Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2013) xxx– xxx
Contents lists available at SciVerse ScienceDirect
Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology
jou rn al hom epage: www.elsev ier .com/ locat e/ jomsmp
ffectiveness of buccal fat pad in surgical management of oral submucousbrosis: A prospective study of 20 cases�
hoyeb K. Shaikh, Madan Mishra ∗, Gaurav Singh, Jitender K. Aurora, Saif Khurhsidepartment of Oral and Maxillofacial Surgery, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
a r t i c l e i n f o
rticle history:eceived 27 December 2012eceived in revised form 6 April 2013ccepted 15 April 2013
eywords:ral submucous fibrosisuccal fat pad
a b s t r a c t
Objectives: The objectives of this study were to evaluate the effectiveness of pedicled buccal fat pad in thesurgical management of oral submucous fibrosis and assessment of interincisional opening, relief fromsymptoms, wound healing and relapse rate.Study design: A total of 20 patients of oral submucous fibrosis of group IVa (Khanna and Andrade) wereselected for the study. Patients were strongly advised for discontinuation of any adverse oral habits.Patients were followed up for one year.Results: Mean preoperative mouth opening was 11.25 mm (SD 3.46 mm) and intraoperative mean mouthopening achieved was 41.75 mm (SD, 3.74 mm). Mean postoperative mouth opening after 1 year followup was of 31.05 mm (SD 6.80 mm). None of the cases showed infection at any postoperative time interval.A total of 2 (10%) patients reported of burning sensation and a total of 1 (5%) had wound dehiscence whichwas subsequently managed successfully. A total of 2 (10%) patients showed relapse. Overall success rate
was 90%.Conclusion: Buccal fat pad functions well as a pedicled graft in the surgical management of oral submucousfibrosis. The healing was uneventful with the uptake of graft but vigorous postoperative physiotherapywas necessary for the first three months and continuing it for a minimum for 1 year to maintain thepostoperative mouth opening achieved intraoperatively.
Sushruta in the ancient Indian medicine text during the thirdnd fourth century described a condition termed “vidari” underouth and throat disease as progressive narrowing of mouth and
ain on taking food, all these being observed to be characteristiceatures of oral submucous fibrosis [1].
Schwartz in 1952 coined the term atrophica idiopathica mucosaris in 5 Indian women from Kenya; Joshi in 1953 subsequentlyermed the condition first time as oral submucous fibrosis [2–4].ral submucous fibrosis is a chronic debilitating fibrotic diseasef oral cavity typically affecting the buccal mucosa [4], tongue,
Please cite this article in press as: Shaikh SK, et al. Effectiveness of buccal fat
study of 20 cases. J Oral Maxillofac Surg Med Pathol (2013), http://dx.doi.o
ips, soft palate [5] and sometimes also pharynx and oesoph-gus [3], occasionally preceded by vesicle formation [6]. It islways associated by fibrous band and histopathologically observed
� AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asianociety of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathol-gy; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japaneseociety of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.∗ Corresponding author. Tel.: +91 9565740127.
juxtraepithelial inflammatory reaction followed by a fibroelasticchange of lamina propria with epithelial atrophy leading to stiffnessof the oral mucosa, trismus and inability to eat [7].
Various reported etiological factors for the disease can be arecanut, capsaicin in chillies, micronutrient deficiencies of iron, zincand essential vitamins. A possible autoimmune basis to the diseasewith demonstration of various auto-antibodies and an associationwith specific human leukocyte antigens has been reported, whichraises the possibility of a genetic predisposition of some individualsto develop oral submucous fibrosis (OSMF) [8]. In the past variousstudies on surgical treatment of OSMF with various kinds of graftshave been introduced, such as nasolabial flaps [9], split-thicknessskin grafts [10], radial forearm flap [11], superficial temporal facialflap with split skin graft [10] and palatal island flap [12]. Thesegrafts have their own limitations and require surgeon’s skill. Theintroduction of buccal fat pad (BFP) for the surgical management ofOSMF is proved to be very efficient. The surgical procedure is easyand donor site is in close proximity.
