Abstract
The use of buccal fat pad in the management of osteoradionecrosis has not been described previously. A series of 10 consecutive cases of osteoradionecrosis treated with a combination of sequestrectomy and buccal fat pad is presented. The data were obtained by reviewing operative and medical records. The combination of sequestrectomy and buccal fat pad flap was successful in 86% of cases of stage II osteoradionecrosis and in 0% of cases of stage III. The overall success rate was 60%. Based on the result of this series, this treatment regime appeared to be beneficial in stage II osteoradionecrosis.
Osteoradionecrosis (ORN) is one of the most significant morbidities associated with radiation therapy of the head and neck. ORN was described in 1922, but it remains a clinically challenging lesion and the treatment outcome is still unsatisfactory. A wide range of treatments has been suggested. Non-surgical treatment includes the use of antibiotics or antiseptic irrigation, hyperbaric oxygen (HBO), ultrasound therapy and more recently the combination of pentoxifylline–tocopherol–clodronate (PENTOCLO). Surgical intervention ranges from less invasive surgery such as sequestrectomy to resection followed by vascularised free flap reconstruction.
Buccal fat pad flap (BFP) is a versatile local flap located within the oral cavity. It has been used extensively in the management of oro-antral communication with excellent and predictable outcomes. It has also been used successfully in other situations, such as in coverage of post-excisional defect, primary cleft palate repair, temporomandibular surgery and sinus floor augmentation procedures. The unique attribute of this flap is its rich vascularity. It has been reported that the facial artery, transverse facial vessels and the multiple branches of the internal maxillary artery are the source of its nutritional supply. These vessels have multiple anastomoses between them that eventually form a vascular plexus within the BFP.
Radiation therapy is known to eradicate tumour cells but also to cause damage to the adjacent normal tissue. Following irradiation, reduction in vascularity and cellular depletion of the surrounding normal tissue can be observed. Revascularisation of the irradiated tissue has been one of the strategies to reverse the changes caused by irradiation. The use of HBO, ultrasound therapy and vascularised free flap in treating ORN would increase the vascularity of these tissues. The aim of this study is to describe the use of BFP in the management of ORN in the authors’ centre.
Materials and methods
The operative records of patients treated in the Department of Oral & Maxillofacial Surgery, Universiti Kebangsaan Malaysia Medical Centre from 2005 to 2010 were reviewed retrospectively to identify all ORN cases treated using BFP. The patients’ demographic and clinical data were recorded. Details about their treatment and its outcomes were also retrieved.
All patients were diagnosed with ORN by clinical and radiographic examination. ORN was diagnosed if there was bone exposure that lasted for more than 3 months with signs of bone necrosis radiographically. The ORN was staged based on its extension to stage I, II and III ( Table 1 ) and categorised according to its size. The extension classification was a modification of a previously described clinical staging system by Schwartz and Kagan.
| Stages | Description |
|---|---|
| Stage I | Superficial involvement only. Only the exposed cortical bone is necrotic |
| Stage II | Localised involvement. Cortical and medullary areas of the alveolar bone are necrotic |
| Stage III | Diffuse involvement. Full thickness of the bone is affected. Involving lower border (mandible) or antrum (maxilla) |
All the patients received similar treatment consisting of sequestrectomy with the use of BFP to obliterate and close the wound. The anatomy and technique to raise this flap is described in the literature. Tumour recurrence at the site of ORN was ruled out by incisional biopsy in all cases. Treatment outcome was categorised as ‘failed’ or ‘healed’. The cases were described as ‘failed’ if the symptoms and bone exposure persisted or recurred within 6 month of treatment. The lesions were described as ‘healed’ if: there was complete resolution of symptoms; absence of persistent or recurrent clinical bone exposure 6 month after treatment; and no signs of ORN progression radiographically.
Results
10 patients were identified and included in the current case series. There were seven males and three females with a mean age of 56 years (range 24–74 years). Six of ten patients were of Chinese ethnicity while the remaining four were Malays. Nasopharyngeal carcinoma was the most frequent tumour in this series with six patients (60%). Three patients were diagnosed with squamous cell carcinoma of the tongue while the other patient had a primary tumour in the vertebra. The patients’ characteristics are presented in Table 2 .
| Patient no. | Race | Gender | Age | Tumour site | ORN max/mand | Trigger event | Staging | ORN size | Infected | Pathologic fracture |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Chi | F | 62 | NPC | Max | Post-RT Extraction | II Max | 1 cm × 2 cm | Yes | No |
| 2 | Chi | M | 57 | NPC | Mand | Pre-RT extraction | II Mand | 2 cm × 1 cm | Yes | No |
| 3 | Malay | M | 24 | NPC | Mand | Post-RT Extraction | III Mand | 4 cm × 2 cm | Yes | Yes |
| 4 | Chi | M | 74 | Tongue | Mand | Post-RT Extraction | III Mand | 5 cm × 3 cm | Yes | No |
| 5 | Malay | M | 51 | Vertebra | Max | Post-RT Extraction | II Max | 2 cm × 2 cm | Yes | No |
| 6 | Chi | M | 56 | NPC | Mand | Pre-RT extraction | II Mand | 3 cm × 2 cm | Yes | No |
| 7 | Malay | F | 47 | Tongue | Mand | Pericoronitis 48 | II Mand | 3 cm × 2 cm | Yes | No |
| 8 | Chi | M | 74 | NPC | Mand | Post-RT Extraction | II Mand | 3 cm × 2 cm | Yes | No |
| 9 | Chi | M | 50 | NPC | Mand | Periapical infection | II Mand | 3 cm × 2 cm | Yes | No |
| 10 | Malay | F | 68 | Tongue | Mand | Periapical infection | III Mand | 10 cm × 5 cm | Yes | No |
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