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Year : 2015  |  Volume : 5  |  Issue : 2  |  Page : 179-184

The use of Buccal fat pad free graft in regenerative treatment of peri-implantitis: A new and predictable technique

Department of Oral and Maxillofacial Surgery, The Baruch Padeh Medical Center, Tiberias, Israel

Date of Web Publication5-Feb-2016

Correspondence Address:
Dr. Fares Kablan
The Baruch Pade Medical Center, Poria, M.P. The Lower Galilee, Tiberias
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DOI: 10.4103/2231-0746.175759

PMID: 26981467

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Introduction: Peri-implantitis is a common condition, but no particular treatment protocol has shown to be definitively effective. Fat tissue in the oral cavity is widely available and easily accessed. The aim of the current study is to present a novel technique in the treatment of peri-implant lesions, utilizing a free fat tissue graft from the buccal fat pad (BFP). Patients and Methods: Free fat graft (FFG) was harvested from the BFP in eight patients and used with bone substitutes to regenerate 22 peri-implant lesions. Mechanical debridement of the implants surface and the granulation tissue were made with curettes or with Er: YAG laser. Clinical parameters such as plaque index, bleeding on probing, pocket depth, gingival recession, and the clinical attachment level were recorded as a baseline during the follow-up period. In addition, radiological evaluation was made preoperative during the follow-up period. Results: The donor site of the free fat graft was healed without cosmetic defect in all patients. Twenty-two peri-implant lesions were followed up for 12 months. Bleeding on probing and the pocket depth were significantly improved, and the clinical attachment level was achieved and maintained during the follow-up period due to the fibrous healing of the free fat graft. Satisfactory esthetic and functional outcomes of the treated implants were achieved and maintained. Conclusions: Free buccal fat graft heals by fibrosis. The fibrotic tissue adheres strongly to the implant surface and with stand the recurrence of the peri-implant lesion and provides stable and predictable outcome.

Keywords: Buccal fat pad, fibrous healing, free fat tissue, peri-implantitis, soft tissue grafts

How to cite this article:
Kablan F. The use of Buccal fat pad free graft in regenerative treatment of peri-implantitis: A new and predictable technique. Ann Maxillofac Surg 2015;5:179-84

How to cite this URL:
Kablan F. The use of Buccal fat pad free graft in regenerative treatment of peri-implantitis: A new and predictable technique. Ann Maxillofac Surg [serial online] 2015 [cited 2021 Oct 17];5:179-84. Available from: https://www.amsjournal.com/text.asp?2015/5/2/179/175759

  Introduction Top

Peri-implantitis is defined as an inflammatory process affecting the soft and hard tissue around a functional osseointegrated implant, resulting in the loss of supporting bone.[1],[2] Several treatment modalities have been used and reported in the treatment of peri-implantitis and include different devices for mechanical debridement, topical antiseptic/antimicrobial materials, Er: YAG laser device, and different bone regenerative procedures.[3],[4],[5],[6],[7],[8] The ER: YAG laser in the treatment of peri-implantitis is used for debridement of the infected implant surface and in the vaporization of granulation tissue and leads to clean implant surface with healthy peri-implant intra-pocket.[8],[9],[10],[11]

The buccal fat pad (BFP) was first defined as fat tissue by Bichat in 1802. The BFP is located in the masticatory space and consists of central body (corpus) with four extensions: Buccal, pterygoid, superficial, and deep temporal. The body and the buccal extension make up more than 50% of the BFP. They are accessible from the oral cavity and are the portions of the BFP that may be used as donor sites for fat tissue grafts.[12],[13],[14] Egyedi [15] was the first to report the use of the BFP as a pedicled graft in 1977; since then, several publications have described the different applications of the BFP as a pedicled graft.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31]

The concept of transplanting autogenous fat as free graft is well-documented for cosmetic surgery. It has been used more than 100 years, and its clinical behavior, characteristics, and healing are well known in this area of medicine.[32] The main mechanism of healing of free fat grafts (FFGs) is by fibrosis.[33]

In 1983, Neder reported the use of BFP as a free graft for oral lesion reconstruction in two patients.[34] Kablan and Laster in 2012 first reported the use of free buccal fat graft (FBFG) with bone augmentation.[35] In their report, they discussed the advantages of the FBFG and the clinical and histologic healing stage, the main healing nature of the FFGs was fibrosis of the graft.[35] Therefore, I believe that the use of FBFG with bone substitute may lead to a long-term significant improvement of the peri-implantitis lesion, due to the fibrosis healing of the FBFG, and may create satisfactory clinical attachment level.