The BFP was first recognized as such and described by Bichat in
pad in surgical management of oral submucous fibrosis: A prospectiverg/10.1016/j.ajoms.2013.04.011
1802 [13,14]. It is a mass of specialized fatty tissue which is distinctfrom subcutaneous fat and remains constant in terms of size evenin extreme weight gain or loss and not proportional to total body fat[15,16]. The bulk of BFP occupies the buccal space and rests on the
I. Published by Elsevier Ltd. All rights reserved.
2 S.K. Shaikh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2013) xxx– xxx
pIaa[[pfla
eowdIv[
2
obreta
ntipPborabttdc
Postoperatively, all patients received prophylactic antibioticsand nasogastric feeding for 1 week. Mouth opening exercises werestarted within 36 h. This intensive exercise was carried out daily
Fig. 1. Preoperative mouth opening.
eriosteum that covers the posterior buccal aspect of the maxilla.t has a rich blood supply through the small branches of the facialrtery, the internal maxillary artery, and the superficial temporalrtery and vein by an abundant network of vascular anastomosis17]. On an average the volume of BFP is 9.6 ml (range 8.3–11.9 ml)18]. Defects up to 3 cm × 5 cm can be closed with BFP without com-romising its blood supply [19]. Tideman et al. reported that the BFPap is epithelialized within 2–3 weeks, thus obscuring any need ofdditional skin graft [19].
The advantages of using buccal fat pad are: it is a quick, simple,qually effective and technically easier flap to use where most of theral and maxillofacial surgeon can develop expertise and executeith ease with no special or costly armamentarium and the proce-ure would be affordable to every socioeconomic state of people.
t heals with minimal scarring having low relapse [13], can be har-ested through same resection bed, thus has a very low morbidity17] with excellent functional outcomes [9].
. Materials and methods
A total of 20 clinically diagnosed patients (5 females–15 males)f OSMF group IVa (Khanna and Andrade) having mouth openingetween 2 and 15 mm (Fig. 1), aged 16–53 years, were taken upandomly irrespective of age, sex, caste and creed. Approval of thethical committee of the institute was taken for all the patients ofhe study. Patients were strongly advised for discontinuation of anydverse oral habits.
The operations were performed under general anesthesia withasal intubation either blind nasal, retrograde or fiber optic intuba-ion keeping the mouth opening in view. The patients underwentnfiltration along the planned incision line parallel to the occlusallane with 2% lignocaine with 1:80,000 adrenaline. A No. 15 Bardarker blade was used for incising fibrotic bands on each side of theuccal mucosa at the level of the occlusal plane away from Stensenrifice. The incision line extended from the pterygomandibularaphe and/or anterior faucial pillars to as far as the premolar regionnd/or corner of mouth depending on the extend of the fibroticands detected by palpation. The incised fibrotic bands were fur-
Please cite this article in press as: Shaikh SK, et al. Effectiveness of buccal fat
study of 20 cases. J Oral Maxillofac Surg Med Pathol (2013), http://dx.doi.o
her disentangled manually until no restrictions were felt. Bilateralemporalis myotomy and coronoidectomy or coronoidotomy wasone in all the cases (five patients had coronoidectomy and rest hadoronoidotomy). The mouth was then forced open with a Heister
Fig. 2. Intraoperative mouth opening.
mouth gag to an acceptable range of more than 35 mm (Fig. 2).Prophylactic extractions of all the erupted third molars were done.Bilateral buccal defects ranging from 4 cm × 2.5 cm to 5.5 cm × 3 cmwere covered with BFP after hemostasis. The buccal fat pad (mainbody and buccal extension) was approached through the posteriorsuperior margin of the created buccal defect posterior to the zygo-matic buttress. After blunt dissection, through the submucosa thebuccal fat pad was teased out gently until a significant amount wasobtained to cover the defect without tension. The interrupted mat-tress sutures were placed by use of No. 3-0 Vicryl to secure the flap(Fig. 3). Same procedure was performed on the opposite side. Thebuccal fat pad covered the entire defect eliminating the possibilityof secondary epithelialization.
