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CASE REPORT
Year : 2014  |  Volume : 1  |  Issue : 3  |  Page : 74-76

Buccal fat pad for the closure of oro-antral fistula


1 Department of Oral and Maxillofacial Surgery, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India
2 Department of Public Health Dentistry, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India

Date of Web Publication24-Mar-2015

Correspondence Address:
Ronak Mafatbhai Desai
Department of Oral and Maxillofacial Surgery, Vyas Dental College and Hospital, Kudi Haud, Pali Road, Jodhpur - 340 616, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.153897

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  Abstract 

Oro-antral communication and subsequent formation of an oro-antral fistula (OAF) is a common complication that occurs during extraction of the maxillary molars and also as a result of operative procedure involving maxillary sinus. The incidence of this complication may vary from 0.31% to 3.8% after simple extraction of maxillary posterior teeth. Many procedures have been proposed for the closure of OAF. Local flaps are usually adequate to close minor to moderate size defects; these include buccal or palatal alveolar flaps and their modifications and buccal fat pad. This article describes the closure of an OAF in a 49-year-old male patient with buccal fat pad.

Keywords: Buccal fat pad, maxillary sinus, oro-antral fistula


How to cite this article:
Desai RM, Prakash VJ, Chauhan R, Mahajan R. Buccal fat pad for the closure of oro-antral fistula. J Health Res Rev 2014;1:74-6

How to cite this URL:
Desai RM, Prakash VJ, Chauhan R, Mahajan R. Buccal fat pad for the closure of oro-antral fistula. J Health Res Rev [serial online] 2014 [cited 2019 Dec 9];1:74-6. Available from: http://www.jhrr.org/text.asp?2014/1/3/74/153897


  Introduction Top


Oro-antral communications may develop as a complication of dental extractions, but may also result from accidental or iatrogenic trauma, neoplasm, or infection. Some of the traditional methods that are being employed in the repair of oro-antral communications include buccal advancement flaps, palatal rotation and palatal transposition flaps, tongue flaps, and nasolabial flaps. Buccal fat pad (BFP) is increasingly being employed in the repair of oro-antral fistula (OAF) and other oral defects worldwide.

Various surgical techniques have been suggested for the closure of oral defects, such as primary closure, buccal mucosal graft, split-thickness skin graft, allogeneic graft, regional rotational flap, and distant flap. The type and size of the defect determine the technique to be used. The use of the BFP as a grafting source in the closure of intraoral defects has gained popularity in the last quarter of this century.

The use of the BFP in the closure of palatal defects has gained popularity in recent years. Egyedi [1] was the first to report the use of BFP as a pedicled graft for the closure of oro-antral and oronasal communications: A split-thickness skin graft was used to line the oral side of the fat pad. Neder [2] reported the use of the BFP as a free graft for reconstruction of defects within the oral cavity. Tideman et al. [3] have shown that BFP need not be covered by a skin graft when brought into the mouth because it epithelializes readily within 2-3 weeks. These reports confirmed that it is possible to use the BFP as an unlined pedicled graft for the closure of maxillary defects.


  Case report Top


A 49-year-old male reported to the Department of Oral and Maxillofacial surgery, Vyas Dental College, Jodhpur with the chief complaint of spontaneous missing of root piece of upper right first molar. He also complained of pain and heaviness in right maxillary sinus region since 15 days. He had no relevant medical and dental history. On clinical examination, no root piece was found at the maxillary right first molar region. On palatal side, a small opening was seen communicating the oral cavity and maxillary sinus [Figure 1]. Patency of communication was confirmed by cotton wool test and mouth mirror fog test water holding procedure. PNS view was advised, in which the right maxillary sinus appeared hazy with no clear sign of root piece in the sinus [Figure 2].

Under local anesthesia and all aseptic conditions, an elliptical incision was made around the opening and the fistulous tract was removed [Figure 3].

Using Caldwell-Luc approach, the right maxillary sinus was exposed and explored. On exploration, root piece was identified and removed along with sinus lining. After retrieval of root piece, antral lavage was done with sterile saline solution [Figure 4].
Figure 1: Clinical appearance of oro-antral fistula

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Figure 2: PNS view

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Figure 3: Excision of fistula tract

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Figure 4: Right maxillary sinus exposed by Caldwell-Luc approach

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After retrieval of root piece for closure of OAF, BFP was mobilized by making a horizontal incision through the periosteum under the reflected mucoperiosteal flap. Blunt dissection was done to expose BFP and then it was grasped with a thin hook, and transposed into the defect, expanded, and sutured to the margins using 4-0 vicryl. BFP was covered with mocoperiosteal flap and was secured over the defect with 4-0 vicryl [Figure 5].
Figure 5: a) Exposure of oro antral fistula, b) Heamostasis, c) closure of oro antral fistula with 3-0 silk sutur

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Postoperative healing was uneventful. The patient was kept on an antral regime for 2 weeks and hard foods were avoided from the operated side for the next 1 week. The patient was evaluated on day 5 and 7. No dehiscences, infection, or flap necrosis was observed.


