Root coverage with buccal fat pad placed on restored cervical abrasion: Case report with three-year follow-up.

A patient was reported with Class II gingival recession (GR) of 5 mm. After restoring abrasion with glass ionomer cement, a full-thickness flap was raised and using blunt dissection through the buccinator and loose surrounding fascia buccal fat pad (BFP) was exposed into the mouth. It was easily spread over the maxillary roots of 14, 15, and 16. It was secured and immobilized using sutures. Postoperatively, the patient did not report swelling or trismus. At 3-year postoperative, gingival margin was at cementoenamel junction, stable and healthy and did not show any recession. Thus, it can be concluded that BFP for covering GR is an excellent technique. It is simple surgical procedure with easy handling of the flap. It provides excellent color and texture match and can also be considered as an excellent procedure for increasing the width of attached gingiva.

INTRODUCTION

Gingival recession (GR) is one of the most common defects of gingiva causing unesthetic facial appearance and can be defined as the displacement of the marginal gingival tissue apical to the cementoenamel junction with exposure of the root surface to the oral environment.[1] It is multifactorial which can be due to anatomic factors such as high frenal attachments or muscle pull, malpositioned teeth, bone dehiscence, orthodontic tooth movement, or direct trauma associated with malocclusion. Physiologic recession (aging) or pathologic factors are associated with periodontal pathology or smoking.[234] GR increases with age and is more commonly seen in people with low socioeconomic status or in persons with aggressive brushing habits. Gorman [5] suggested that the most common causes of GR are tooth malalignment and toothbrushing.

The mechanism of GR is still unclear; however, the presence of inflammation and tissue destruction causing apical migration of the soft tissue along with bone resorption can be considered as the most likely explanation.[1] Thus, GR may be a part of one of the stages of the disease or a part of the healing phase as a result of tightening of the gingival cuff and formation of the long junctional epithelium.[1] The main problem that it causes is sensitivity and poor esthetics.[6] Other problems such as root caries, cervical, or root abrasions may also occur.[6] Thus, to restore function and esthetics, root coverage procedures should be performed. Root coverage is the most challenging esthetic procedure. Takei and Azzi [7] and Takei et al.[8] stated that the prognosis for Miller Classes I and II [9] is good to excellent, whereas only partial coverage can be expected for Class III, and Class IV has a very poor prognosis with current techniques.

There are many techniques available such as the use of lateral pedicle graft, connective tissue graft, free gingival graft, coronally advanced graft, and semilunar coronally advanced flap; all are used with varying degree of success. Even today, after many innovative surgical procedures and evolution of techniques, 100% root coverage may not be achieved. Thus, there is always a need to search a surgical procedure which can ensure and maintain stable root coverage. The use of buccal fat pad (BFP) for root coverage is one such technique, however, the coverage depends on the defect, nonetheless this technique is useful in increasing the width if the connective tissue and maintains the level of the recession covered. The BFP was first mentioned by Heister in 1732[10] and described by Bichat in 1802.[11] Scammon [12] was the first to describe its anatomy. In short, it can be described as adipose tissue extending posteriorly for 2 cm through the mucosa and the fibers of the buccinator muscle and has specialized type of fat termed as syssarcosis, which enhances intermuscular motion.[1213] It is not subjected to lipid metabolism and maintains its volume and structure over a long period of time.[131415]

It rests on the periosteum that covers the posterior aspect of the maxilla and is bounded by buccinator muscle medially, masseter muscle and mandibular ramus laterally, and the lateral pterygoid muscle superiorly.[1216] It consists of a main body and four extensions,[16] buccal, pterygoid, superficial, and temporal extensions.[17] Its buccal extension is the most superficial and constitutes about 55%–70% of total weight,[16] enters the cheek below the parotid duct, and is also partially responsible for cheek contour. The pterygoid extension lies posteriorly into pterygopalatine fossa and inferior orbital fissure.[16] The temporal extension passes upward, below the zygomatic arch and comprises two parts, deep and superficial portions.[16] The deep part lies directly on the temporalis muscle and its tendon, separating the muscle from the zygomatic and frontal process of the zygoma and turns backward arch and it extends behind the lateral orbital wall into the infratemporal space.[16] The superficial part of the temporal process of the BFP stays between the deep temporal fascia, temporalis muscle, and tendon.[16]

The rich blood supply from the buccal and deep temporal branches of the maxillary artery, the superficial temporal artery (transverse facial artery), and a small branch of the facial artery,[16] explains quick epithelialization and high success rate of this flap.[1718] The average volume of the fat is 9.6 ml (range 8.33–11.9 ml)[19] with 6.29 mm as mean thickness and an approximate weight of 9.3 g.[20] Unlike subcutaneous fat, the BFP has its own system of lipolysis, and thus, even in cases of extreme weight loss or gain, it changes little in terms of size and volume.[2122]

CASE REPORT

A 32-year-old male patient reported at the dental office with a chief complaint of receding gums and visibility of root portion of teeth with generalized sensitivity to hot and cold food stuff. The patient was healthy with no systemic disease and no adverse habit such as smoking. The patient had Class II recession with cervical abrasions in relation to (irt) 14.15 and 16 and Grade II furcation irt 16. Recession irt 14 and 15 was 5 mm, and irt 16, it was 7 mm, there were no pockets, all the measurements were done with UNC 15 probe. After 1 month of completion of phase I therapy, abrasion was filled with glass ionomer cement irt 14.15 and 16. The use of the pedicled buccal fat pad flap was planned to cover the recession and augment the final width of the keratinized mucosa coronal to recession.

