REPAIR OF THE PERFORATED SINUS MEMBRANEWITH BUCCAL FAT PAD DURING SINUSAUGMENTATIONAli Hassani, DMD, MS; Arash Khojasteh, DMD; Marzieh Alikhasi, DDS, MS

Several reports demonstrate successful use of the buccal fat pad (BFP) as pedicled graft in

reconstructing small to medium sized maxillary defects. BFP harvesting has so far been shown to be

an easy, well-tolerated, and uncomplicated technique for oral reconstruction. This case report

proposes the use of BFP for repairing of the perforated sinus membrane during sinus augmentation.

Key Words: sinus augmentation, Schneiderian membrane, graft

INTRODUCTION

Loss of maxillary molar teeth leads to rapidloss of bone in the alveolus and increasesthe size of the maxillary sinus. Bone losscan extend to the alveolar process, leavingonly a thin wall of bone between themaxillary sinus and the oral cavity.1 Aug-

mentation of the maxillary sinus floor is a well-documented technique and is generally accepted asan implantology procedure to facilitate placement ofdental implants in the posterior atrophic maxilla. Theclassic procedure for maxillary sinus floor augmenta-tion entails preparation of a trap door including theSchneiderian membrane in the lateral sinus wall.2

Pikos3 reported that perforation of the Schneiderianmembrane is the most common complication thatoccurs during the sinus elevation augmentation. Itsprevalence is between 20% and 60%.3 Perforation ofthe Schneiderian membrane is most likely to happen

at sharp angle and ridge lines, septa, and spines.3–5 Itcan also happen when the membrane is beingelevated off the inferior and anterior bony aspect ofthe sinus and can occur due to irregularities of thesinus floor.4,6,7 Previous sinus surgery, which oftenresults in a tissue scar, and absence of alveolar boneare also possible risk factors.4 Many methods havebeen advocated for treatment of perforation of theSchneiderian membrane during the sinus floor eleva-tion and augmentation.3,8–11

A pedicled graft of the buccal fat pad (BFP), whichenables the closure of oral defects even up to an areaof 60 3 50 mm12 and a thickness of 6 mm,13 has oftenbeen used for the reconstructions of intraoral de-fects.12–17 The BFP is an encapsulated, rounded,biconvex fatty structure located between the bucci-nator medially and the anterior margin of the massetermuscle and the mandibular ramus and zygomatic archlaterally.18 Recently, Stajcic17 reported the successfuluse of the BFP for the closure of an oro-antral fistula in56 cases. Wong19 found that by using the BFP foradditional and immediate blood and nutrition supplyand protection of the graft, the quality of bone couldbe improved for other parts as well.19 Adult subcuta-neous fat tissue is an abundant source of multipotentcells. Recently, several publications have reported thatadipose tissue contains a population of cells able todifferentiate into different cell types, including adipo-cytes, osteoblasts, myoblasts, and chondroblasts.20

Previous studies have shown that adipose-derivedadult stem cells express bone marker proteins,

Ali Hassani, DMD, MS, is an assistant professor in the Departmentof Oral and Maxillofacial Surgery, Azad University of MedicalSciences, Tehran, Iran.Arash Khojasteh, DMD, is chief resident, Department of Oral andMaxillofacial Surgery, Taleghani Hospital, Beheshti University ofMedical Sciences, Tehran, Iran.Marzieh Alikhasi, DDS, MS, is assistant professor, Department ofFixed Prosthodontics, School of Dentistry, Medical Sciences/University of Tehran, Tehran, Iran. Address correspondence to DrAlikhasi at Department of Fixed Prosthodontics, School ofDentistry, Medical Sciences/University of Tehran, Ghods St,Enghelab St, Tehran, Iran. (e-mail: m_alikhasi@yahoo.com)

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CLINICAL

including alkaline phosphatase, type I collagen,osteopontin, and osteocalcin, and produce a mineral-ized matrix as shown by alizarin red staining.21 Byplacing the BFP between fast-growing fibrous tissueand the defect itself, slow-growing osseoprogenitorcells can migrate into the bone defect and lead to thereossification of this area.22

Large perforations represented in the literature anabsolute contraindication to continuation of thesurgery, especially if the graft material is in granulesor chips. The presence of foreign bodies that are freeto move inside in the sinus appears to create thesituation for initial pathologies of the mucosa.9

This article reports the use of a pedicled BFP graft forclosing a large perforated sinus membrane at the sametime as sinus augmentation with bone graft material.

CLINICAL CASE

A 49-year-old man was referred to a prosthodontistwith a complaint of discomfort with missing teeth. Theposterior portions of maxilla were edentulous andlacked sufficient bone for implant placement withoutsinus augmentation. The alveolar height in theposterior maxillary area was less than 3 mm (Figure1). Oral examinations showed that his oral hygiene wasappropriate, with no lesions noted. His past medicalhistory included no remarkable disease. Because thepatient strongly wished to have fixed prosthesis,placement of osseointegrated implants after sinusaugmentation was planned. Patients did not displaysigns and symptoms of sinus or intraoral diseases.

