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Versatality of pedicled buccal fat pad in surgical management of oral submucous fibrosis--a study in 20 cases.

INTRODUCTION

The buccal fat pad (BFP) is a supple and lobulated mass, easily accessible and mobilized. Egyedi (1) was the first to report on the application of the BFP as a pedicled graft lined with a split-thickness skin graft for the closure of oroantral and oronasal communications. Neder (2) described the use of BFP as a free graft to cover intraoral defects. In recent years, it has become a well-accepted graft for covering intraoral defects. (3,4,5) The anatomy of the BFP and its clinical significance have been studied by Tideman et al. (6), Dubin et al. (7), and Stuzin et al. (8), and the results of the studies support the clinical application of the BFP.

Oral submucous fibrosis (OSF) is a chronic progressive disease of the oral cavity and has been defined as an insidious, chronic, fibrotic change in the oral mucosa. In the late stages, mouth opening is limited by severe scarring which causes trismus; this may be treated surgically or nonsurgically, with usually unpredictable results. Pindborg, Sirsat (9) regarded OSF as an important precancerous lesion. Surgical treatment is the method of choice in patients with marked limitation of mouth opening, but has been reported to give rise to varying results. (10,11,12,13,14,15)

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

The purpose of this study was to present a new application of BFP to the surgical treatment of OSF in twenty patients by achieving a stable mouth opening with minimum morbidity.

MATERIAL AND METHODS:

Twenty patients with histopathologically proven OSF were treated surgically by the author in 2006 2009 at the Department of Oral and Maxillofacial Surgery, Kamineni institute of dental sciences, Andhra Pradesh. All patients had marked trismus, with involvement of the muscle layer. The defects in the buccal area were grafted with a pedicled BFP. The patients were followed up for 10-30 months. Patient evaluation included:1) the preoperative amount of mouth opening; 2) the intraoperative mouth opening; and 3) the postoperative mouth opening. The mouth opening was measured from the edges of the first central incisors (Fig-1a).

[FIGURE 1a OMITTED]

Of the twenty patients 17 were males and 3 were females. All the patients had bilaterally palpable fibrous bands. None of the Patients were previously treated for OSMF. The mouth opening measured as the inter incisal distance was ranging between 422mm with a mean of 15.6mm (Fig 1b).

[FIGURE 1b OMITTED]

METHOD:

The operations were performed under general anesthesia with nasal intubation. The incisions were made with an electrosurgical knife along each side of the buccal mucosa at the level of the occlusal plane away from the Stenson's orifice(Fig-2). They were carried posteriorly to the pterygomandibular raphe or anterior pillar of the fauces and anteriorly as far as the corner of the mouth, depending upon the location of the fibrotic bands which restricted the mouth opening. These fibrotic bands were always detectable by palpation. The wounds created were further freed by manipulation until no restrictions were felt (Fig-3). The mouth was then forced open with a mouth opener to an acceptable range of approximately 35 to 40 mm (Fig-4). The coronoid processes were approached from the wounds created and resected if a 35-mm mouth opening could not be achieved. A mouth opening of 35 mm as measured from the incisor edges was considered to be the minimum acceptable opening in an adult. (16) Bilateral buccal defects of 3.5 x 2.0 to 5.5 x 3.0 [cm.sup.2] were covered with BFP grafts after hemostasis. The BFP was approached via the posterior- superior margin of the created buccal defect, and then dissected with an index finger. The BFP was teased out gently until a sufficient amount was obtained to cover the defect without tension (Fig-5). The BFP was then secured in place with horizontal mattress sutures (Fig- 6). The same procedure was performed on the other side. The BFP covered the buccal defects posteriorly to the soft palate, and anteriorly to the cuspid region. The remaining defect was left for secondary epithelialization. All patients received prophylactic antibiotics and a liquid diet for 1 week. Mouth opening exercises started within 36 hours postoperatively, and intensive exercise was continued daily for at least 3 months. Daily exercise should last as long as 1 year.

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RESULTS:

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

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).

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[FIGURE 10a OMITTED]

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[FIGURE 11a OMITTED]

[FIGURE 11b OMITTED]

[TABLE 3 OMITTED]

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 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) Yen (19) was the first to succeed in covering the buccal defect with a split-thickness skin graft in treating a case of OSF. Khanna & Andrade (11) 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 supply (6). 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 coronoidectomy (11) 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.

