IJDA, 1(1), 2009 5

Versatality of pedicled buccal fat pad in surgicalmanagement of oral submucous fibrosis – A study in 20 cases

Col. Jeevan Kumar KA1, Brahmaji Rao J2

Dept. of Oral & Maxillofacial SurgeryKamineni Institute of Dental Sciences,Narketpally, Nalgonda District,Andhra Pradesh, India Abstract:

The pedicled buccal fat pad has been widely used for the repair oforal defects. A new application of this flap in the treatment ofpatients suffering from trismus caused by oral submucous fibrosisis reported. The patients underwent incision of the fibrotic bandsand coverage of the buccal defect with a pedicled buccal fat padflap. The surgical technique is described, and the results suggestthat this is a logical, convenient, and reliable technique for thetreatment of oral submucous

Key words: Buccal fat pad; Oral submucous fibrosis;Surgical treatment.

Professor1

Assoc. Professor2

Email for correspondence:jeevan1983@yahoo. com

INTRODUCTION

The buccal fat pad (BFP) is a supple and lobulatedmass, easily accessible and mobilized. Egyedi1 wasthe first to report on the application of the BFP as apedicled graft lined with a split-thickness skin graftfor the closure of oroantral and oronasalcommunications. Neder2 described the use of BFPas a free graft to cover intraoral defects. In recentyears, it has become a well-accepted graft forcovering intraoral defects.3,4,5 The anatomy of the BFPand its clinical significance have been studied byTideman et al. 6, Dubin et al. 7, and Stuzin et al. 8, andthe results of the studies support the clinicalapplication of the BFP.

Oral submucous fibrosis (OSF) is a chronicprogressive disease of the oral cavity and has beendefined as an insidious, chronic, fibrotic change in theoral mucosa. In the late stages, mouth opening islimited by severe scarring which causes trismus; this

may be treated surgically or nonsurgically, withusually unpredictable results. Pindborg, Sirsat9

regarded OSF as an important precancerous lesion.Surgical treatment is the method of choice in patientswith marked limitation of mouth opening, but hasbeen reported to give rise to varyingresults.10,11,12,13,14,15

The BFP is mainly used to cover defects in theposterior maxilla, the buccal region, the hard palate,the soft palate, the retromolar andpterygomandibular regions after tumor resection,and oroantral communications after tooth extraction.

The purpose of this study was to present a newapplication of BFP to the surgical treatment of OSFin twenty patients by achieving a stable mouthopening with minimum morbidity.

MATERIAL AND METHODS:

Twenty patients with histopathologically provenOSF were treated surgically by the author in 2006-

Article InfoReceived: 20th June, 2009Review Completed: 27th July, 2009Accepted: 2nd September, 2009Available Online: 18th January, 2010© NAD, 2009 - All rights reserved

INDIAN JOURNAL OF DENTAL ADVANCEMENTS

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ORIGINAL RESEARCH

IJDA, 1(1), 20096

Fig- 1a. Pre op Mouth opening

2009 at the Department of Oral and MaxillofacialSurgery, Kamineni institute of dental sciences, AndhraPradesh. All patients had marked trismus, withinvolvement of the muscle layer. The defects in thebuccal area were grafted with a pedicled BFP. Thepatients were followed up for 10-30 months. Patientevaluation included:1) the preoperative amount ofmouth opening; 2) the intraoperative mouthopening; and 3) the postoperative mouth opening.The mouth opening was measured from the edgesof the first central incisors (Fig-1a).

METHOD :

The operations were performed under generalanesthesia with nasal intubation. The incisions weremade with an electrosurgical knife along each sideof the buccal mucosa at the level of the occlusal planeaway from the Stenson’s orifice(Fig-2). They werecarried posteriorly to the pterygomandibular rapheor anterior pillar of the fauces and anteriorly as far asthe corner of the mouth, depending upon thelocation of the fibrotic bands which restricted themouth opening. These fibrotic bands were alwaysdetectable by palpation. The wounds created werefurther freed by manipulation until no restrictionswere felt (Fig-3). The mouth was then forced openwith a mouth opener to an acceptable range ofapproximately 35 to 40 mm (Fig-4). The coronoidprocesses were approached from the woundscreated and resected if a 35-mm mouth openingcould not be achieved. A mouth opening of 35 mmas measured from the incisor edges was consideredto be the minimum acceptable opening in an adult.16

Bilateral buccal defects of 3. 5x2. 0 to 5. 5 x 3.0 cm2

were covered with BFP grafts after hemostasis. TheBFP was approached via the posterior- superior

