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Pedicled buccal fat pad flap as a reliable surgical strategy for the treatment ofmedication-related osteonecrosis of the jaw (MR-ONJ)
Horatiu Rotaru, MD, DDS, PhD Min-Keun Kim, DDS Seong-Gon Kim, DDS, PhDYoung-Wook Park, DDS, PhD
PII: S0278-2391(14)01529-8
DOI: 10.1016/j.joms.2014.09.023
Reference: YJOMS 56513
To appear in: Journal of Oral and Maxillofacial Surgery
Received Date: 24 July 2014
Revised Date: 14 September 2014
Accepted Date: 27 September 2014
Please cite this article as: Rotaru H, Kim M-K, Kim S-G, Park Y-W, Pedicled buccal fat pad flap as areliable surgical strategy for the treatment of medication-related osteonecrosis of the jaw (MR-ONJ),Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/j.joms.2014.09.023.
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Pedicled buccal fat pad flap as a reliable surgical strategy
for the treatment of medication-related osteonecrosis of
the jaw (MR-ONJ)
Horatiu Rotaru, MD, DDS, PhD,* Min-Keun Kim, DDS,† Seong-Gon Kim, DDS, PhD, Young-Wook
Park, DDS, PhD∫
*Associate Professor, Department of Cranio-Maxillofacial Surgery, Iuliu Hatieganu University of
Medicine and Pharmacy, Cluj-Napoca, Romania
†Assistant Professor, Department of Oral and Maxillofacial Surgery, Gangneung-Wonju National
University, Gangneung, Korea
Associate Professor, Department of Oral and Maxillofacial Surgery, Gangneung-Wonju National
University, Gangneung, Korea
∫Professor, Department of Oral and Maxillofacial Surgery, Gangneung-Wonju National University,
Gangneung, Korea
Corresponding Author: Min-Keun Kim
Department of Oral and Maxillofacial Surgery, Colledge of Dentistry, Gangneung-Wonju National
University, 7 Jukhyun-gil, Gangneung 210-702, Korea
Tel: 82-33-640-2753, Fax: 82-33-640-3103, E-mail: [email protected]
Acknowledgements
This study was supported by a grant from the Next-Generation BioGreen21 Program (Center for
Nutraceutical & Pharmaceutical Materials no. PJ009013), Rural Development Administration,
Republic of Korea.
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Pedicled buccal fat pad flap as a reliable surgical strategy
for the treatment of medication-related osteonecrosis of
the jaw (MR-ONJ)
Abstract
Purpose: The purpose of this study was to evaluate the covering range of pedicled buccal fat pad
flap (PBFP) and the long-term results of this treatment in patients with medication-related
osteonecrosis of the jaw (MR-ONJ).
Patients and methods: A total of 10 patients (two men and eight women, average age 72.9 years
old) diagnosed with MR-ONJ were selected. The patients were treated with PBFP. Data from
patients regarding MR-ONJ stage, defect size, bone exposure after surgery, operation time,
admission period, duration of antibiotic therapy, recurrence of disease, and postoperative
complications were analyzed retrospectively.
Results: Six patients were diagnosed with MR-ONJ stage 2, and four patients were diagnosed with
MR-ONJ stage 3. The maximum defect in the study was 62 mm X 18 mm. Among the 10 patients,
there was only one bony exposure, which occurred on postoperative day 2 after receiving PBFP.
This exposure may have been due to an incomplete resection of the affected bone. There were no
severe donor site morbidities, and all patients demonstrated satisfactory healing status without
incident.
Conclusions: According to our evaluation, PBFP was able to effectively cover a relatively large
surgical defect. Complications were minimal, and there was no recurrence of bony exposure
during follow-up. In conclusion, PBFP was a reliable treatment option for the management of
denuded bone in MR-ONJ patients.
