Buccal Defects Research Articles

Reconstruction of the buccal mucosa following release for submucous fibrosis using two radial forearm flaps from a single donor site

Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and can severely limit mouth opening. The use of bilateral forearm flaps to fill buccal defects following trismus release has proven to be effective and reliable. However, it requires the sacrifice of radial arteries from both forearms. We have developed a technique that allows for the harvest of two independent flaps from a single forearm donor site. Two separate flaps are designed on the same radial artery and concomitant vein pedicle. The distal flap is marked in the standard fashion and the proximal skin paddle is designed in the middle third of the forearm, based on septocutaneous branches of the radial artery. The two flaps are elevated and subsequently divided into two independent free flaps. Between June 2004 and June 2007, a total of 16 flaps were harvested from eight donor sites for buccal mucosa defects following trismus release. Improvements in mouth opening and buccal pliancy were evaluated by comparing preoperative and postoperative inter-incisal distance (IID) and maximal mouth capacity. All flaps survived completely, and all donor sites were closed primarily, except for one. The mean flap size was 6.6x2.6cm (range: 6x2.5cm-7x3cm), mean pedicle length was 5.7cm, mean ischaemia time was 46min and mean total operating time was 8h 45min. At an average of 19.8 months follow-up, the inter-incisal distance averaged 29.13mm, an increase of 20.88mm compared with the preoperative measurement. The maximal mouth capacity averaged 55.63cc, an increase of 9.38cc compared with the preoperative measurement. Two independent small flaps can be harvested safely from one radial forearm donor site. This approach is a useful option for reconstruction of bilateral buccal defects, particularly following submucous fibrosis release. The donor-site morbidity is minimal and limited to one forearm.

Two small flaps from one anterolateral thigh donor site for bilateral buccal mucosa reconstruction after release of submucous fibrosis and/or contracture

Oral submucous fibrosis causes health-related and social problems for affected patients. Free flap reconstruction has proved effective for maintaining mouth opening after release of fibrosis. Two independent free flaps from separate donor sites, such as bilateral forearm flaps or bilateral anterolateral thigh (ALT) flaps, were traditionally required for reconstruction. The former option sacrifices one of the two major arteries in the forearm. Both options are time consuming and required two donor sites. To eliminate these disadvantages, we developed a technical modification that allows harvesting of two independent flaps from one ALT thigh based on one descending branch of the lateral circumflex femoral artery (d-LCFA). Eighteen flaps from nine donor sites were harvested for post-release reconstruction of oral submucous fibrosis. Mean flap size was 4.1 x 7.5 cm, mean pedicle length was 7.6 cm, mean ischaemia time was 104 min and mean total operation time was 13 h and 19 min. All donor sites were closed primarily, with one exception. One flap failed and was replaced with a contralateral ALT flap. One patient developed a wound infection and another developed a seroma at the recipient site. Four flaps required secondary de-bulking in three patients. The improvement in mouth opening was evaluated by inter-incisor distance (IID): mean preoperative IID was 9.6mm (range: 0-20mm), mean follow-up time was 16.2 months (range: 10-33 months); mean postoperative IID was 23.8mm and mean improvement in IID was 15.3mm (range: 10-27 mm). In conclusion, two independent flaps can be harvested from d-LCFA of the same thigh, instead of from both thighs, to reconstruct bilateral buccal defects after release of submucous fibrosis and/or contracture.

Micro‐CT analysis of alveolar bone healing using a rat experimental model of critical‐size defects

This study was designed to establish a rat model of a critical size alveolar bone defect. Standardized buccal or mesiobuccal alveolar bone defects were made around the right first mandibular molar of 12-week-old rats, and the left was used as a control. Alveolar bone healing was examined quantitatively by three-dimensional micro-computed tomographic imaging. Bone matrix production of osteoblasts and osteocytes during repair of alveolar bone defects was examined with in situ hybridization for type I collagen. Buccal defects were repaired significantly and the volume decreased by 88.3% in week 24, whereas mesiobuccal defects were repaired little. Osteoblasts and osteocytes expressed type I collagen in both defects in week 3 but showed little expression by week 6 and thereafter, leaving the mesiobuccal defects largely unrepaired. The mesiobuccal defect is a critical-size defect that is not ultimately repaired with bone. It may be an appropriate experimental model for investigating the effectiveness of bone regenerative agents in human alveolar bone loss.

