Role of buccal fat pad versus collagen in the surgical

management of oral submucous fibrosis: a comparative

evaluation
A. DWIVEDI1, G. SINGH2, A. GAUR3

1BDS, MDS, Consultant Oral and Maxillofacial Surgeon, Mani Dental Care, Rewa (MP), India
2BDS, MDS, Professor and Head, Department of Oral and Maxillofacial Surgery, Sardar Patel Post Graduate of Dental and Medical Sciences,
Lucknow, (UP), India
3BDS, MDS, Professor, Department of oral and maxillofacial surgery, Sardar Patel Post Graduate of Dental and Medical Sciences, Lucknow
(UP), India

TO CITE THIS ARTICLE

Dwivedi A, Singh G, Gaur A. Role of buccal fat pad versus collagen in the surgical management
of oral submucous fibrosis: a comparative evaluation. J Osseointegr 2022;14(1):49-52. KEYWORDS Oral submucous fibrosis; Buccal fat pad; Collagen
DOI 10.23805/JO.2022.14.20 sheet; Surgical management.

with epithelial atrophy leading to stiffness of the oral

ABSTRACT mucosa and causing trismus and inability to eat (1,2).
Patients generally complain of burning sensation while
Aim This study was conducted to assess the efficacy of buccal eating spicy food. The fibrosis also leads to difficulty in
fat pad and collagen in the surgical management of oral swallowing, mastication, speech and pain in the throat.
submucous fibrosis. In advanced cases, there may be severe trismus, and
Materials and methods This camparative study was totally inelastic mucosa forced against the teeth leading
conducted on 20 patients with reduced mouth opening due to chronic ulceration and subsequent infection. The
to oral submucous fibrosis (Khanna and Andrade Classification pathogenesis of the disease is multifactorial including
Grade 3 and 4 a), randomly divided into 2 groups. In one group, areca nut chewing, ingestion of chillies, genetic and
the buccal fat pad was harvested and in another group, only immunologic processes, nutritional deficiencies and
wet bovine collagen sheet was applied as surgical dressing in other factors.
the intra-oral wound after fiberotomy. The treatment of patients with OSMF depends on the
Results Both the dressings resulted in the achievement of degree of clinical involvement. If the disease is detected
nearly normal mouth opening with insignificant differences at a very early stage, cessation of the habit is sufficient
in the proportion of relapse. Buccal fat pad as an autogenous along with medicines consisting of multivitamins, B-
graft has the advantage of better vascular supply, minimum complex etc. Patients’ diet should include proteins, vitamin
donor site morbidity, better strength and resilience during the D, E and B-complex and micro-nutrients. Intralesional
healing phase. Xenogeneic collagen has better availability, no injections of dexamethasone in the fibrotic bands along
donor site morbidity, ease of application and better coverage with hyaluronidase weekly for 4-6 weeks followed by
of the surgical wound. aggressive physiotherapy and regular monitoring of
Conclusion Considering post-operative healing and surgical mouth opening is also performed. Alfa-lipoic acid and
convenience, use of collagen sheet is a superior method to the Lycopene are anti-proliferative, anti-inflammatory and
transposition of the buccal fat pad. antioxidant drugs used as the first line of treatment.
Antioxidants restrict the damage caused by reactive free
radicals to cells and cellular components (3,4).
The management of OSMF aims at improving mouth
INTRODUCTION opening and relieving associated symptoms. Surgical
management comprises the release of fibrosis by excision
Oral submucous fibrosis (OSMF) is an insidious, chronic of fibrous bands with or without grafts. In cases with
disease affecting any part of the oral cavity and severe trismus, bilateral coronoidectomy and temporalis
sometimes the pharynx. Occasionally proceeded by myotomy can be done to relieve the trismus and enhance
and/or associated with vesicles formation, it is always the mouth opening (5). The buccal fat pad is a supple
related to the juxta-epithelial inflammatory reaction and lobulated mass of a specialized fatty tissue which is
followed by the fibro-elastic change in lamina propria distinct from subcutaneous fat, easily accessible and can

© ARIESDUE March 2022; 14(1) 49

 Dwivedi A., Singh G. and Gaur A.