pad in surgical management of oral submucous fibrosis: A prospectiverg/10.1016/j.ajoms.2013.04.011
S.K. Shaikh et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2013) xxx– xxx 3
fy(tsw
fv
3
ItHma
Fig. 4. One week postoperative mouth opening.
or at least 3 months and with reduced frequency for as long as 1ear. The patients were analyzed for postoperative mouth openinginterincisal distance in millimetres), infection, changes in symp-oms (painful ulcerations, burning sensation, and intolerance topices), wound dehiscence and relapse at different time intervalshich lasted for 1 year (Figs. 4 and 5).
The statistical analysis was done using SPSS (Statistical Packageor Social Sciences) Version 15.0 statistical analysis software. Thealues were represented in number (%) and mean ± SD.
. Results
In our study 20 patients of oral submucous fibrosis of groupVa (Khanna and Andrade), the age of the patient ranged from 16
Please cite this article in press as: Shaikh SK, et al. Effectiveness of buccal fat
study of 20 cases. J Oral Maxillofac Surg Med Pathol (2013), http://dx.doi.o
o 53 years with the peak incidence from 21 to 30 years (60%).igh preponderance in male was observed the ratio being 3:1. Theean preoperative mouth opening was of 11.25 mm (SD 3.46 mm)
nd mean intraoperative mouth opening achieved was 41.75 mm
Fig. 6. Graph showing preoperative, intraoperative and postoperativ
Fig. 5. One year postoperative mouth opening.
(SD 3.74 mm). The mean postoperative mouth opening after 1 yearwas 31.05 mm in (SD 6.80 mm) (Fig. 6). There was no evidence ofinfection but remission of symptom (painful ulceration) was foundin 2 of 20 cases. One patient had developed partial wound dehis-cence at 1st week follow up which was subsequently managed.Improvement in the physiologic function of the buccal mucosa,such as suppleness and elasticity, was noted in all other cases. Thetime taken for epithelialization of BFP was 4 weeks to 5 weeks andwithin 6 months normal contour and elasticity of the mucosa wasrestored. Two patients showed complete relapse as they developedrefibrosis and trismus, probably because of their noncompliance tophysiotherapy.
pad in surgical management of oral submucous fibrosis: A prospectiverg/10.1016/j.ajoms.2013.04.011
4. Discussion
A variety of surgical modalities have been used for the treat-ment of advanced oral submucous fibrosis. Simple excision of the
e mouth opening of all the patients at different time intervals.
[19] Tideman H, Bosanquet A, Scott J. Use of buccal fat pad as pedicled graft. J OralMaxillofac Surg 1986;44:435–40.
[20] Chang YM, Tsai CY, Kildal M, Wei FC. Importance of coronoidotomy and mas-
ARTICLEOMSMP-161; No. of Pages 4
S.K. Shaikh et al. / Journal of Oral and Maxillofacia
brous bands can increase scarring and exacerbate the condition.esults with split-thickness skin grafting, or fresh human amniono cover the raw surfaces after resection of fibrous bands have beenisappointing [5,10]. The incidence of shrinkage, contracture and
nfection of the grafts was high because oral conditions were poornd the symptoms usually recurred [5,10]. Resurfacing the defectsith various local flaps has several disadvantages. Tongue flaps are
ulky and require additional division surgery. Bilateral tongue flapsause disarticulation and dysphagia and increase the risk of aspi-ation. Involvement of the tongue (in 38% of cases) may precludehe use of tongue flaps. Both the nasolabial flap and palatal islandap have limited size and difficulty in reaching the posterior rawurface. Use of the nasolabial flap also results in facial scars andequires a second operation for division [5,10]. The bilateral radialorearm flaps requires two microsurgeries are required, the proce-ure is more time-consuming and technically demanding, and it
nvolves two forearm donor sites with sacrifice of bilateral radialrteries.