Comparison of anterolateral thigh flap and forearm flap in repair of head and neck defects

Objective To report the clinical results and the advantages/disadvantages of anterolateral thigh flap (ALT) and forearm flap (FAF) in reconstruction of head and neck defect after cancer ablation. Methods 20 FAFs and 12 ALTs were performed to repair the head and neck tumor ablation defects. Of the 20 FAFs, 7 were used for repair of the through and through buccal defects, 4 for circumferential bypopharyngeal defects, 2 for plate defects, 1 for parotid area skin defect, 4 for floor of the mouth defects, and 2 for defect, of the base of the tongue, while of the 12 ALTs, 3 were used for repair of the defects of the base of the tongue, 4 for plate defects, and 5 for the floor of the mouth and/or lower gum defects. Survival of the flaps, function of the recipient site, and impact to the donor site were compared between these two groups to analyze the advantages/disadvantsges and key technique details of these two flaps. Results 19 FAFs totally survived. Vascular crisis occurred in 2 cases of FAF, of which 1 flap survived after conservative treatment, while the other 1 developed partial necrosis. All the 12 ALTs survived, without vascular crisis. 2 of the 14 planed ALTs were abandoned and replaced by FAFs, of which 1 because of absence of the perforating branch and the other 1 because of injury of the perforating branch. Secondary defects of the ALTs could be closed primarily, while secondary defects of the FAFs should be closed with skin grafts. Conlusion Both ALT and FAF can be performed with high survival rate. Each has its own advantages. Selection of the donor site deponds on situation of the defect and purpose of the reconstruction. Key words: Head and Neck; Anterolateral thigh flap; Forearm flap; Transplantation; Microsurgery

Placement of Two‐Part Implants in Sites With Different Buccal and Lingual Bone Heights

Recipient sites for implants often exhibit a vertical discrepancy between the buccal and lingual bone crest. The potential to preserve the lingual bone when placing the implant within the dimension determined by the buccal bone in such sites remains to be evaluated. Five dogs were included in this study. The premolars were extracted on one side of the mandible, and a buccal defect was prepared by the resection of a 2-mm-high portion of the buccal bone wall. Three months later, two test (surface modification on the shoulder part of the implant) and two control implants were placed within the area of the buccal bone defect. Following placement, the implant margin at the buccal side coincided with the buccal bone crest, whereas the implant margin at the lingual side was in a subcrestal position. Regular abutments with a turned surface were connected to the control implants, whereas experimental abutments with a modified surface were connected to the test implants. A plaque-control program was initiated. Four months later, biopsies were obtained and prepared for histologic analysis. The marginal bone level was located at a more coronal position at the lingual aspect than at the buccal aspect of the test implants, whereas the buccal and lingual bone levels were similar at control implants. It is suggested that different marginal bone levels are obtainable at the lingual and buccal aspects when two-part implants with suitable surface characteristics are placed in sites with different buccal and lingual bone heights.

上顎および頬部皮膚欠損に対して磁性アタッチメントを利用した顎補綴症例

症例の概要：73歳の男性で，審美，発音および咀嚼機能障害を主訴に右側上顎および頬部皮膚欠損に対する補綴装置の再製を希望し来院した．そこで，磁性アタッチメントを用いた上顎補綴装置を製作し，オブチュレーターとエピテーゼの結合にも磁性アタッチメントを用いた．考察：上顎前歯部の歯軸傾斜を変更することで口唇閉鎖が可能となったこと，咽頭部後縁封鎖が可能となったこと，補綴装置の維持力が向上したことにより，審美，発音および咀嚼機能が改善されたと考えられる．結論：上顎および皮膚欠損を有する症例に磁性アタッチメントを応用することで補綴装置の維持力が増強し，非常に有用であることがわかった．

The effect of non-resorbable barrier membrane on the change of buccal and lingual alveolar bone in immediate implant placement into periapically infected extraction sockets

Purpose: Many researches showed loss of alveolar bone in fresh extraction socket and even in case of immediate implant placement. The aim of this study was to evaluate the effect of non-resorbable barrier membrane on the change of buccal and lingual alveolar bone in immediate implant placement into periapically infected extraction sockets. Materials and methods: Immediate implants were placed into artificially induced periapical lesion of mandibular premolars after complete debridement using buccal bone defect made by a 6mm trephine bur in 4 mongrel dogs. Before flap repositioning, a non-resorbable barrier membrane was placed on the buccal defect in the experimental group. No membrane was placed in the control group. In 12 weeks after placement, the dogs were sacrificed and undecalcified histologic specimens were prepared. The vertical distance from the smooth-rough surface interface(SRI) to gingiva, 1st bone contact and bone crest were measured in buccal and lingual side. The horizontal thicknesses of gingiva and bone at 0, 1, 2 and 3 mm below SRI were measured. Results: The buccal bone was resorbed more than lingual bone in both groups and there was statistical significance(p<0.05). The distances from SRI to 1st bone contact were 2.45±2.35 mm in experimental group and 4.49±3.10 mm in control group. In all vertical level, lingual bone was thicker than buccal bone(p<0.05). Conclusion: Buccal bone was reduced more than lingual bone in immediate implant placement into periapically infected extraction sockets. Placement of non-resorbable barrier membrane reduced the buccal bone resorption. However there was no statistical significance. (J Korean Acad Periodontol 2009;39:71-76)