Before starting with the surgical procedure, surgical area was anesthetized, glass ionomer cement (GIC) restoration was planed [Figure 1], and a full-thickness flap was raised [Figure 2a]. There are three approaches to harvest BFP. A horizontal incision through the mucosa on the buccal aspect of the vestibule in the molar region will readily expose the BFP [Figure 2b]; second approach is to give a vertical mucosal incision slightly lateral to the anterior margin of the ascending ramus, this will result in a forward bulging of the fat pad [Figure 2c]; a third approach to the fat pad is elevation of a mucoperiosteal flap in the molar region on the lateral aspect of the maxillary alveolar process and then a horizontal incision of the periosteum at the level of the buccal sulcus [Figure 2d].[23] The choice of exposure depends on the requirements of the specific situation in which the flap is used. For this clinical procedure, third approach was used. Using blunt dissection through the buccinator and loose surrounding fascia, BFP was exposed into the mouth. The body of the BFP and the buccal extension were gently mobilized by blunt dissection, taking care not to disrupt the delicate capsule and vascular plexus and to preserve as wide a base as possible [Figure 3]. BFP was easily spread over the maxillary roots of 14, 15, and 16, 1–2 mm apical to cementoenamel junction (CEJ), acknowledging possible wound contraction. BFP was first stabilized using horizontal mattress suture, over which mucogingival flap was placed which was not covering BFP completely and was sutured with Vicryl 3-0 [Figure 4] (Polyglactin 910, Ethicon, Johnson and Johnson).

Figure 1

Preoperative root planing of glass ionomer cement restoration immediately before the surgery

Figure 2

(a) Removal of fat pad after elevation of a mucoperiosteal flap in the molar region through a horizontal incision of the periosteum at the level of the buccal sulcus. (b) Buccal fat pad approach through a horizontal vestibular incision in the mucobuccal fold; (c) Buccal fat pad approach through a vertical incision slightly lateral to the anterior margin of the ascending ramus; (d) Buccal fat pad approach through horizontal incision after elevation of mucoperiosteal flap in the molar region on the maxillary alveolar process at the level of the buccal sulcus

Figure 3

Mobilization of buccal fat pad

Figure 4

Stabilization using horizontal mattress suture

Patient was prescribed with capsule amoxicillin 500 mg TDS for 5 days, tablet ibuprofen 300 mg + paracetamol 325 mg SOS, chimeral forte, chlorhexidine (0.12%) mouthwash twice daily for 2 weeks. The patient was instructed to eat a soft diet. Among other oral hygiene instructions and methods, the patient was asked to use a soft brush and brush very gently over the surgical area even after suture removal and not to exert too much pressure during brushing. His brushing habit was changed to modified bass method, and every time, he would come for check he was asked to bring his brush along so that his method of brushing could be checked. He was asked to use floss and rinse mouth with warm saline rinse 2–3 times daily. Furthermore, patient's scaling was done at every 6 months.

RESULTS

Postoperative healing was uneventful; the patient was comfortable and did not report swelling or trismus. Sutures were removed 10 days after the surgery. No dehiscence, infection, or necrosis was observed. At suture removal, the flap was covered with healthy looking oral mucosa, with areas of thick gingiva and irregular gingival margins and interdental papillae [Figure 5]. Furthermore, at the period between the surgery and at the end of 3 years, patient did not report pain or any other complication related to the surgery. To check for this, the patient was called at 1 month, 3 months, 6 months, 12, 18, 24, 30, and 36 months to check for gingival index, plaque index, and clinical attachment loss [Table 1]. While evaluating patient's oral hygiene, he was asked to brush at the dental office and any flaw was rectified. Visual analog was not used as the patient was comfortable and did not report any pain or discomfort. At 3-year postoperative, gingival margin was at CEJ, stable and healthy and did not show any recession [Figure 6]. Throughout the period of 3 years, the patient maintained excellent oral hygiene.

