tothe graft. Both of these prerequisites could be aided byjudicious use of the buccal fat pad as described byHeister.11 Consistent with the result of the presentstudy, Liversedge and Wong5 showed that usage ofpedicled BFP provides an immediate blood supply to arecipient site and promotes rapid neovascularization ofthe grafted material. They also mentioned that it has an

ess flap, bone removal, and lifting of sinus membrane andrance to sinus opening covered with BFP. D, Passive closure

-thicknC, Ent

additional protective function of providing a multilayer

d-parti

OOOOE372 Hassani et al. March 2009

wound closure over all types of maxillary bone grafts,thereby preventing graft exposure and enhancing suc-cess.5 The blood supply to the BFP derives from thebuccal and deep temporal branches of the maxillaryartery, from the transverse facial branch of the super-ficial temporal artery, and from some small branches ofthe facial artery.12 This rich blood supply of the pedi-cled BFP suggested that it could provide critical vas-

Fig. 2. A, Ridge resorption and sinus pneumatization in the pofollow-up): panoramic radiograph. C, Implant supported fixe

Fig. 3. Schematic drawing illustrating measurement land-marks. IBH defines the distance from the intraoral marginalbone to the lowest point of the original sinus floor. Sinus boneheight plus IBH shows SBH.

cular support to the mucus membrane covering and to

the bone grafts comparing to the bioresorbable mem-branes, which promotes both calcified and soft tissuehealing.5 In this study, a mean of 1.72-mm loss of bone

maxilla. B, Augmented sinus and inserted implants (3-monthal prosthesis (6-month follow-up): panoramic radiograph.

Table I. Initial and secondary bone height after 3 and6 months in all patientsPatient IBH (mm) SBH1 (mm) SBH2 (mm)

1 3.00 15.00 11.02 4.00 11.00 9.03 5.00 13.00 12.04 2.50 9.50 8.55 6.00 12.00 10.06 5.00 9.00 7.07 3.00 14.00 12.08 4.00 13.00 12.09 3.50 12.00 11.010 4.50 11.00 10.011 1.50 15.00 13.0Mean 3.82 12.22 10.5

IBH, initial bone height; SBH1, primary vertical bone graft plus sinusbone height; SBH2, secondary vertical bone graft plus sinus boneheight.

sterior

between the second and third measurements of bone

OOOOEVolume 107, Number 3 Hassani et al. 373

was demonstrated. This resorption is consistent withsimilar results of using xenogenic grafting materi-als.28,30

Because no complications occurred during these pro-cedures, the authors believe that in conditions like sinusperforation in which the blood supply is somehowcompromised, this procedure might be more significantand it would be the subject of future study. Knowingthat sinus perforation is the most common complicationthat occurs during sinus augmentation,31 and consider-ing the proper healing and remodeling of the graftmaterial in the sinus area that depends on the vascular-ization of the sinus membrane, the surrounding bonewall, and the elevated sinus wall,32 the size of mem-brane perforations might play a role on the long-termsuccess of dental implants placed into the augmentedsinus area.31 BFP could also serve as a bed for granu-lation tissue layer if the mucosal layer becomes perfo-rated and physically obliterates dead space and acts asa soft tissue barrier to fluids and infection.5 In addition,the BFP pedicled graft facilitates a 2-layer closure ofthe overlying soft tissues, where graft exposures anddehiscences from oral function may lead to catastrophicfailure of the procedure.5 BFP, as coverage, is a simpleand easy flap to use, is well mobilized, has a rich bloodsupply, demonstrates strong ability of infection resis-tance, and can be associated with other pedicled flaps.The flap morbidity and the failure rate are very low andthe epithelialization will be completed in few weeks.The proximity to the defect gives the opportunity forthe whole operation to be done by a single incision andthe transformation of the fat cells to normal gingivalcells can improve the situation of dental implants.There may be some complications like reduction in oralopening, partial necrosis, infection, excessive scarring,

Fig. 4. Mean values of the IBH, SBH1, and SBH2in allpatients.

and sulcus obliteration.5

Some of the complications like discrepancy in vol-ume, dehiscence, and fistula formation may be attrib-uted to excessive tension of the BFP that the surgeonmust perform to deal with the large defects in cases liketumor removal or in cases of defects far from the donorsite, such as central hard palate defects. Because thesize of the defects in sinus augmentation is not largeand its location is near the donor site, these problemsare of little importance and were not seen in this study.Using bioresorbable membranes to close the lateralwall of the maxillary sinus is common and has advan-tages like ease of use, bioresorbability, and rapid con-formation to the underlying tissues.33 Marinucci et al.34

also reported that collagen membranes could enhancethe secretion of type I collagen and alkaline phospha-tise, and accelerate the proliferation of osteoblasts, sug-gesting that these membrane types promote bone re-generation through a direct effect on osteoblasts.Actually, the validity and reliability of using BFP cansignificantly increase with more comprehensive re-search in this field and directly comparing it with dif-ferent types of membranes, and analyzing statistically.A limitation of this study was small sample size. Alsoit would have been cleaner to have either all implantsplaced at the time of sinus augmentation or all implantsplaced secondarily. On the other hand, collecting datafrom human subjects strongly contributes to validatingthe results. As the morbidity was negligible and the costwas less than the traditional use of resorbable mem-branes, further studies can be designed to compare theeffect of the BFP with collagen membranes.

It is clearly evident from the current studies that theincreasing number of cases of BFP transfer reflects atendency in modern reconstructive surgery to use sim-pler reconstructive techniques that, being equally effec-tive, are technically easier and have fewer complica-tions. Use of the BFP as a pedicled flap has so far beenshown to be an easy, well-tolerated, and uncomplicatedtechnique for oral reconstruction.

CONCLUSIONWithin the limitations of this study, the authors con-

cluded that BFP might be a substitute for bioresorbablecollagen membranes in maxillary and sinus floor bonegrafts. They also suggested that the vascularity of thispedicled flap could be responsible for good implantsurvival in the posterior maxillary area.

Special thanks to Dr Ahmad Masjedi for hisprofessional tracing of the panoramic radiographs.

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Reprint requests:

Arash Khojasteh, DMD, MSDepartment of Oral and Maxillofacial Surgery, Taleghani HospitalShahid Beheshti University of Medical SciencesTabnak Ave, VlenjakTehran, Iran.

arashkhojasteh@yahoo.com