Osteo-Odonto-Keratoprosthesis in Japan

Osteo-odonto-keratoprosthesis (OOKP) is a keratoprosthesis technique in which the patient's own tooth root is used to support an optical cylinder. It was invented by Strampelli in 1963 and modified and established by Falcinelli about 10 years later. This method is particularly useful for restoring sight in end-stage Stevens-Johnson syndrome (SJS) and ocular cicatricial pemphigoid (OCP). We started performing OOKP surgery in June 2003 supported by Dr Christopher Liu of Sussex Eye Hospital, Brighton, UK. Till now, we have performed 4 OOKP surgeries for end-stage SJS and OCP. We modified the original method by using artificial buccal mucous membranes to the bone and buccal mucous membrane defects for better wound healing. Case 1 was a 49-year-old woman (SJS), and the corrected visual acuity was 0.5 in 4 years 8 months. Case 2 was a 68-year-old woman (SJS), and the corrected visual acuity was 0.04 in 3 years 10 months. Case 3 was a 63-year-old man (SJS), and the corrected visual acuity was 0.1 in 3 years 2 months. Case 4 was a 71-year-old woman (OCP), and the corrected visual acuity was 0.04 in 1 year 3 months. Despite some minor optical cylinder troubles such as MRSA colonization, tilting, and buccal mucous coverage, their visual acuities were stable without any serious complications. It was demonstrated that OOKP is useful for visual rehabilitation and durable with minimum eye care for severe ocular surface diseases.

Vaginal and Labial Grafting to the Oral Cavity: A Review of 7 Cases

In Brief Objective: Grafting materials for the repairs of oral mucosal and urethral defects have been the subjects of extensive research. Methods: A series of 7 patients is presented in which oral mucosal defects were corrected using grafts from vaginal and labia minora epithelium. Six patients had undergone previous grafting procedures. The details of the donor site retrieval are described. Patients were evaluated postoperatively for donor site morbidity and success of the grafting procedure. Results: In this series of patients, epithelium from the vagina and the labia minora proved to be excellent tissue for grafting of oral mucosal defects. All patients had greater than 85% take of their grafts. Conclusions: According to the findings in this series, vaginal epithelium appears to offer an ideal grafting material to repair mucosal defects in the oral cavity. These findings coincide with reports of successful grafting of buccal mucosa to urogenital epithelium. Vaginal epithelium is hypothesized to be a suitable graft tissue for buccal defects.

Anterolateral Thigh Flap Reconstruction of Full Thickness Buccal Defect

Objective: To present our experience with the anterolateral thigh flap in reconstructing a full thickness defect of the buccal mucosa and cheek.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Private Hospital&#x0D; Patient: One&#x0D; Results: A 36 year old male with a T4aN0M0 Stage IVa buccal carcinoma on the left underwent wide excision, marginal mandibulectomy and modified radical neck dissection with preservation of the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle. The resultant through-and-through defect of the cheek skin measuring 8 x 6cm and buccal mucosa measuring 6 x 10 cm with a concomitant ¼ upper lip and 1/3 lower lip defect was reconstructed with an anterolateral thigh free flap. The patient recovered uneventfully and underwent adjuvant concurrent chemoradiotherapy 1 month post-operation. At 2 ½ months post-operation, he had no oral incontinence and could resume a normal diet with good speech.&#x0D; Conclusion: The anterolateral thigh free flap is an excellent soft-tissue flap for reconstruction of a full thickness defect of the buccal area.&#x0D; Key words: Surgical flap, Carcinoma, squamous cell, Oral cancer

P019: Anterior Lateral Thigh Flap for Buccal Mucosal Defect

P019: Anterior Lateral Thigh Flap for Buccal Mucosal Defect

Bipaddled radial forearm flap for the reconstruction of bilateral buccal defects in oral submucous fibrosis

