Closure of Oroantral Communications With Bichat's … · Closure of Oroantral Communications With Bichat’s Buccal Fat Pad ... CAUSE OF OROANTRAL COMMUNICATION ... closure of oronasal

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Oral Maxillofac Surg7:1460-1466, 2009

Closure of Oroantral CommunicationsWith Bichat’s Buccal Fat Pad

Paul W. Poeschl, MD, DMD,*

Arnulf Baumann, MD, DMD, PhD,† Guenter Russmueller, MD,‡

Ellen Poeschl, MD, DMD,§ Clemens Klug, MD, DMD, PhD,¶ and

Rolf Ewers, MD, DMD, PhD�

Purpose: The aim of the present study was to evaluate the use of the pedicled buccal fat pad for the closureof oroantral communications (OACs) and to describe our experience with this surgical procedure.

Patients and Methods: A retrospective review of 161 patients treated at the University Hospital forCranio-Maxillofacial and Oral Surgery in Vienna, Austria, from 2000 to 2005, with the diagnosis of an OACwas performed. All defects were closed by application of a buccal fat pad. Data were obtained from chartreview, a compiled database, and clinical follow-up and included the location of the defect, the cause ofthe OAC, the modality of anesthesia, intraoperative complications, any complications during the processof wound healing, and any late adverse effects.

Results: The buccal fat pad for closure of an OAC was successfully used in 161 patients at ourdepartment. In 12 patients (7.5%), the closure of the OAC was insufficient, and a second operation wasnecessary. Excluding all severe and complicating cases such as tumor-related defects or previouslytreated cases, the overall success rate for closure of the OAC was nearly 98%. No late complicationsoccurred, and all patients were free of pain or any limitations after the 6-month follow-up period.

Conclusions: According to the recommendations and anatomic limitations reported in publishedstudies and discussed in the present report, the application of the buccal fat pad is a safe and reliableprocedure for closing an OAC.© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1460-1466, 2009
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roantral communications (OACs) are a commonomplication in dentoalveolar and maxillofacial sur-ery and are often seen, especially after complicatedooth extractions. The presence of an OAC itself is notmajor problem; however, if proper treatment is notrovided, severe complications with persistent sinus-

tis can occur. Therefore, the exact diagnosis andreatment of OACs is indispensable to avoid negativeequelae for the patient. A number of different tech-iques have been described for the closure of anAC, and their application is now a routine proce-ure in oral and maxillofacial surgery. Since the firstescription of its application in 1977 by Egyedi,1 theuccal fat pad (BFP) has become more and more

eceived from the University Hospital for Cranio-Maxillofacial and

ral Surgery, Medical University of Vienna, Vienna, Austria.

*Senior Consultant.

†Professor.

‡Resident.

§Resident.

¶Vice Chairman.

�Chairman.

1460

opular in oral surgery. Originally described as annatomic structure without any obvious function, itas for a long period even considered a surgicaluisance.2,3 However, during the past 3 decades, itas proved of value for the closure of OACs and is aell-established tool in oral and maxillofacial surgery.

n the present retrospective study, we report ourxperience with the BFP in the treatment of OACs inlarge series of 161 patients.

atients and Methods

A total of 161 patients with OACs of different ori-ins were treated at the University Hospital for

Address correspondence and reprint requests to Dr Poeschl,

niversity Hospital for Cranio-Maxillofacial and Oral Surgery, Med-

cal University of Vienna, Waehringer Guertel 18-20, Vienna A-1090

ustria; e-mail: [email protected]

2009 American Association of Oral and Maxillofacial Surgeons

278-2391/09/6707-0016$36.00/0

oi:10.1016/j.joms.2009.03.049

mailto:[email protected]