be mobilized in the oral cavity. The accelerated wound was applied as surgical dressing in the intra-oral wound.
healing property of the buccal fat pad can be attributed Patency as dressing material was compared. Follow up
to its rich vascular anastomoses through the small was performed on day 1 and 3, week 1, 2, 4, and 6, 3
branches of facial, internal maxillary and superficial and at 6 and 12 months postoperatively. Parameters of
temporal artery and veins (6). The clinical application assessment were pain (visual analogue scale), mouth
of buccal fat pad is strongly grounded on the results of opening, relapse and wound dehiscence. The statistical
studies on its anatomy and clinical significance by Stuzin analysis was done using SPSS (Statistical Package for
et al. (6) and Tideman et al. (7). Social Sciences) Version 15.0 statistical analysis software.
A resorbable naturally occurring collagen has been
incorporated into various medical devices and is used
for multiple purposes. For intra-oral applications RESULTS
homogenized reconstituted collagen mixed with cell
culture media has been used for burn treatment and Pain postoperatively was evaluated using Visual Analogue
endodontic repair (8). Resorbable collagen wound Scale (VAS) and the median pain score between both the
dressing has been used in oral wounds and closure of groups was not found statistically significant on day 1,3
grafted areas or extraction sites because they stabilize and 7. A significant difference in pain score was seen
blood clots, protect surgical sites and accelerate the on week-2 postoperatively (p=0.012), Group II reported
healing process. Collagen-based membranes have been with a median score of 1.0 and group I reported with
widely used in periodontal dressing and implant therapy 1.5. At week 4, the median pain score of patients of both
as barriers that prevent the migration of epithelial cells groups was 0 and none of the patient-reported pain 6
and enhance migration and attachment of fibroblasts weeks onwards. Mean pain score of patients of group I
through its space-making ability (9,10). was more than that of group II (Fig. 1).
Pre-operative mouth opening was not statistically
significant in both groups (p=0.403). Intra-operative
MATERIALS AND METHODS mouth opening and mouth opening at consecutive
follow-ups were found to be higher in group II (collagen
The study was conducted in the Department of Oral group). A significant difference was found on day-1
and Maxillofacial Surgery, Sardar Patel Post Graduate (p=0.046) and day-3 (p<0.001). In both the groups,
Institute of Dental and Medical Sciences Lucknow (India) at all follow-up periods, mouth opening was found to
from February 2016 to December 2017 after approval be higher than baseline and changes were found to be
from the institutional ethical committee. 20 patients statistically significant at all the periods of observation
with reduced mouth opening due to OSMF (Khanna and in both groups (Fig. 2).
Andrade Classification Grade 3 and 4 a), randomly divided Wound dehiscence was observed only at week-1 and 2
into 2 groups. Written consent in patients' regional of follow-up. Partial wound dehiscence was observed in
language was obtained. The patients were operated and patients of group II at week 1 (p=0.531) and 2 (p=0.606)
were kept under observation for a particular time period of follow-up which was not statistically significant when
in O.P. Chaudhary Hospital and Research Centre Lucknow compared with group II. At week 4, complete healing
by the same authors. Fibrotomy, masseter and temporalis of intra-oral wounds was observed in both groups. At
myotomy and coronoidectomy were done along with week-1, no incidence of relapse was found in any of the
prophylactic extraction of all third molars in all the groups. The proportion of relapse was higher in group II
patients. In one group, the buccal fat pad was harvested as compared to group I at all the consecutive follow-up
and in another group, only wet bovine collagen sheet periods, at week 2(30.0% vs 0.0%); at 1 year (20.0% vs

FIG. 1 Mean pain scores. FIG. 2 Changes in mouth opening.

50 © ARIESDUE March 2022; 14(1)