Key words: MR-ONJ, surgical management, pedicled buccal fat pad flap, soft tissue coverage
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Introduction
Medication-related osteonecrosis of the jaw (MR-ONJ) is a drug-related disease and has been
frequently reported in the jaw bone.1,2,3 One of the predisposing factors for MR-ONJ is a history
of surgical trauma to the jaw bone.4 Denuded necrotic bone after implant surgery or extraction of
a tooth has frequently been associated with the clinical presentation of MR-ONJ. Although
conservative treatment has been an option for MR-ONJ, painful disease states require intensive
intervention.5,6
The surgical treatment for MR-ONJ is removal of the necrotic bone and the covering bone
defect using a flap. Trials using local mucosal flaps have exhibited high failure rates due to poor
vascularity.7 Additionally, the size of the local mucosal flap is limited. Therefore, large mucosal
defects cannot be covered using local mucosal flaps. Microvascular flaps might be more reliable in
poorly vascularized regions than local mucosal flaps. Large soft tissue defects can also be covered
successfully with microvascular flaps. However, donor site morbidity and extended operation times
are disadvantages of the use of microvascular flaps.8
Fat tissue is highly vascularized. Some technical reports have found that pedicled buccal fat pad
flaps (PBFPs) can be applied many types of intraoral mucosal defects.9 Autogenous fat grafts have
been used to improve the quality of the recipient tissue.10 In addition, autogenous fat grafts can
accelerate revascularization in burn wounds.11 As MR-ONJ patients have poorly vascularized beds,
PBFPs might represent a good treatment option for covering denuded bone areas. Fat tissue also
contains stem cells.12 The stem cells in fat tissue can differentiate into many types of cell.13 Fat-
derived stem cells act as endothelial progenitor cells and promote angiogenesis.14 Indeed, patients
with small maxillary defects have been successfully treated with PBFPs.15 However, no studies on
the PBFP coverage range, associated complications, or long-term follow-up in the treatment of
MR-ONJ have been conducted.
Patients diagnosed with MR-ONJ were included in the present study. The purpose of this study
was to evaluate the PBFP covering range and the long-term consequences of using PBFPs. All
complications associated with PBFP were also recorded.
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Patients and methods
Patients
A total of 10 patients diagnosed with MR-ONJ according to the guidelines of the American
Association of Oral and Maxillofacial Surgeons (AAOMS) were selected.16 The guidelines for this
diagnosis include the presence of exposed bone in the maxillofacial region over a period of eight
weeks, a history of current or previous treatment with bisphosphonates, and no history of jaw
radiation. The patients were treated by PBFP. All operations were performed by a single surgeon.
This study was approved by the Gangneung-Wonju National University Dental Hospital IRB.
Surgical procedures
Under local anesthesia, Stensen s duct was identified using a probe to avoid potential damage
during the dissection procedure (Fig 1). The mucosal incision line isillustrated in Figure 1. This
incision could not be too close to the orifice of the parotid duct and was created considering the
passage of the parotid duct. Before PBFP grafting, the recipient site was prepared (Fig 2A). After
the mucosal incision, the muscle overlying the pedicled fat pad was transected enough to allow
the fat pad to come out spontaneously (Fig 2B). In this procedure, the dissection was performed
carefully to avoid damage to the parotid duct; thus, the authors recommend confirming the
passage of parotid duct again using the probe before beginning dissection of this area. During
the dissection procedure, the capsule overlying the buccal fat pad was preserved, and the small
vessels overlying the capsule of the buccal fat pad were preserved by careful dissection with a
blunt instrument to maintain vascular supply. This point is very important because the small
vessels provide the blood supply to the PBFP. To maintain the flaps in the appropriate positions, a
tagging suture within the pedicled fat pad was created (Fig 2C). In this procedure, the operator
should consider reducing the dead space and maintaining a vestibular depth that is not too
shallow. Because the fat pad is very fragile, 4-0 or 5-0 sutures are recommended for tagging the
fat pad. Mucosal suturing was performed just above the fat layer (Fig 2D). The primary closure of
the overlying mucosa helps to protect the fat pad, but if needed, some exposure of the fat pad
can be allowed to maintain vestibular depth (Fig 3).
Clinical Assessment
We examined the age, sex, type of medication, duration of medication, stage of MR-ONJ
(AAOMS, 2009)16, and follow-up duration. We also retrospectively evaluated the defect size,
operation time, admission period, bone exposure after surgery, duration of antibiotic therapy,
recurrence of disease, and postoperative complications.