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ranio-Maxillofacial and Oral Surgery, Vienna Medicalniversity, from 2000 to 2005. In most cases, the

eason for the OAC was a complicated tooth extrac-ion. Other reasons included surgical defects afterumor resection of the maxilla, cyst removal, sinusrafting, osteonecrosis, trauma, and peri-implantitis.he mean age of the patients was 39 years (range 15

o 90), and the number of men and women was 86nd 75, respectively. The patient details and distribu-ion of the indications and localization of the OAC areisted in Tables 1 and 2, respectively. Data were ob-ained by chart review, from the compiled database,nd clinical follow-up. Usually the patients were dis-issed from the follow-up program after 6 months,hen the healing process was regular and no compli-

ations or any adverse effects had occurred. In thease of complications, the follow-up period was pro-racted until complete healing had been observed.hus, the mean follow-up period was 6 months (rangeto 11). The parameters evaluated included the loca-

ion of the defect, the cause of the OAC, the anesthe-ia method, intraoperative complications, any compli-ations during wound healing, and late adverseffects such as prosthetic difficulties, persistent pain,eformities, or limited mouth opening.To ensure the healthy status of the maxillary sinus

efore surgery, all patients underwent a panoramicadiograph examination. In the case of a longer per-isting OAC or acute maxillary sinusitis, the sinus wasinsed daily with an antiseptic solution (Betaisodona;undipharma, Vienna, Austria) and saline solution,ntil the fluid draining from the nose was clear. Thisrocedure is also important to ensure open and effi-ient drainage from the maxillary sinus to the nasalavity. Computed tomography scans of the maxillaryinus were only taken on a symptom-driven basishen the clinical findings were doubtful. When de-

ecting an OAC immediately after a tooth extraction,urgeons have always relied on the panoramic radio-raph, the clinical signs, and the rinsing procedure. Inroblematic cases, the quick use of an endoscope can

Table 1. CAUSE OF OROANTRAL COMMUNICATION

Cause Patients (n)

Tooth extraction 130Tumor 7Cyst 9Osteonecrosis 5Trauma 4Sinus graft 4Peri-implantitis 2Total 161

oeschl et al. Closure of Oroantral Communications. J Oral Max-llofac Surg 2009.

e very helpful. We only closed the OAC using a BFPf the status of the sinus was considered healthy.

All procedures were undertaken in a fully equippedperating room under sterile conditions as regulatedy the hospital authorities. Articaine was used for

ocal anesthesia, or the operation was performed withhe patient under general anesthesia. The approachor raising the BFP was done by a horizontal incisionf the periosteum posterior to the area of the zygo-atic buttress after raising a mucoperiosteal flap. In

he case of tumor resection, the BFP often pops outrbitrarily through the larger incisions used for tumoremoval. It was then mobilized by blunt dissectionnd exposed until the desired volume was availableor the planned closure. Next, it was carefully andently advanced into the defect until tension-free ad-ptation was possible. Only resorbable sutures weresed. Depending on the size of the defect, duration ofhe persisting OAC, and amount of remaining mucosalissue, the procedure varied as follows (Figs 1-6):

1. In the case of an intraoperatively detected OACafter a minor surgical procedure such as toothextraction, cyst removal, or necrosectomy, thedefect was closed immediately using the pedi-cled BFP, which was expanded and sutured tothe adjacent mucosal margins, as described byHanazawa et al.4 The mucoperiosteal flap wasthen replaced and fixed to the BFP.

2. Depending on the mass of the mobilized BFP,horizontal mattress sutures were additionally ap-plied between the adjacent mucosal margins ofthe palate and the vestibular sulcus to minimizethe uncovered BFP surface and reduce the vol-

Table 2. LOCALIZATION OF OAC AFTER TOOTHEXTRACTION (N � 130)

Maxilla (Tooth Position) Patients (n)

RightThird molar 7Second molar 15First molar 27Second premolar 7First premolar 2Total 58

LeftThird molar 16Second molar 13First molar 34Second premolar 8First premolar 1Total 72

ooth numbers according to universal numbering system.


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1462 CLOSURE OF OROANTRAL COMMUNICATIONS

3. In cases in which the OAC had persisted forsome time and an organized fistula had devel-oped between the maxillary sinus and oral cav-ity, the fistula was excised and inverted as aninner layer, followed by the expansion of theBFP as described.