The aim of the present report was to introduce additional use of the FBFG, as a simple method developed by the author, for the treatment of peri-implant lesions.

  Patients and Methods Top


During the last 2 years, the free fat tissue graft was used as a soft tissue graft in a combination with bone substitutes to regenerate 22 peri-implant lesions. Clinical parameters such as plaque index, bleeding in probing, pocket depth, gingival recession, and the clinical attachment level were recorded as a baseline during the follow-up period. In addition, radiological evaluation was made before the operation and during the follow-up period.

The BFP was accessed intraorally via a small incision as described in detail at the technique presentation paragraph. The recipient site was prepared by mechanical debridement of the implants surface with Er: YAG laser, some were debrided with curettes. Following the removal of the granulation tissue, the site was grafted with bone substitute and FBFG. Once FBFG was in place, the flap was placed coronally and sutured firmly. Follow-up was held every 2 weeks for the first 3 months and thereafter every 3 months. The healing process was uneventful. The clinical parameters in the treated lesions using FBFG were recorded at the follow-up visits after surgery.

  Technique Top

The donor site

The FBFG was harvested from the BFP via the standard approach [Figure 1]. This approach allows access to the BFP through a small horizontal incision in the free mucosa above the second and the third maxillary molars [Figure 1]a. Through blunt dissection, the fat tissue is accessed [Figure 1]b and easily mobilized to the oral cavity by progressive blunt dissection [Figure 1]c. The desired FFG is harvested [Figure 1]d and [Figure 1]e, the BFP is pushed back in its place, and the incision is sutured [Figure 1]e.
Figure 1: The donor site. The standard approach to the buccal fat pad. Horizontal incision above the second and third maxillary molars (a). The fat tissue is reached via blunt dissection (b). The fat tissue is mobilized to the oral cavity (c). The desired fat tissue volume is harvested (d). Suturing of the donor site incision (e)

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The recipient site

Full thickness flap was designed and raised around the implants, and the peri-implantitis lesion was evaluated [Figure 2]a. First, the entire implant surface was cleaned and decontaminated, using curettes or Er: YAG laser [Figure 2]b, wave length 2940 nm (Syneron, Israel). Second, the residual bone surfaces were also cleaned and decontaminated [Figure 2]b. Third, the granulation tissue was removed and evaporated by the laser [Figure 2]b. Throughout rinsing of the site with normal saline was performed to remove all the debris at the surgery site.
Figure 2: The recipient site. Surgical procedure at the recipient side: Raising a full thickness flap around the diseased implants (a). Implant surface debridement and decontamination, using Er:YAG laser, wave length 2940 nm (b). Augmentation around the implants using xenograft bone substitute (c). Covering the site with FBFG (d). Securing the site with sutures (e)

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Bone substitute was used to augment the recipient site around the implants [Figure 2]c and was covered with FBFG [Figure 2]d. Bovine-derived bone was used as the bone substitute except the first case in which titanium granules were used. The FBFG was easily spread over the bone and around the implants, and then secured by four sutures: Two at the buccal side and two at the lingual or palatal side of the flap. The recipient site original flap was coronally positioned and sutured over the FFBG. The FFBG can be left partially exposed [Figure 2]e.{Figure 2}

  Case Presentations Top

Case 1

A 29-year-old female was referred because of exposed old implants at the anterior maxilla. Her main complaint was severe esthetic problem. Upon examination, two implants in the position of the left maxillary central and lateral incisors suffered from an evident recession of 5 mm at the buccal aspect and 2 mm at the palatal aspect [Figure 3]a,[Figure 3]b,[Figure 3]c. A mild bleeding on probing was also observed. She was treated in one stage; the treatment included harvest of FFG from right BFP [Figure 3]d and [Figure 3]e, mechanical debridement of the implants and granulation tissue with curettes [Figure 3]f and [Figure 3]g. Placing of bone substitute (titanium granules) [Figure 3]h and FBFG over the bone [Figure 3]i was performed, following coronal repositioning of the flap and suturing [Figure 3]j and [Figure 3]k.
Figure 3: Case 1: Peri-implant lesions involving implants in the place of left central and lateral incisors. Clinical preoperative view (a-c). FBFG harvesting (d and e). Intraoperative clinical pretreatment view (f and g). Regenerative treatment with bone substitute (h) and FBFG (i-k). Treatment outcome and follow-up (l-n)

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Follow-up examinations at 2 weeks and 1 month after the surgery showed uneventful recovery. At 4 months, satisfying improvement of the hard and soft tissue around the 2 implants was noted. The final fixed prosthesis was performed with good esthetic outcome [Figure 3]l,[Figure 3]m,[Figure 3]n. The patient has been followed for 18 months.