Results
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A summary of the 10 patients is presented in Table 1. The pre- and post-operative clinical
characteristics of the selected patients are shown in Figure 3. Six patients were diagnosed as stage
2, and four patients were diagnosed as stage 3 based on the AAOMS guidelines.16 The mucosal
defect sizes varied among patients. The largest lesion in this study was 62 mm X 18 mm in Case
10 (Fig 3). The lesion in the mandible extended from the ascending ramus to the contralateral
mandibular incisor. The follow-up period was uneventful, and the lesion healed well.
Among the 10 patients, there was only one bony exposure (Case 8 in Fig 3). The patient had
MR-ONJ in the left maxilla. Two days after the initial operation, the bony exposure occurred at the
site just adjacent to the affected tooth. The remaining necrotic bone was resected immediately,
and the affected tooth was extracted. PBFP covered the surgical defect again and healed very well
without bony exposures.
All of the defects could be covered using unilateral PBFP. The average operation duration was
52.1 ± 10.4 minutes. The average admission period was 6.5± 5.2 days. The average duration of
antibiotic therapy was 26.6 ± 6.4 days. There were no severe donor site morbidities, such as
severe bleeding, ecchymosis, or parotid duct injury. The average follow-up period was 12.4 ± 5.25
months. The follow-up period was uneventful, and all patients exhibited good healing.
Discussion
MR-ONJ is a drug-induced disease that is difficult to control. When MR-ONJ is treated with
conservative therapy, it is not quickly cured.17 Therefore, patients require prolonged treatment. In
the patients in this study, the denuded bone of MR-ONJ was successfully managed using necrotic
bone removal and PBFP. Given that PBFP is a straightfoward procedure compared with those
required for other flaps, this procedure should be considered as a treatment for MR-ONJ.
Since the first report of MR-ONJ, many MR-ONJ patients have been reported. The incidence of
MR-ONJ in the Korean population is approximately 0.04% (1/2300 people).18 However, an
appropriate treatment strategy has not been established. According to the AAOMS 2009
treatment strategy, surgical management should be delayed in the early stages (stages 1 and 2) of
MR-ONJ19 because the surgical management carries some risk of aggravating the patient s
condition. Poor vascular beds in the area involved in MR-ONJ often hinder the normal healing
process. In such cases, the denuded area may even be extended following surgical intervention.20
However, conservative treatment also has some limitations. For MR-ONJ patients with pain,
conservative treatment does not resolve patient discomfort. Additionally, conservative treatment
requires too much time for complete healing and frequently results in failure to heal.17,20
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Microvascular flaps have been used for the reconstruction of soft tissue defects in MR-ONJ
patients.21,22 Reconstruction using local flaps often fails due to the poorly vascularized network of
the recipient bed.7 The disadvantages of microvascular flaps are donor site morbidity23 and poor
esthetics.24,25 The color of the skin does not match that of the oral mucosa. However, the oral
mucosa reconstructed using PBFP was well-matched with the adjacent normal oral mucosa.
Compared with the secondary healing of conservative treatment, the mucosa reconstructed with
PBFP was better esthetically (Fig 3). However, the esthetic aspect of PBFP should be demonstrated
in future comparative studies. These results might be due to the ability of PBFP to promote
wound healing. Buccal fat pads contain many stem cells.12 Stem cells from the buccal fat pad have
been widely studied.26 These stem cells may contribute to the esthetic healing of mucosal defects.
In this study, all patients were treated with surgical necrotic bone removal and PBFP to cover
the surgical defects. The results revealed that all surgical wounds were covered well with soft
tissue. There were no bony exposures after the healing period. Soft tissue sealing might be
important for the prevention of additional bone infections. Similar results have also been reported
in another study in which MR-ONJ was found to be manageable with PBFP combined with
surgical debridement.18,30 Most of the patients experienced resolution following a single operation.
One patient exhibited delayed healing after the operation. This patient received additional
marginal bone resection and then healed uneventfully (Fig 3). Remaining necrotic bone might
disturb the normal healing process. Therefore, not only soft tissue coverage by PBFP, but also the
sufficient removal of the avascular necrotic bone was important for successful treatment.28,29
The complications of PBFP were primarily transient and included tenderness and swelling of the
buccal area. Potential serious complications might include parotid gland duct injury or excessive
bleeding. However, these serious complications were not observed in this case study. Donor site
morbidity was also not observed. A limitation of PBFP might be the size of flap. In this study, the
maximum size of the denuded bone was approximately 62 mm x 18 mm (Fig 3). Therefore, most
intraoral denuded areas can be reconstructed using PBFP. As the donor site was located near the
recipient site, all operations could be performed in a single operatory field.