Yeh first reported the use of BFP with promising results andinimal morbidity. In his study of 9 patients, the range preopera-
ive mouth opening was 8–16 mm (mean 12.1 mm) [17,18]. In theresent study of 20 patients the mean preoperative mouth openingas 2–15 mm (mean 11.25 mm).
In the present study prophylactic extraction of all the thirdolars were done intraoperatively, which were erupted or par-
ially erupted. This was done to avoid trauma to the flap at theetromolar region. Since in advanced stage the fibrosis progress tonvolve temporalis tendon, therefore bilateral temporalis myotomynd coronoidectomy or coronoidotomy was done in all the cases tochieve a mouth opening of more than 35 mm (five patients hadoronoidectomy and rest had coronoidotomy). Chang et al. [20] did
similar study and explained the importance of coronoidotomy andasticatory muscle myotomy in surgical release of trismus caused
y submucous fibrosis and the results were similar to that achievedn our study. The mean intraoperative mouth opening achieved inhe present study was 41.75 mm.
The mean post operative mouth opening achieved in the presenttudy was of 31 mm over a follow up period of one year. The meanncrease in mouth opening was 18.9 mm, which was comparableo the results achieved by Yeh and Sharma et al. [17,18]. None ofhe patient in the present study showed any signs of infection. Allhe patents were kept on nasogastric feeding for 5–7 days. Everylternate day, intraoral irrigation was done and proper oral hygieneas maintained. Yeh [17] in his study concluded that BFP is a well
acularized flap and more resistant to infection than any other kindf free graft. Tideman et al. has reported infection rate of BFP as 0.6%nly.
In the present study the time taken for epithelialization of BFPas 4–5 weeks and within 6 months normal contour and elastic-
ty of the mucosa was restored. Similar results were found in theistological studies by Sharma et al. [18].
Sharma et al. in their study of 28 patients found no evidence ofemission of symptoms such as burning sensation, painful ulcera-ion and tolerance to spices [18]. But in our study two patients hadeveloped burning sensation which was mild in nature at 6 monthsollow up. This was probably due to reappearance of fibrous bandss the case was suggestive of mild relapse.
In the present study one patient had partial dehiscence atst week follow up. This was due to impaired vascularity of thetretched ends of the flap that was sutured to the corner of theouth. This area was left for secondary epithelialization.There was complete relapse in two patients as they developed
Please cite this article in press as: Shaikh SK, et al. Effectiveness of buccal fat
study of 20 cases. J Oral Maxillofac Surg Med Pathol (2013), http://dx.doi.o
efibrosis and trismus. Their mouth opening reduced to 5 mm and4 mm after a follow up period of one year. Relapse resulted from
PRESSery, Medicine, and Pathology xxx (2013) xxx– xxx
inactive postoperative rehabilitation because of lack of compliancefrom patient and to perform mouth opening exercise.
5. Conclusion
This study was primarily aimed to evaluate the efficacy ofpedicled buccal fat pad in surgical management of oral submu-cous fibrosis. Based on the findings of our study the followingconclusions were derived: (1) buccal fat pad functions well as apedicled graft in the surgical management of oral submucous fibro-sis; (2) it is a quick, simple, equally effective and technically easierflap to use where most of the oral and maxillofacial surgeon candevelop expertise and execute with ease with no special or costlyarmamentarium and the procedure would be affordable to everysocioeconomic state of people; (3) healing was uneventful with theuptake of the flap as it has a rich blood supply; (4) post operativemorbidity was negligible and patient uptake was good as it washarvested from the same resection bed; (5) buccal fat pad epithe-lialized within 4–5 weeks; (6) early and intensive postoperativemouth opening exercise was very important to achieve adequatemouth opening afterward. Two patients did not cooperate and bothhad significant relapse; (7) bilateral temporalis myotomy and coro-noidotomy or coronoidectomy can be taken into consideration toachieve maximum intraoperative mouth opening in severe cases.