4. When the BFP was used to close large defects aftertumor resection, maximal mobilization of the flapwas done, and the whole accessible BFP wasengaged.

esults

The BFP for closure of an OAC was successfullyngaged in 161 patients at our department. The max-mal defect size was 56 � 42 mm after tumor resec-ion. The surgical procedure was performed usingocal anesthesia in 107 patients and with the patientnder general anesthesia in 54 patients. In 12 patients7.5%), closure of the OAC was insufficient, and aecond operation was necessary. Of these 12 patients,had had large defects after tumor resection and 6

ad had a chronic and complicating recurrent OACfter other attempts at closure. Excluding all severend complicating cases, such as tumor-related defects

IGURE 1. OAC after tooth extraction of first molar. Incision foraising mucoperiosteal flap indicated as red dotted line.

poeschl et al. Closure of Oroantral Communications. J Oral Max-llofac Surg 2009.

r previously treated cases, the overall success rateor the closure of OAC was nearly 98%. The details ofhe evaluated complications are listed in Table 3.

The typical clinical course of the exposed BFP inhe oral cavity was as follows (Figs 7-11). The surfaceurned from the typical fatty yellow to a paler yellow/hite color after 3 to 4 days. Usually the surfacesecame a lighter and lighter red after 1 week, andtrong granulation was visible until the complete cov-rage of the fatty surface by newly formed re-epithe-ialized mucosa. The sometimes initially voluminousissue showed continuous shrinkage and reached theormal mucosal level after 3 to 4 weeks. The depth ofhe vestibular sulcus increased continuously in almostll cases, and prosthetic rehabilitation was feasible inll cases. The 8 patients with pain persisting longerhan 2 weeks or a limited mouth opening had aelayed healing progress, but were all 8 were free ofny limitations at the end of the follow-up period.outh opening exercises and analgesics were pre-

cribed to these patients.

iscussion

The use of the BFP for the closure of OAC has been

IGURE 2. Planned incision in case of longer persisting OAC withpithelialized fistula.


reviously reported.4-9 Its successful application has

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een documented for reconstruction of the palatalegion, buccal mucosa, closure of oronasal fistulas,overage of the surface of bone grafts, and recon-truction after post-traumatic defects in the maxillary

FIGURE 3. View after raising of mucoperiosteal flap.


IGURE 4. BFP expanded into defect after incision of periosteumturquoise line).

ioeschl et al. Closure of Oroantral Communications. J Oral Max-llofac Surg 2009.

egion.4-9 Since its first description in 1732 by Heis-er10 and in 1802 by Bichat,11 its potential clinicalpplications was hidden for almost 2 centuries. To-ay, the term “boule de Bichat” is still common inrench reports, and within the German nomenclaturehe sole name “Bichat” is widely used to describe theFP. Anatomically, it consists of a central body and 4rocesses—the buccal, pterygoid, superficial, andeep temporal process.12 The buccal and deep tem-oral branches of the maxillary artery, transverse fa-ial branches of the superficial temporal artery, andranches of the facial artery provide the blood sup-ly.12-14 Each process has its own capsule and isnchored to the surrounding structures by ligaments.he possible function of the BFP include the preven-

ion of negative pressure in newborns while sucking,eparating the masticator muscles from one anothernd from the adjacent bony structures, enhancementf intermuscular motion, and the protection of neu-ovascular bundles.5,12,15 The buccal process is lo-ated superficially within the cheek and is partiallyesponsible for the cheek contour. The BFP seems toave its own mechanism of lipolysis, independent ofhe subcutaneous fat.14,16,17 Therefore, it can be ap-lied even in thin or cachectic patients.18 Because of

IGURE 5. View after closure of wound, with BFP surface leftncovered.


ts rich blood supply, it can be considered as a pedi-

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led graft with an axial pattern and should be consid-red as an ideal and reliable tool for reconstructingefects in the maxillary region. In particular, the bodynd buccal process can be easily reached through theral cavity and are therefore available for reconstruc-ive procedures.18 The size of the covered defect haseen up to 60 � 50 � 30 mm in published re-orts.16,19 Furthermore, reports have been publishedf the successful closure of OAC after tooth extrac-ion, although the reported series included only amall number of cases.4,7,20-22 In our series, we in-luded 130 patients with an OAC after tooth removal,nd the overall success rate for closure using the BFP

IGURE 6. View after closure of wound, with horizontal mattressuture in situ, and BFP surface left uncovered.