Versatality of pedicled buccal fat pad Col. Jeevan Kumar & Brahmaji Rao

Fig-1b. Pre pointer Incisal Mouth opening

S. AGE/ POST OPERATIVE MOUTH OPENINGNO SEX 1st 3rd 5th 7th 9th Six

week week week week week months

1. 18/M 20mm 26mm 30mm 32mm 35mm 36mm

2. 22/M 26mm 32mm 36mm 34mm 38mm 40mm

3. 28/M 25mm 29mm 32mm 35mm 35mm 40mm

4. 19/M 22mm 28mm 32mm 36mm 40mm 42mm

5. 36/M 24mm 28mm 28mm 28mm 28mm 28mm

6. 19/M 25mm 29mm 32mm 35mm 35mm 40mm

7. 21/M 30mm 35mm 40mm 44mm 44mm 45mm

8. 28/M 28mm 35mm 38mm 40mm 40mm 43mm

9. 26/M 24mm 26mm 26mm 26mm 26mm 26mm

10. 36/F 25mm 29mm 32mm 35mm 35mm 40mm

11. 19/M 26mm 30mm 34mm 36mm 36mm 40mm

12. 45/F 24mm 28mm 33mm 35mm 36mm 38mm

13. 23/M 20mm 24mm 27mm 30mm 32mm 38mm

14. 19/M 25mm 29mm 32mm 35mm 35mm 40mm

15. 23/M 26mm 30mm 32mm 35mm 35mm 41mm

16. 27/M 24mm 28mm 33mm 35mm 36mm 38mm

17. 18/M 18mm 22mm 26mm 30mm 34mm 38mm

18. 33/F 28mm 35mm 38mm 40mm 40mm 43mm

19. 44/M 22mm 26mm 26mm 30mm 32mm 36mm

20. 22/M 24mm 30mm 35mm 35mm 38mm 40mm

Of the twenty patients 17 were males and 3 werefemales. All the patients had bilaterally palpablefibrous bands. None of the Patients were previouslytreated for OSMF. The mouth opening measured asthe inter incisal distance was ranging between 4-22mm with a mean of 15. 6mm (Fig 1b).

Table No 1.

IJDA, 1(1), 2009 7

margin of the created buccal defect, and thendissected with an index finger. The BFP was teasedout gently until a sufficient amount was obtained tocover the defect without tension (Fig-5). The BFP wasthen secured in place with horizontal mattresssutures (Fig- 6). The same procedure was performedon the other side. The BFP covered the buccal defectsposteriorly to the soft palate, and anteriorly to thecuspid region. The remaining defect was left forsecondary epithelialization. All patients receivedprophylactic antibiotics and a liquid diet for 1 week.Mouth opening exercises started within 36 hourspostoperatively, and intensive exercise wascontinued daily for at least 3 months. Daily exerciseshould last as long as 1 year.

Versatality of pedicled buccal fat pad Col. Jeevan Kumar & Brahmaji Rao

Fig -3. Excision of fibrotic Bands

Fig-4. Intra Op Mouth Opening of 40 mm

Fig -2. Incision line Fig -5. BFP Teased Out to cover the defect

Fig -6. BFP Sutured to the defect

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RESULTS:

The results were found to be satisfactory in allbut two patients, as shown in

Versatality of pedicled buccal fat pad Col. Jeevan Kumar & Brahmaji Rao

Fig -9. Six weeks Post op

Fig -7. Ten Days Post op

Fig -8. Three weeks Post op

Case. No Age /Sex Maximum Mouth opening(Inter Inscisal Distance) Pre Op

1. 18/M 6mm

2. 22/M 13mm

3. 28/M 18mm

4. 19/M 4mm

. 5 36/M 20mm

6. 19/M 10mm

7. 21/M 22mm

8. 28/M 14mm

9. 26/M 20mm

10. 36/F 20mm

11. 19/M 15mm

12. 45/F 21mm

13. 23/M 19mm

14. 19/M 14mm

15. 23/M 10mm

16. 27/M 20mm

17. 18/M 13mm

18. 33/F 20mm

19 44/M 16mm

20. 22/M 18mm

Table No 2.

As a result of a successful surgical procedure, the

size of the intraoperative mouth opening ranged

from 40 to 42 mm. Only two patients needed bilateral

coronoidectomy as the mouth opening intra

operatively was less than 30mm. However after

carrying out the coronoidectomy their mouth

opening was almost 40 – 42 mm on the OT table. The

patients were discharged 5-7 days after the

operation. The range of the mouth opening

measured at that time was 20-30 mm. The pedicled

grafts took uneventfully and epithelialized in 3-4

weeks (Fig-7,8). Two patients (cases 5 and 9) failed

to exercise several times daily, and finally

experienced a significant relapse. The remaining

patients did cooperate and exercised daily, and the

results were satisfactory (Fig-9)( Table-2). The

postoperative mouth-opening range at six months

was 26-43 mm (mean: 40. 5 mm)(Fig-10a&b). Overall

follow-up period was 10-30 months (mean: 21. 3

months). (Fig-11a&b). ( Table 3 & 4).