References
[1] Mehta AK, Panwar SS, Verma RK, Pal AK. Buccal fad pad reconstruction in oralsubmucous fibrosis. MJAFI 2003;59:340–1.
[2] Schwartz J. Atrophica idiopathica mucosa oris. In: Demonstrated at the 11thint dent congress. 1952.
[3] Joshi SG. Fibrosis of the palate and pillars. Indian J Otolaryngol 1953;4:1.[4] Jiang X, Hu J. Drug treatment of oral submucous fibrosis: a review of literature.
J Oral Maxillofac Surg 2009;67:1510–5.[5] Isaac U, Issac JS, Khoso NA. Histopathologic feature of oral submucous fibrosis:
a study of 35 biopsy specimens. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2008;56:556–60.
[6] Pindborg JJ. Oral submucous fibrosis as a precancerous condition. J Dent Res1966;45:546–53.
[7] Tupkari JV, Bhavthankar JD, Mandale MS. Oral submucous fibrosis (OSMF): astudy of 101 cases. J Indian Acad Oral Med Radiol 2007;19:311–8.
[8] Tilakaratne WM, Klinikowski MF, Saku T, Peters TJ, Warnakulasuriya S.Oral submucous fibrosis: review on aetiology and pathogenesis. Oral Oncol2006;42:561–8.
[9] Mehrotra D, Pradhan R, Gupta S. Retrospective comparison of surgical treat-ment modalities in 100 patients with oral submucous fibrosis. Oral Surg OralMed Oral Pathol Oral Radiol Endod 2009;107:e1–10.
10] Mokal NJ, Raje RS, Ranade SV, Prasad JS, Thatte RL. Release of oral submucousfibrosis and reconstruction using superficial temporal fascia flap and split skingraft—a new technique. Br J Plast Surg 2005;58:1055–60.
11] Lee JT, Cheng LF, Chen CH, Wang CH, Hsu H, Chien SH, et al. Bipaddled radialforearm flap for the reconstruction of bilateral buccal defects in oral submucousfibrosis. Int J Oral Maxillofac Surg 2007;36:615–9.
12] Khanna JN, Andrade NN. Oral submucous fibrosis: a new concept in surgicalmanagement. Report of 100 cases. Int J Oral Maxillofac Surg 1995;24:433–9.
13] Rapidis AD, Alexandridis CA, Eleftheriadis E, Angelopoulos AP. The use of thebuccal fat pad for reconstruction of the oral defects: review of the literatureand report of 15 cases. J Oral Maxillofac Surg 2000;58:158–63.
14] Poeschl PW, Baumann A, Russmueller G, Poeschl E, Klug C, Ewers R. Closure oforoantral communication with Bichat’s buccal fat pad. J Oral Maxillofac Surg2009;67:1460–6.
15] Baumann A, Ewers R. Application of the buccal fat pad in oral reconstruction. JOral Maxillofac Surg 2000;58:389–92.
16] Chakrabarti J, Tekriwal R, Ganguli A, Ghosh S, Mishra PK. Pedicled buccal fatpad flap for intraoral malignant defects: a series of 29 cases. Indian J Plast Surg2009;42:36–42.
17] Yeh CY. Application of buccal pad fat for the surgical treatment of oral submu-cous fibrosis. Int J Oral Maxillofac Surg 1996;25:130–3.
18] Sharma R, Thapliyal GK, Sinha R, Suresh MP. Use of buccal fat pad for treatmentof oral submucous fibrosis. J Oral Maxillofac Surg 2012;70(1):228–32.
pad in surgical management of oral submucous fibrosis: A prospectiverg/10.1016/j.ajoms.2013.04.011
ticatory muscle myotomy in surgical release of trismus caused by submucousfibrosis. Plast Reconstr Surg 2004;113:1949–54.