  Discussion Top


The BFP was first described by Heister in 1732, [4] who believed this structure to be glandular in nature and termed it the "glandula molaris." Bichat [5] is credited with recognizing the true nature of the BFP. The buccal fat represents a specialized type of tissue that is distinct from subcutaneous fat. In the infant, it prevents indrawing of the cheeks during sucking; in the adult, the BFP enhances intermuscular motion. It serves to line the masticator space, separating the muscles of mastication from each other, from the zygomatic arch, and from the ramus of the mandible. [6]

The BFP has gained popularity in recent years. The advantages of the BFP flap are the simplicity and ease of the technique and the high success rate. [7] When properly dissected and mobilized, the BFP provides a suitable flap with a relatively large range of movement. This flap is supplied by the small vessels in the flap base. Therefore, it must be handled with great care, while preserving a wide base; otherwise, a free fat graft will result.

Anatomically, the BFP is described as consisting of a central body and four extensions: Buccal, pterygoid, superficial, and deep temporal. [8] The main body is situated deeply along the posterior maxilla and upper fibers of the buccinator. The buccal extension lies superficially within the cheek and is largely responsible for cheek fullness. The pterygoid extension lies deep to the medial aspect of the mandibular ramus, resting between the ramus and the lateral surfaces of the medial and lateral pterygoid muscles. Mainly the buccal part is mobilized for oral reconstruction. It is very important to preserve the thin capsule of this part during the luxation, so that the small blood vessels will not be damaged. The blood supply of the BFP comes from three sources: The maxillary artery (buccal and deep temporal branches), the superficial temporal artery (transverse facial branch), and the facial artery (small branches). The rich blood supply may explain the high success rate with this flap. It also may be one reason for the quick epithelialization of the fat.

The size of the BFP is constant among different persons regardless of the overall body weight and fat distribution. [9] The easy mobilization of the BFP and its excellent blood supply and minimal donor site morbidity make it an ideal flap. It can be very useful in older patients to reconstruct defects quickly under local anesthesia.


  Conclusion Top


Pedicled BFP is a reliable flap for the repair of OAF. The easy mobilization of the BFP and its excellent blood supply and minimal donor site morbidity make it an ideal flap. It should also be considered as a reliable back-up procedure in the event of failure of other techniques. The success rate of the BFP is in the reconstruction of oral defects. Judicious use of buccal fat pad reconstruction offers an easy way to reconstruct small to medium defects of the oral cavity with low morbidity.

 
  References Top

1.
Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or ore-nasal communications. J Maxillofac Surg 1977;5:241-4.  Back to cited text no. 1
[PUBMED]    
2.
Neder A. Use of buccal fat pad for grafts. Oral Surg Oral Med Oral Pathol 1983;55:349-50.  Back to cited text no. 2
[PUBMED]    
3.
Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as a pedicled graft. J Oral Maxillofac Surp 1986;44:435-40.  Back to cited text no. 3
    
4.
Heistcr L. Compendium Anatomicum. Nuremberg, Germany: G. C. Beri; 2002. p. 1-32.  Back to cited text no. 4
    
5.
Bichat F. Anatomic Gbni-Rale. Appliquandila Physiologic Ctiiamkdecine. Paris, France: Brosson, Gabon etCie; 1802. p. 24-38.  Back to cited text no. 5
    
6.
Stuzin JM, Wagstrom L, Kawamoto HK, Baker TJ, Wolfe SA. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990;85:29-37.  Back to cited text no. 6
    
7.
Kim YK. The use of a pedicled buccal fat pad graft for bone coverage in primary palatorrhaphy: A case report. J Oral Maxillofac Surg 2001;59:1499-501.  Back to cited text no. 7
    
8.
Fleming P. Traumatic herniation of buccal fat pad: A report of two cases. Br J Oral Maxillofac Surg 1986;24:265-8.  Back to cited text no. 8
[PUBMED]    
9.
Ranke H. An absorbent pad in the mcnschlichcn jaw . Arch Anat Path 1884;97:52.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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