Table 3. COMPLICATIONS (N � 161)

Complication n (%)

Intraoperative complication 0Pain �2 wk 3 (2)Limited mouth opening 5 (3)Cheek deformity 1 (0.6)Prosthetic problems 0Recurrent OAC 12 (7.5)

bbreviation: OAC, oroantral communication.

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as nearly 98%. Therefore, the BFP can be consideredsafe method for closure. Earlier reported findings

ave supported our findings.4,7,20,21 The quick epithe-ialization of the uncovered fat is a characteristiceature of the pedicled BFP flap and histologicallyroven.4,18,22 The layer above the originally uncov-red BFP consists of stratified squamous epitheliumigrating from the adjacent mucosal regions. A cru-

ial point for surgical success is the careful and gentlereparation of the BFP. Extensive pulling or fragment-

ng of the tissue can result in complete failure owingo a breakdown in the vascular supply of the flap. Thisan explain the high failure rate after tumor resectionhen reconstructing large defects exceeding 40 � 40m.9 Our findings revealed the same results, with a

ailure rate of 42% (3 of 7) after ablative tumor sur-ery. All these failures were large defects with diam-ters of more than 50 � 50 mm. Therefore, the BFP

IGURE 7. Bisphosphonate-induced osteonecrosis in the rightaxilla of a patient with lung cancer and osteolytic bony metasta-

es before surgery.


IGURE 8. View on first postoperative day after necrosectomy andecortication with consecutive OAC covered by BFP.


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an only be recommended for small tumor-relatedaxillary or palatal defects (stage T1 and small stage2 tumors), if the margins of the defect can be ap-roximated to reduce the OAC size.9,22,23 None of ourumor patients had undergone radiotherapy beforeurgery; however, we believe the engagement of aFP flap for small tumor-related defects in previously

rradiated patients is still worthwhile, especially inases in which time-consuming restorative proce-ures are not possible. However, clinical data are notet available to prove this theory.When using the BFP for closing simple OACs result-

ng from tooth extractions, concerns could arise re-arding the necessity of this procedure. Definitely,everal other surgical methods exist for successfulanagement of OACs. The one in most widespread

se is the buccal sliding or advancement flap, whichrobably represents the standard procedure for OAC

FIGURE 9. View 1 week after surgery.


IGURE 10. View 1 month after surgery showing only remainingesorbable sutures still visible and most of BFP already covered byew mucosal tissue (photographed using intraoral mirror).

toeschl et al. Closure of Oroantral Communications. J Oral Max-llofac Surg 2009.

losure. However, despite the simplicity and safety ofhe procedure, it has some drawbacks. First, it resultsn a decreased vestibular sulcus depth, thus compli-ating the prosthetic rehabilitation. Second, it cannote applied in cases in which the gingival region haseen severely damaged. Third, its success is question-ble in difficult cases of previously operated OACs.he pedicled BFP flap seems to be the more reliableethod in difficult cases, keeping in mind a proper

perating technique.4,7 Therefore, it can be consid-red a true alternative for OAC closure.We could not observe any problems regarding later

rosthetic restorations in our study. These findingsgree with other published reports.4,7,18 The reported

failures in the previously operated patients withecurrent OACs were because the maxillary sinushowed signs of infection at surgery or osteonecroticaterial was not removed properly during the proce-

ure. In all these cases, the surgeon responsible forhe operation expressed concerns regarding the ex-ected success of the OAC closure immediately afterhe procedure because of these reasons. Therefore,he absence of any inflammatory signs is absolutelyandatory for surgical success.The main advantages of the pedicled BFP flap forAC closure are that it is a simple procedure; isidely applicable; the incidence of failure is low; theegative side effects are rarely seen and mostly tem-orary; the prosthetic rehabilitation is feasible with-ut limitations; it has minimal donor site morbidity; itsuccess is independent of patient age and generalondition; and it can be used in association with otheraps as a second layer.Its main drawback is that it can only be used once

nd limitations exist concerning the potential size of

IGURE 11. View 2 months after surgery showing complete res-itution to original condition, with only slight groove next to alveolaridge (photographed with intraoral mirror).


he defects to be covered. However, keeping in mind

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ts recommendations and limitations, its application issafe and successful procedure for closing OACs.