REFERENCES:

(1.) Egyedi P. Utilization of the buccal fat pad for closure of oro-antral and/or oro nasal communications. J Max-Fac Surg 1977; 5: 241-244.

(2.) Neder A. Use of buccal fat pad for grafts. Oral Surg 1983; 55: 349-350.

(3.) Ho KH. Repair of palatal defects with inclined buccal fat pad graft. Oral Surg 1988; 65: 523-525.

(4.) Samman N, Cheung Lk, Tmeman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac Surg 1993;22: 2-6.

(5.) Stajclc Z. The buccal fat pad in the closure of oro-antral communications: a study of 56 cases. J Cranio-Max-FacSurg 1992; 20: 193-197.

(6.) Tideman H, Bosanquet A, Scott J. Use of the buccal fat pad as pedicled graft. J Oral Maxillofac Surg 1986;44: 435-440.

(7.) Dubin B, Jackson It, Halim A, Triplett Ww, Ferreira M. Anatomy of the buccal fat pad and its clinical significance. Hast Reconstr Surg 1989;83: 257-262.

(8.) Stuzln Jm, Wagstrom L, Kawamotohk, Baker Tj, Wolfe Sa. The anatomy and clinical applications of the buccal fat pad. Plast Reconstr Surg 1990; 85: 29-37.

(9.) Pindborg Jj, Sirsat Sm. Oral submucous fibrosis. Oral Surg 1966; 22:764-779.

(10.) Canniff Jp, Harvey W, Harris M. Oral submucous fibrosis: its pathogenesis and management. Br Dent J 1986;160: 429434.

(11.) Khanna Jn, Andrade Nn. Oral submucous fibrosis: a new concept in surgical management. Report of 100 cases. Int J Oral Maxillofac Surg 1995; 24:433-439.

(12.) Morawetz G, Katsikeris N, Weinberg S, Listrom R. Oral submucous fibrosis. Int J Oral Maxillofac Surg 1987; 16:609-614.

(13.) Oliver Aj, Radden Bg. Oral submucous fibrosis. Case report and review of the literature. Aust Dent J 1992; 37:31-34.

(14.) Simpson W. Submucous fibrosis. Br Dent J 1969; 6: 196-200.

(15.) Divya Mehrotra, R. Pradhan. Retrospective comparison of surgical treatment modalities in 100 patients with oral submucous fibrosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:1-10.

(16.) Freihofer Hpm. Restricted opening of the mouth with an extra-articular cause in children. J Cranio-Max-Fac Surg1991;19: 289-298.

(17.) Pindborg Jj, Bhonsle Rb, Murti Pr, Gupta Pc, Dafrary Dk, Mehta Fs. Incidence and early forms of oral submucous fibrosis. Oral Surg 1980; 50: 40-44.

(18.) Paissat DK. Oral submucous fibrosis. IntJ Oral Surg 1981; 10: 307-312.

(19.) Yen Djc. Surgical treatment of submucous fibrosis. Oral Surg 1982;54 :269-271.

Col. Jeevan Kumar KA [1], Brahmaji Rao J [2]

Dept. of Oral & Maxillofacial Surgery Kamineni Institute of Dental Sciences, Narketpally, Nalgonda District, Andhra Pradesh, India

Professor [1]

Assoc. Professor [2]

Article Info

Received: 20th June, 2009

Review Completed: 27th July, 2009

Accepted: 2nd September, 2009

Available Online: 18th January, 2010

Email for correspondence: jeevan1983@yahoo. com
Table No 1.

                  post operative mouth opening

S.    age/   1st    3rd    5th    7th    9th    Six
no    SEX    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

Table No 2.

                           Maximum Mouth opening
Case. No   Age/Sex   (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 4.

                  post operative mouth
s no   duration   opening (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
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Article Details
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Title Annotation:Original Research
Author:Jeevan, Kumar K.A.; Brahmaji, Rao J.
Publication:Indian Journal of Dental Advancements
Article Type:Clinical report
Date:Oct 1, 2009
Words:2349
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