The anti-angiogenic effect of bisphosphonates represents a likely mechanism for MR-ONJ.30
Poor vascular supply and bacterial infection are the main causes of incomplete healing in MR-ONJ
patients.31 Therefore, improving vascularization of the surgical wound and adding sufficient soft
tissues for protecting from the bacterial infection would be critical for achieving adequate healing
following the surgical management of the MR-ONJ. PBFPs have very rich vascular networks32 to
supply sufficient blood to the surgical wound. Moreover, there are few complications or
morbidities associated with the PBFPs. Therefore, the PBFPs are reliable treatment option for the
management of denuded bone in MR-ONJ patients.
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Recently, there has been some evidence that additional drugs may be implicated in the
development of ONJ. Therefore, there has been a move proposed to call this surgical complication
drug-induced jaw osteonecrosis. The additional drugs to be aware of are denosumab and
bevacizumab.33, 34 Because the anti-angiogenic and anti-osteoclastic activities of these agents may
contribute to pathogenesis of osteonecrosis of the jaw, PBFP may also be applied to ONJ induced
by these drugs.
Conclusion
According to our evaluation, PBFP was able to effectively cover surgical defects upto a size of
62 mm X 18 mm. The duration of antibiotic therapy was shortened. Complications were minimal,
and there was no recurrence of bony exposure during follow-up. In conclusion, PBFP was a
reliable treatment option for the management of denuded bone in MR-ONJ patients.
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Figure Legends
Figure 1.Schematic of the surgical procedures. Note the identification of the parotid duct using
the probe, the tagging suture in the corner of the mucosal flap, the preserved micro-vessels and
the capsule of the pedicled buccal fat pad.
Figure 2. Surgical procedures for the pedicled buccal fat pad (PBFP) graft. (A) The surgical defect
after resection showing perforation of the anterior wall of the left maxillary sinus. (B) The pedicled
buccal fat pad was dissected. The capsule and the micro-vessels overlying the fat pad were
preserved, and the two traction sutures were applied for the appropriate surgical field. (C) The
flap was positioned at the surgical defect. (D) Mucosal sutures were performed over the PBFP.
Figure 3.Presentations of representative cases. The border of the lesion was indicated in the
preoperative radiograph (arrows).
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Table 1. Demographic data and patient information Pt. Age Sex BP
used
Route Lesion MR-
ONJ
Stage
F/U
(Mo)
Defect
size
(mm)
Op
Time
(min)
Admission
(day)
Bone
exposure
Post Op
Antibiotic
therapy(day)
Recurre
nce
Complicati
on
1 77 F PN PO Mn Post 2 17 21X14 56 4 No 21 No No
2 62 M ZN IV Mx Post 3 18 26X9 65 14 No 28 No No
3 79 F PN PO Mn Post 2 16 18X11 45 1 No 35 No No
4 75 F PN PO Mn Post 3 12 18X20 40 3 No 28 No No
5 72 M AN PO Mn Post 2 15 16X11 50 1 No 28 No No
6 78 F AN PO Mn Post 2 15 15X13 40 7 No 14 No No
7 75 F AN PO Mn Post 2 15 23X13 45 1 No 35 No No
8 57 F ZN IV Mx Post 3 8 45X16 60 14 YES 28 No No
9 81 F AN PO Mn Post 2 3 33X15 50 10 No 28 No No
10 73 F AN PO Mn 3 5 62X18 70 10 No 21 No No
Medication-Related osteonecrosis of the jaw (MR-ONJ) stage was determined according to the American Association of Oral and Maxillofacial
Surgeons BRONJ staging system, 2009.13 Abbreviations: Pt, patient; F, female; M, male; BP, bisphosphonate; PN, pamidronate; ZN, zolendronate; AN,
alendronate; PO, per os; IV, intravenous; Mn, mandible; Mx, maxilla; F/U, follow-up; Op, operation; Mo, month
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