cknowledgment

The authors would like to thank Man-Phuong Huynh for creationf the graphics.

eferences1. Egyedi P: Utilization of the buccal fat pad for closure of ore-

antral and/or ore-nasal communications. J Maxillofac Surg5:241, 1977

2. Messenger KL, Cloyd W: Traumatic herniation of the buccal fatpad: Report of a case. Oral Surg Oral Med Oral Pathol 43:41,1977

3. Wolford DG, Stapleford RG, Forte RA, et al: Traumatic hernia-tion of the buccal fat pad: Report of case. J Am Dent Assoc103:593, 1981

4. Hanazawa Y, Itoh K, Mabashi T, et al: Closure of oroantralcommunications using a pedicled buccal fat pad graft. J OralMaxillofac Surg 53:771, 1995

5. Dean A, Alamillos F, Garcia-LoPez A, et al: The buccal fat padflap in oral reconstruction. Head Neck 23:383, 2001

6. Herring SM: Reconstruction of facial contour deformity withthe buccal fat pad flap. Ann Plast Surg 29:450, 1992

7. Stajcic Z: The buccal fat pad in the closure of oro-antral com-munications: A study of 56 cases. J Craniomaxillofacial Surg20:193, 1992

8. Yeh CY: Application of the buccal fat pad to the surgicaltreatment of oral submucous fibrosis. Int J Oral Maxillofac Surg25:130, 1996

9. Rapidis A, Alexandridis CA, Eleftheriadis E, et al: The use of the
buccal fat pad for reconstruction of oral defects: Review of
literature and report of 15 cases. J Oral Maxillofac Surg 58:158,2000

0. Heister L: Compendium Anatomicum Norimbergae, Germany.G. C. Weberi, 1732, p l46

1. Bichat F: Anatomise generale, appliquee a la physiologie et al lamedecine. Paris, France, Brosson, Gabon et Cie, 1802

2. Zhang MH, Yan Y, Ming Q, et al: Anatomical structure of thebuccal fat pad and its clinical adaptations. Plast Reconstr Surg109:2509, 2002

3. Dubin B, Jackson IT, Halim A, et al: Anatomy of the buccal fatpad and its clinical significance. Plast Reconstr Surg 83:257,1989

4. Stuzin JM, Wagstrom L, Kawamoto HK, et al: The anatomy andclinical applications of the buccal fat pad. Plast Reconstr Surg85:29, 1990

5. Stuzin JM, Wagstrom L, Kawamoto HK, et al: Anatomy of thefrontal branch of the facial nerve: The significance of thetemporal fat pad. Plast Reconstr Surg 83:265, 1989

6. Tideman H, Bosanquet A, Scott J: Use of the buccal fat pad asa pedicled graft. J Oral Maxillofac Surg 44:435, 1986

7. Jackson IT: Anatomy of the buccal fat pad and its clinicalsignificance. Plast Reconstr Surg 103:2059, 1999

8. Baumann A, Ewers E: Application of the buccal fat pad in oralreconstruction. J Oral Maxillofac Surg 58:389, 2000

9. Fujimura N, Nagura H, Enomoto S: Grafting of the buccal fatpad into palatal defects. J Craniomaxillofacial Surg 18:219,1990

0. Hai KH: Repair of palatal defects with unlined buccal fat padgrafts. Oral Surg Oral Med Oral Pathol 65:523, 1988

1. Stajcic Z, Todorovic L, Pesic V, et al: Tissucol, gold plate, thebuccal fat pad and the submucosal palatal island flap in closureof oroantral communication. Dtsch Zahnarztl Z 43:1332, 1988

2. Samman N, Cheung LK, Tideman H: The buccal fat pad in oralreconstruction. Int J Oral Maxillofac Surg 22:2, 1993

3. Colella G, Tartaro G, Giudice A: The buccal fat pad in oral
reconstruction. Br J Plast Surg 57:326, 2004

Documents

Closure of Oroantral Communications With Bichat's … · Closure of Oroantral Communications With Bichat’s Buccal Fat Pad ... CAUSE OF OROANTRAL COMMUNICATION ... closure of oronasal