Review - ZZI 03/2016

The buccal fat pad – case reports

Christoph Staudigl1, Thomas Bernhart2

Introduction: The buccal fat pad is regularly used to reconstruct defects in the maxilla and to close oro-antral communications. One of its properties, the ability to convert free gingiva to keratinized mucosa, can be exploited to create beneficial conditions for peri-implant soft tissue.

Treatment method, case report 1: A 36-year old patient with insulin-dependent diabetes mellitus presented with complaints in the upper right quadrant. Tooth 16 was not worth preserving and was extracted, causing an oro-antral communication. The defect was successfully closed using a pedicled buccal fat pad flap.

Treatment method, case report 2: An oro-antral fistula was diagnosed in a 45-year old patient, persisting 6 months since extraction of the first left molar in the maxilla. After reconstruction of the bony defect using a bone block augmentation technique the soft tissue defect was reconstructed with the buccal fat pad to obtain adequate soft tissue width.

Results and discussion: The use of the buccal fat pad as a pedicled graft can be used reliably for the closure of oro-antral communications.

Keywords: anatomy; oral surgery; management of complications; keratinized gingiva; buccal fat pad; antral closure

Cite as: Staudigl C, Bernhart T: The buccal fat pad – case reports. Z Zahnärztl Implantol 2016; 32: 214–222

DOI 10.3238/ZZI.2016.0214–0222

Introduction

The buccal fat pad, first described by Heister in 1732, was classified incorrectly as glandular tissue, the molar glands, based on its appearance and connective tissue capsule [8]. Bichat recognized this structure as fat tissue and named it the buccal fat pad [3]. Since then, other anatomists have studied the embryology, anatomy and function of the buccal fat pad, which is closely associated anatomically and functionally with the muscles of mastication [6, 11, 14].

The buccal fat pad is divided anatomically into a main part and various processes. According to their position, these processes are called the buccal, pterygoid, and superficial and deep temporal processes. The theoretically possible complications, such as injury of the parotid duct or maxillary artery, can be deduced from the relation to the different neighboring structures (Fig. 1–3).

The main part begins cranial to the parotid duct and extends to the posterior maxilla deep to the masseter muscle. At the level of the upper second molar, distal to the zygomaticoalveolar crest, the buccal fat pad is nearly directly below the mucosa in the vestibular fold. Posteriorly, the main part then passes the maxillary tubercle and enters the pterygopalatine fossa, where it is closely related to the maxillary artery and its branches and to the maxillary branch of the trigeminal nerve. This part of the fat pad in the pterygopalatine fossa is classified by Zhang et al. as the distinct pterygopalatine process [14].

The buccal process is the most superficial part. It passes anteriorly below the anterior border of the masseter muscle inferior to the parotid duct. It lies on the buccinator muscle and extends as far as the facial artery and vein. The parotid duct runs either on the anterior border of the buccal process or passes directly through it to reach the oral cavity. The buccal branch of the facial nerve is also at the anterior end.

The pterygoid part passes in posteroinferior direction from the main part to lie between the lateral and medial pterygoid muscles and the ramus of the mandible. It can extend as far as the mandibular foramen where it comes in close contact with the lingual nerve and mandibular neurovascular bundle.

The deep temporal process passes medially between the zygomatic arch and the tendon of the temporalis muscle and terminates at the greater wing of the sphenoid, the lateral wall of the orbit.

The superficial temporal process passes between the superficial and deep layers of the temporal fascia.

The buccal fat pad is supplied by a dense network of arteries: the posterior superior alveolar artery, the deep temporal artery, the maxillary artery, the transverse artery of the face and the facial artery contribute vessels [6, 11, 14].

It supports the muscles of mastication functionally as a layer known as a syssarcosis. In babies it prevents the cheeks from collapsing when they suck. Later in life it constitutes an important sliding layer between the muscles of mastication and a damping and protective structure for nerves and vessels. The buccal fat pad has already attained its definitive size at birth. This size remains almost constant throughout life. It gives children's cheeks their chubbiness, thus contributing to the proportions of the child's face (“baby scheme”). An increase in the surrounding structures during growth leads to a reduction of this prominence and its contribution to the shape of the cheek.

Its constancy of size, which is relatively independent of age and nutritional status, is explained by its role as a structural fat. Structural fats are a group of fat tissues that have damping functions in the human body, e.g., the orbital fat pad. They are the last reserve to be mobilized in the case of extreme food shortage. This is why the buccal fat pad is usually found even in cachectic patients.

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