Oral submucous fibrosis can result in progressive closure of the mouth. A total of 10 patients with advanced oral submucous fibrosis were surgically treated. The procedure consisted of (1) release of all the intraoral fibrotic tissue, (2) masticatory muscle myotomy and coronoidotomy, and (3) reconstruction with a bipaddled radial forearm flap. Preoperative mouth opening was 0–5 mm (mean 2.3 mm). The intraoperative mouth opening was 12–20 mm (mean 16 mm) after submucous release, and 32–42 mm (mean 35.5 mm) after further release via myotomy and coronoidotomy. The proximal flap included one perforator in four patients and two perforators in the remaining six patients. The flaps were 8–9 cm in length and 2–2.5 cm in width. Nine flaps survived uneventfully. Arterial thrombosis was noted in one flap, which was successfully salvaged. Temporomandibular joint subluxation developed in one patient. Two patients needed flap revision due to bulkiness. The postoperative mouth opening was 18–38 mm (mean 28.2 mm) after a mean of 21 months’ follow-up, and the mean increase was 25.9 mm. A bipaddled radial forearm flap, using a single donor site, can cover two separate buccal defects after release of oral submucosal fibrosis and obviate the need for a second free flap.

Esthetic Buccal Flap for Correction of Buccal Fenestration Defects During Flapless Immediate Implant Surgery

Esthetic Buccal Flap for Correction of Buccal Fenestration Defects During Flapless Immediate Implant Surgery

Radical Surgical Resection of Locally Invasive Oro‐Cutaneous Tumors in the Buccal Region of 2 Horses

To report treatment and wound healing after radical surgical mass excision in the equine buccal region. Clinical case reports. An 11-year-old Warmblood gelding and a 9-year-old Norwegian Trotter gelding. Large tumoral masses were removed from the buccal region by radical electrosurgery, creating large defects into the oral cavity. Wound ultimately healed by second intention. Buccal defects in both horses healed well by second intention without tumor recurrence. Locally invasive tumors involving the cheek region of the horse can be successfully treated by radical electroexcision alone, creating transmural defects up to 14 cm length x 8 cm height. Large transmural defects in the cheek region of the horse, formed by radical surgery can heal satisfactorily by second intention healing without undue discomfort to the patient or major complications.

Posterior Tibial Artery Flap in Poliomyelitis Patients with Lower Extremity Paralysis

Poliomyelitis is a disease that can render affected individuals incapacitated to a variable degree. A normal lifespan is expected and therefore the patients deserve every effort at curative cancer resection and reconstruction. Those with lower extremity paralysis rely heavily on their upper limbs and torso for ambulation; therefore, their compromised limbs may be a better donor site for flaps. All poliomyelitis patients with lower extremity paralysis over a 20-month period who underwent head and neck reconstruction were selected for a retrospective review. Perioperative complications were noted and outpatient follow-up was performed. Three patients underwent reconstruction of defects using the posterior tibial artery flap. Two patients required reconstruction of a buccal defect and one patient required soft palate reconstruction. All patients healed without complications and none required reexploration. At a mean follow-up of 10 months, there was no incidence of donor limb vascular compromise, cold intolerance, or long-term paresthesias. The posterior tibial artery free flap has been used successfully in the past; however, its popularity has been limited because of sacrifice of the posterior tibial artery. Nevertheless, in patients with lower extremity paralysis, this flap may fulfill the requirements of a thin, pliable flap with minimal hair that has a long pedicle and a reliable blood supply. Most importantly, the use of this flap obviates the need to use flaps that fulfill the same requirement, such as forearm flaps, that would be taken from patients' functioning limbs.

Repair of buccal defects with anterolateral thigh flaps

The ideal reconstructive method for the buccal mucosa should provide durable, stable coverage and a natural contour, while simultaneously minimizing morbidity of both the defect and donor sites. Since the first report of the anterolateral thigh flap in 1984, it has become one of the most commonly used flaps for the reconstruction of various soft-tissue defects. From March 2004-April 2005, 24 free anterolateral thigh flaps were used to reconstruct buccal defects, including the retromolar trigone and as far as the oral commissure, and in some cases with extension to the neighboring palatal region and tongue. The study comprised 1 female and 23 male patients, with ages ranging from 26-63 years (mean age, 45.8 years). Two flaps required reoperation due to vascular compromise, and both were salvaged with arterial and venous anastomosis revisions, giving an overall success rate of 100%. Primary thinning of the flap was performed in 10 cases. In 2 cases, additional vastus lateralis muscle was included in the flap to fill the large defect. In 2 cases, marginal necrosis with dehiscence of the flap was observed, one of these patients having a history of atherosclerosis and diabetes mellitus (marginal skin necrosis and infection of the donor area were also observed in this patient). In 2 patients, seroma collection was observed in the neck at the dissection site. Chart reviews showed that most patients had a history of betel-nut chewing (95.8%) or a combination of smoking and betel-nut chewing (79.2%). During the follow-up period of 4-12 months, a sufficient level of mouth-opening with interincisal distances of 34 mm, 44 mm, and 48 mm was achieved in all 3 cases reconstructed after release of the trismus. Although it has some variations in the vascular pedicle, irregularity in derivation from the main vessels, and minimal morbidity of the donor site, the anterolateral thigh flap, with its evident functional, structural, and cosmetic advantages, can be considered an excellent and ideal flap option, and a first choice for most buccal defects.