Figure 5

At suture removal

Table 1

Month wise gain in attachment levels (in mm)

Figure 6

Postoperative at the end of 3 years

DISCUSSION

New attachment involves the regeneration and reattachment of principle fibers into newly formed cementum which has been exposed to a periodontal pathology previously.[24] The main reason for nonestablishment of a new attachment following periodontal is the apical migration of the oral epithelium. Cole et al.[25] showed that new attachment is possible on citric acid-treated roots, provided hard- and soft-tissue cells are prevented from occupying the wound area adjacent to the root during the initial phase of healing.[262728] Keeping this concept into consideration, many membranes were also used for the treatment of recession with varying degree of success. For severe recession problems, newer concepts and newer surgical procedures are required which can maintain long-term stable gingival margin at CEJ. In the quest of doing so, root coverage with BFP demonstrating stable gingival margin at the end of 3 years seems one of the suitable answers.

The use of the BFP to cover intraoral defects was first described by Egyedi,[29] who used it in the form of a pedicled graft for closure of postsurgical maxillary defects in 4 cases. Since then, many attempts have been made to repair GR, oroantral fistulas, and for reconstruction of intraoral structures. A study presented by Tideman et al.[21] about the use of pedicellate graft with the BFP to correct buccal and maxillary defects concluded that such grafts present good results.

The reason why BFP is used for root coverage is because it is an encapsulated structure with an excellent blood supply from the maxillary, superficial temporal, and facial arteries [2930] and this “surround kind” of blood irrigation system makes it possible to use this tissue without much risk of necrosis.[19] High vascularity may also be one reason for rapid epithelialization of the fat. BFP being syssarcosis type of fat is independent of subcutaneous fat; thus, extreme weight gain or loss patient does not affect its size and volume,[2930] and so, it changes very little in terms of size and volume. A major advantage is its location, wherein the buccal pad can be approached through the same flap, through deeper dissection and it eliminates the requirement of a second surgical site; hence, it avoids the need of soft tissue from the palate or any other intraoral site. Hao [31] considered maxillary defects ideal for reconstruction with this technique, due to its anatomical advantages. Postoperative radiotherapy exerts no negative effects on flap survival.[29] And keeping the surgical principles into consideration, the flap must cover the entire defect and should be sutured without tension.

Histologically, fat is replaced by fibrous tissue.[3233] The transpositioned part of the BFP flap re-epithelializes and transforms into parakeratotic stratified squamous epithelium and dense connective tissue without fat cells.[2232] According to Fan et al.,[33] these changes are apparent in 4–6 weeks. In his histological study of BFP on animals, during the 1st week, regenerated basal cells appear on the surface of fat tissue along with exduated fibroprotein on the surface, coagulation necrosis, and granulation tissue on the surface.[33] In the 2nd week, regenerated epithelium is thin, less obvious Rete Pegs and fat cells are replaced by collagen fibers and fibroblasts. By 4th–6th week, BFP is completely epithelized, fat cells are being replaced by fibers and residual cells become flat.[33] In the 8th–10th week, it undergoes parakeratosis in 6–7 layers and fat cells are completely replaced by collagen fibers and fibroblasts. However, histological studies are still required to evaluate the type of attachment that takes place and how well fibers are embedded to form new attachment as after 3 years of surgical procedure gingival margin was at CEJ which remained constant.

Before positioning the flap, the recession defect was filled with GIC as for optimal functional and esthetic results. In a report by Santamaria et al.,[34] GR associated with noncarious lesion can be treated successfully by GIC restoration combined with a coronally advanced flap or with and without a connective tissue graft. Authors also stated that after healing, parts of the restoration were covered by soft tissue. In another report by Alkan et al.,[35] GR was successfully treated with connective tissue graft and GIC restoration. Histology showed the presence of connective tissue and epithelium in direct contact with this material. These studies provide information that GIC facilitates fibroblast adhesion.[36] Keeping this in correlation with the present study, GIC restoration was used to fill the defects, to observe its association with BFP. Furthermore, there are chances of failure of BFP,[37] and to avoid such complication, GIC was used for fibroblast adhesion. However, there was no histology done, so the exact mechanism by which fibroblast adhesion takes place, or in this case, how BFP adhesion takes place cannot be commented upon.

Contraindications of this surgical process include mobile teeth with extensive bone loss, uncooperative patients who are not willing to maintain oral hygiene, infection or tumor in place of BFP, and generalized recession. Few complications that might take place are postoperative swelling, difficulty in mouth opening, and supposed necessity of gingivoplasty;[37] however, no such complication was observed in this technique which may be, depends on the type of technique, used for harvesting BFP.

CONCLUSION

Using BFP for covering GR is an excellent technique. It is simple surgical procedure with easy handling of the flap. It provides excellent color and texture match. It also may be considered as an excellent procedure for increasing the width of attached gingival. An added advantage of this technique is that for maxillary posterior defects, another surgical wound is not required; however, this cannot be stated for mandibular defects; nonetheless, this technique is helpful and shows gingival margin stability even after 3 years of surgical procedure. However, cases concerning use of BFP along with bone grafts are lacking, and can BFP be used as a membrane, histology concerning the same, its response in thick and thin gingival biotype, and its use for root coverage of anterior and mandibular teeth are some of the unanswered questions, thus further research using BFP in root coverage is required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.