Local anesthesia was performed with lidocainehydrochloride (Ecocain 2%, Molteni Dental, Scandicci,Italy) with 1:50 000 epinephrine.

Vertical incisions were extended to the anterior andposterior vestibule. The trapezoidal buccal mucoperios-teal flap was then reflected from the alveolar processand the lateral wall of the maxilla. The lateral wall ofmaxillary sinus was fenestrated with a round diamondbar with saline solution irrigation to mark the limits of arectangular area (15 3 10 mm), and a door in the lateralwall was prepared. The Schneiderian membrane wasfreed and separated from the lateral wall of the sinususing blunt instruments. Although care was taken topreserve the mucosal lining, the sinus membrane wastorn. The BFP was exposed by a 2-cm, horizontalperiosteal incision lateral to the maxillary butressextending backwards above the maxillary second molartooth. Blunt dissection through the buccinator andloose surrounding fascia allowed the BFP to herniateinto the mouth. The body of the BFP and the buccalextension were gently mobilized by blunt dissection,taking care not to disrupt the delicate capsule andvascular plexus and to preserve as wide a base aspossible. Pressure on the cheek helped to express the fatinto the mouth (Figure 2). After the pad had beendissected free from the surrounding tissues, it wasgrasped with vascular forceps, gently teased out,advanced, and expanded over the defects. A hole wascreated with a fissure bur (702) through the window intothe maxillary bone transsinusally. An 18-gauge needlepassed through the bur hole, and the penetration site inthe palatal mucosa was marked. Then a suture needlewas passed through the palatal mucosa and graspedwith forceps when it appeared in the elevated sinus, andthe BFP was pulled to the sinus floor. Then the needlepassed through the palatal bone through the osteoto-my site, and the suture was folded in the palatal gingiva(Figure 3). BFP covered the remaining part of theSchneiderian membrane and acted as a barrier betweenthe sinus antrum and the site of graft materialplacement. A 2:1 mixture of autogenous bone andbovine xenograft (Bio-Oss, Geistlich Pharm AG, Wolhau-sen, Switzerland) was used as the graft material, and thesinus was then filled with graft mixture (Figure 4). Themucoperiosteal flap was repositioned and sutured(Figure 5). No surgical splint or dressings were used.

Postoperative antibiotic (amoxicillin, 1.5 gm for 10days) and mouthwash (chlorhexidrine digluconate,0.2% for 6 weeks) were administered. Postoperatively,the decrease of the depth of the vestibular sulcusgradually improved and was restored almost to thepreoperative form about 2 months after the operation.The patient was followed for 4 months after augmen-tation (Figure 6). After that, posterior maxillary alveolarbone was enough for implant placement.

FIGURE 1. Panoramic view of enlarged right sinus.

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DISCUSSION

Anatomically, the BFP consists of a central body and 4extended processes. It possesses favorable character-istics for the reconstruction of intraoral defects,especially in the posterior maxillary region. The blood

supply to the BFP is derived from the buccal and deeptemporal branches of the maxillary artery, the trans-verse facial branch of the superficial temporal artery,and from some small branches of the facial artery.14

This rich blood supply of the pedicled BFP suggestedthat it could provide critical vascular support to themucus membrane covering and to the bone graftscompared to the bioresorbable membranes, whichpromote both calcified and soft-tissue healing.18

This flap is easy to prepare, modify, and relocate,demonstrates a strong ability to resist infection, can beassociated with other pedicled flaps, has a minimalincidence of failure when properly performed, com-pletes its epithelialization in a few weeks, needs nomicrovascular anastomosis, will not lead to perceiv-able deformity in the donor site (cheek), and causesminimal discomfort for patients.15,16

The limitations of BFP pedicled flap should not beoverlooked. This flap can only cover a soft-tissuedefect of limited area. Reduction in oral opening,partial necrosis, infection, excessive scarring, and

FIGURES 5 AND 6. FIGURE 5. Schematic presentation of the closingperforated Schneiderian membrane. FIGURE 6. Close radiographicview of augmented sinus after 4 months.

FIGURES 2–4. FIGURE 2. Perforation of the Schneiderian membrane andreleasing buccal fat pad. FIGURE 3. Rotation of pedicled buccal fatpad and use of it as a replacement for perforated Schneiderianmembrane. FIGURE 4. Placement of bone graft material under thebuccal fat pad to augment the sinus.

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sulcus obliteration might also be some complications.Since the size of the defect in sinus augmentation isnot that large and its location is near the donor site,these problems are of little importance and were notseen in this case. As the cost is less than the traditionaluse of resorbable membranes, further studies could bedesigned to compare the effect of the BFP withcollagen membranes.

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