Mucogingival Pouch Flap for Sandwich Bone Augmentation: Technique and Rationale

This article introduces a novel flap design, mucogingival pouch flap (MPF), to enhance the clinical outcome of sandwich bone augmentation. MPF uses a pouch flap reflection via mucogingival junction extension incisions to provide an improved graft retention, minimized membrane exposure, preserved papilla dimension, and soft tissue camouflage for improved esthetics. There are 4 implant-associated buccal dehiscence defects in 3 patients treated with sandwich bone augmentation technique in conjunction with MPF. All cases yielded an adequate new bone thickness of 1.5-3.5 mm as well as a height of 84% to 100% at 6 months. Rationales, indications, contraindications, advantages, and disadvantages for MPF designs are further discussed.

Immediate repairing of buccal defect by platysma musculotaneous flap

目的 探讨颈阔肌肌皮瓣即刻整复颊癌术后颊部缺损的临床效果.方法采用以颌外动脉作为供血的颈阔肌肌皮瓣修复颊癌术后颊部缺损8例.结果应用以颌外动脉为供血的颈阔肌肌皮瓣即刻整复颊癌术后颊部缺损8例全部成功,获得满意效果.结论以颌外动脉为供血的颈阔肌肌皮瓣有操作简便、创伤小、成活率高等优点,是颊癌术后颊部缺损修复的一种有效方法。

Therapy of bony and fibrous contractures and buccal defects after noma using the temporalis muscle flap

A prospective pilot study was conducted on 12 patients to establish whether, under the difficult conditions prevailing in a developing country, the temporalis muscle flap is suitable as a safe and single-stage procedure for the repair of buccal defects combined with fibrous or osseous contractures of the temporomandibular joint. The surgical procedures were performed from 1998 to 2000 in the Hôpital National du Niamey (Republic of Niger). Primary healing was achieved with all grafts. Local clinical and radiological follow-up (in Niger) was performed on seven patients after 12 and 24 months. Mouth opening of at least 1.5 cm was achieved in all cases, although there was virtually no use of physiotherapy to prevent scar contracture. By contrast with expensive and surgically more complex reconstructions, our use of this procedure shows that even where medical conditions are less than ideal, a satisfactory functional and cosmetic result can be achieved in the long-term.

Measurements of Soft Tissue Volume in Association with Single‐Implant Restorations: A 1‐Year Comparative Study after Abutment Connection Surgery

Patients with buccal defects due to tooth extraction seem to regain some of the contour at the time of abutment surgery and connection of single-implant crown restorations. It can then be assumed that different abutment systems could restore the buccal contour to different degrees. To measure changes in buccal tissue volume after placing restorations with single-implant crowns using two different abutment systems and to measure soft tissue change during the 1 year after single-implant treatment. Eighteen patients were provided with single-implant restorations in the central incisor area. Nine patients in each group were treated with single-implant crowns supported by either CeraOne abutments (Nobel Biocare AB, Göteborg, Sweden) or customized Procera ceramic abutments (Nobel Biocare AB). Study casts were made before abutment connection, at crown placement, and after 1 year. After the casts were scanned, they were analyzed with a computer, using the model before abutment as a reference. In the area of the single implant, sagittal projections provided images of the models that allowed measurements between the contours at the different situations. Radiography and photography for measuring papillary volume were also performed. All patients exhibited increased "buccal volume" after abutment connection and crown placement (p < .01). A trend to greater increase was observed for the Procera group. Both groups also showed a reduction of buccal tissue 1 year later (p < .05-.01), leaving on average more volume in the Procera group. The papillae recovered spontaneously, and no relationship was observed between the presence of papilla and underlying bone support (p > .05). The buccal tissue increased significantly after placement of the abutment cylinder and the implant crown. This increase of buccal contour was reduced after 1 year. Furthermore, no relationship was established between the presence of papillae and the distance between the contact point and the underlying bone crest.