 Oral submucous fibrosis and buccal fat pad versus collagen

10.0%). The difference in the incidence of partial relapse recorded intra-operative mouth opening (42 mm avg.).
among patients of group I and II was not found to be Authors attributed this reduction to post-operative pain
statistically significant at any of the follow-ups. and swelling due to which patients were not able to
open their mouth fully. However, there was a significant
increase in mouth opening in both the groups at the
DISCUSSION end of follow-up. Post-operative day-2 onwards mouth
opening increased steadily. This outcome suggested a
The management of OSMF aims to improve mouth successful outcome in both groups, and this result found
opening and relieve the associated symptoms. Various the support of the various workers who recommend
surgical modalities have evolved mainstay is release surgical resection of fibrous bands such as Kothari et al.
of fibrosis by excision of fibrous bands along with (22), Gupta et al. (23), Kamnath (24) and Chang et al.
temporalis and masseter myotomy and coronoidectomy (25). The proportion of relapse was higher in group II as
to achieve better mouth-opening post-surgically. compared to group I at 3, 6 and 12 months. This can be
Various authors have proposed different grafts/dressing attributed to the fact that collagen is fragile and does
materials for intraoral wound coverage after fibrotomy. not act as a strong interpositional graft so as to prevent
Reconstruction of the defect is done by variety of options repositioning of muscles leading to relapse as reported
such as skin grafts (11), island palatal mucoperiosteal flap by Rastogi et al. (26), Tideman (7) and many other
(12), bilateral tongue flap (13), superficial temporal fascia researchers.
flap with split-thickness skin graft (14), radial forearm flap Wound dehiscence was observed only at 1st and 2nd week
(15), flaps from anterolateral thigh (16), artificial dermis of follow up. At week 1 and 2, partial wound dehiscence
(17), buccal fat pad graft (18) and nasolabial flaps (19). was observed in higher proportion in patients of group-
Authors evaluated two reconstruction modalities, buccal II when compared with group I, but the difference was
fat pad and collagen because they believed that these not statistically significant. None of the patients of either
are relatively convenient and carry less postoperative group had complete wound dehiscence. This can be
morbidity. attributed to the fact that collagen has a high tendency
BFP transplantation has been known since 1892 when to accumulate debris and has least flushing property due
Neder (20) first described it. The first report of use of to more fragility when compared with a buccal fat pad.
buccal pad of fat as a pedicled graft for defects up to 4 This led to secondary infection and subsequent wound
cm diameter covering it with a free split-thickness skin dehiscence occurred. Patients were advised to maintain
graft was made in 1977. It was found in various studies oral hygiene and no further complications occurred. Same
that harvesting of BFP did not produce any marked findings regarding collagen application were reported by
defect on the cheek. In reference to the oral cavity, BFP Rehman et al. (27), Shivpriya et al. (28), Kamnath (24),
is technically easy to harvest and graft as both donor and and Sowjanya et al. (29).
recipient sites are contiguous in the oral cavity, there is no The authors, in a different study, compared collagen
visible scar in the donor area, anatomic proximity permits membrane as a covering material over buccal fat pad
rapid grafting, and the graft can be directly rotated onto versus buccal fat pad in management of OSMF, concluded
the defect, it is not necessary to sever the graft pedicle. that though surgical time increases on the application of
The uncovered pedicle graft provided a bed of tissue for collagen membrane over the grafted buccal fat pad, it is
subsequent epithelialization, thereby obviating the need acceptable as pain score, physical trauma, food lodgement
for split-thickness skin cover. The authors chose pedicled and subsequent infection at the surgical site are reduced.
buccal fat pad and decided not to cover their graft. Collagen when placed over the buccal fat pad graft as
The advantages of collagen sheet as a wound dressing a covering material, provides sufficient protection and
material in OSMF include easy availability of collagen helps in maintaining the structural integrity of BFP during
sheet, the convenience of application, good tolerance the healing phase (30).
to oral tissue, no incidence of allergic reaction in the
patients, obviation of a second surgery to obtain graft
or detachment of the pedicle and there is no morbidity CONCLUSION
associated with donor site healing. Postoperative pain
was controlled in all the patients using the same analgesic In this study, the authors compared two graft materials,
of the same dosage, frequency and was prescribed for the one being autogenous buccal fat pad and the other
same length of time. Postoperative pain was assessed on being collagen sheet which is of animal origin for
the VAS scale of 0-10. By two weeks time, there was a the reconstruction of the intraoral wound created by
declined pattern of pain score observed in both groups, fibrotomy. Buccal fat pad had advantages such as rich
suggestive of proper healing. Samman et al. had shown vascular supply, minimal donor site morbidity, ease of
histological evidence of wound healing in 2-3 weeks (21). surgery as well as no impairment in physiologic functions of
Mouth opening in both groups, on postoperative day cheek after surgery, good patient acceptance and minimal
1, showed a significant reduction as compared with postoperative morbidity, while disadvantages being

© ARIESDUE March 2022; 14(1) 51

 Dwivedi A., Singh G. and Gaur A.

7. Tideman H. Buccal fat pad as a pedicled graft. J Oral Maxillofac Surg

anterior reach of the graft being limited and restricted
1986;44:435-8.
use for larger defects because excessive stretching of 8. Nevins AJ. Endodontic composition and method. US patent 3,968,567. July
BFP invariably impairs the vascularity so the closure of 13,1976.
larger defects cannot be guaranteed without producing 9. Wang HL. Guided tissuee regeneration. Dent Clin North Am 1998;42:505-23.
flap necrosis or creating a new fistula. Collagen sheet 10. Lu HK, Lee HY, Lin FP. Elastic modulus, permeation time and swelling ratio of a
that was grafted in the other group, the authors found new porcine dental collagen membrane. J Periodontal Res 1998;33:243-8.
that despite its weakening by collagenolysis, contributing 11. Yen DJC. Surgical treatment of submucous fibrosis. Oral Surg Oral Med Oral
Pathol 1982;54(3):269-72.
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strong masticatory forces for a sufficient duration of 13. Mehrotra D, Pradhan R, Gupta S. Retrospective comparison of surgical
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uniformly and clinically healthy. Clinically, collagen is well Oral Med Oral Pathol Oral Radiol Endod 2009;107:1-10.
tolerated with no adverse effects. Uneventful wound 14. Mokal NJ, Raje RS, Ranade SV et al. Release of oral submucous fibrosis and
healing was observed without incidence of an allergic reconstruction using superficial temporal fascia flap and split skin graft- a
new technique. Br J Plast Reconstr Surg 2005;58:1055.
reaction despite being xenogenic with minimal morbidity
15. Wei FC, Chang YM, Kildal M, Tsang WS, Chen HC. Bilateral small radial forearm
to the patient. flaps for reconstruction of buccal mucosa after release of submucosal fibrosis:
Hence, in this study, the authors conclude that the use of a new reliable approach. J Plast Reconstr Surg 2001;107:1679-83.
a collagen sheet as a wound dressing material as a surgical 16. Huang JJ, Wallace C, Lin JY et al. Two small flaps from one anterolateral
dressing was more convenient than the buccal fat pad. thigh donor site for bilateral buccal mucosa reconstruction after release
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None.
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