Fig -8. Pedicle Graft

IJDA, 1(1), 2009 9

0

5

10

15

20

25

30

35

40

45

1st week 3rd week 5th week 7th week 9th week six months

Versatality of pedicled buccal fat pad Col. Jeevan Kumar & Brahmaji Rao

Fig -10a. Six months Post op

Fig -10b. Six months Post op

Table No 3.

S NO DURATION POST OPERATIVE MOUTHOPENING (MEAN IN MM)

1. 1st week 24

2. 3rd week 28. 5

3. 5th week 33. 5

4. 7th week 37

5. 9th week 38

6. 6 months 40. 5

Table No 4.

Fig -11b. Two years Post op -Normal MouthOpening

Fig -11a.

DISCUSSION :

Submucous fibrosis is an insidious,chronic

disease which may affect any part of the oral cavity

and sometimes the pharynx, leading to stiffness of

the oral mucosa, and causing trismus.9,17 This disease

is most frequently found in India, and is not

uncommon in Southeast Asia. It has also been

reported from other countries, and it is no longer

IJDA, 1(1), 200910

Versatality of pedicled buccal fat pad Col. Jeevan Kumar & Brahmaji Rao

considered to occur exclusively in Indians and

Southeast Asians, as immigration has resulted in a

worldwide distribution. Betel nut chewing appears

to be the main factor correlating with this disease.

Most patients complain of an irritable oral mucosa

during the early stage of the disease, especially when

spicy foods are eaten. Clinically, there are erosions

and ulcerations. Subsequently, the oral mucosa

becomes blanched and loses its elasticity, and

vertical bands occur in the buccal mucosa, the

retromolar area, the soft palate, and the

pterygomandibular raphe. A fibrotic ring forms

around the entire rima oris. Some patients have

difficulty in whistling and tongue movement.

The literature contains few references to the

successful treatment of OSF. Various treatments to

improve mouth opening have been attempted,

including surgical elimination of the fibrotic

bands,but have been reported as generally

unsatisfactory or impossible.14,18 Yen19 was the first

to succeed in covering the buccal defect with a split-

thickness skin graft in treating a case of OSF. Khanna

& Andrade11 recently reported the new surgical

technique of covering the buccal defects with a

palatal island flap in combination with temporalis

myotomy and coronoidectomy. They had applied it

to 35 patients with good results.

The main mass of the BFP occupies the buccal

space bound medially by the buccinator muscle and

laterally by the masseter muscle, and rests on the

periosteum that covers the posterior buccal aspect

of the maxilla. The BFP has a constant blood supply

through the small branches of the facial artery, the

internal maxillary artery, and the superficial temporal

artery and vein by an abundant net of vascular

anastomoses.6,7,8, On an average, the volume is 9. 6 cc

(range 8. 3-11. 9 cc).8 Defects up to 3x5 cm can be

closed with a BFP alone without compromising the

blood supply6. The buccal extension and the main

body of the fat pad are in close proximity to the

buccal defect, and may be approached through the

same incision. In addition, the buccal fat pad pedicled

flap can cover the whole surgical defect. The BFP also

improves the physiologic functions of the cheek after

the operation; e. g., suppleness and elasticity. With

this technique, there is no need for a second

operation site. The pedicled BFP graft is well

vascularized, and is more resistant to infection than

other kinds of free graft. Therefore, normal eating can

begin after the surgical treatment. Patients can be

discharged 5-7 days after the operation.

Early and intensive postoperative mouth-

opening exercises are very important to achieve

adequate mouth opening afterward. These exercises

should be started as early as possible. The mouth

opening showed progressive improvement and

became maximum within six months with a mean of

40. 5mm. (Table-4). And through out this period it was

ensured that the patients had continued with active

aggressive mouth opening excersises. The grafted

BFP became rigid from fibrotic change. Routine

temporalis myotomy, and coronoidectomy11 seemed

to be unnecessary in all cases. Only two cases needed

coronoidectomy as the intramouth opening was less

than 30 mm. Clinically the Buccal mucosa appeared

normal, retaining its texture without any signs of

fibrosis. The softness and elasticity of the buccal

tissue had improved. Symptoms such as painful

ulceration, burning sensation, and intolerance to

spices had been eliminated in most patients.

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55: 349-350.

3. Ho KH. Repair of palatal defects with inclined buccal fat

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