Case 2

A 58-year-old woman was referred due to chronic peri-implantitis at implants at the position of the right maxillary bicuspids [Figure 4]a. She was suffering from recurrent episodes of swelling and frequent suppuration; pocket depth of 5 mm was recorded. The periapical radiograph revealed severe bone loss around the implants [Figure 4]b. Her treatment included cleaning and disinfection of the implants and removing of granulation tissue with Er: YAG laser [Figure 4]c and [Figure 4]d. Regeneration of the peri-implants lesion was done with bovine-derived bone substitutes and FBFG [Figure 4]e,[Figure 4]f,[Figure 4]g. The clinical and radiographic follow-up revealed an excellent resolution of the periimplantitis. The patient has been followed 14 months with stable outcome [Figure 4]h and [Figure 4]i.
Figure 4: Case 2: Peri-implant lesions involving 2 implants at the first and the second right maxillary bicuspids. Clinical and radiological preoperative view (a and b). Cleaning of recipient site with Er:YAG lazer (c). Recipient site after debridement (d). Harvested FBFG (e). Regenerative treatment with bone substitute and FBFG (f). Suturing of operative site (g). Clinical and radiological treatment outcome and follow-up (h and i)

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Case 3

A 49-year old man, he had full mandibular arch rehabilitation over 8 implant, since 6 years. He was referred due to peri-implantitis. Clinical and radiographic examination revealed moderate to severe peri-implantitis that affects all of the mandibular implants [Figure 5]a. About 3 implants were removed and replaced and 5 implants were saved and treated. The treatment was mechanical debridement of the implants and the granulation tissue with curettes [Figure 5]b. Regeneration of the peri-implants lesion was done with bovine-derived bone substitutes and FBFG [Figure 5]c,[Figure 5]d,[Figure 5]e[Figure 5]f. Ten months follow-up exhibited a significant improvement [Figure 5]g and [Figure 5]h.
Figure 5: Case 3: Peri-implant lesions involving mandibular implants. Radiological and clinical preoperative view (a and clinical intraoperative view (b)). Harvested FBFG (c). FBFG covered with xenograft (d). Regenartive treatment with bone substitute and FBFG (e). Suturing of operative site (f). Treatment outcome and follow-up (g and h)

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Case 4

A 22-year-old female was referred with peri-implant lesion at the upper first right premolar [Figure 6]a,[Figure 6]b,[Figure 6]c. A 8 mm probing depth was recorded around the implant [Figure 6]d,[Figure 6]e. Her treatment included cleaning of the granulation tissue and the implant surface with curettes [Figure 6]f,[Figure 6]h, Regeneration of the lesion was performed with bovine-derived bone substitute and FBFG [Figure 6]i,[Figure 6]j,[Figure 6]k,[Figure 6]l,[Figure 6]m. The clinical evaluation after one month showed improvement of the lesion and the probing depth was 3mm [Figure 6]n,[Figure 6]m,[Figure 6]o,[Figure 6]p,[Figure 6]q. Periapical X-ray 6 weeks after the surgery demonstrate the regenerative bone gain [Figure 6]r. This patient is followed 2 months.
Figure 6: Case 4: Clinical views preoperative, probing depth 8 mm (a and b). Preoperative periapical X-ray (c). Intraoperative views, probing depth 8 mm (d and e), bone loss and granulation tissue (f), debridement of the granulation tissue and implant surface cleaning (g and h), bone graft (i), FBFG (j), and suturing of the FBFG and the recipient site (k and l). Immediate periapical X-ray (m). One month follow-up; 3 mm probing depth (n-q). Periapical X-ray 6 weeks postoperative (r)

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  Results Top

FBFGs were used in 22 peri-implant lesions, in 8 patients (6 women, 2 men; mean age, 39 years; range, 29–62 years). The healing process was uneventful. The BFPs healed very well without complications and esthetic disturbance.

The peri-implantitis signs such as suppuration, local swelling, and bleeding were improved. In six cases (6/8), the probing depth was reduced from 5–6 mm to 2–3 mm. In two cases (2/8) with gingival recession around the implants, new soft tissue attachment was obtained by the treatment and maintained during the follow-up period. The radiographic follow-up showed regeneration of new bone around the treated implants.

  Discussion Top

This clinical case series present the FBFG as a new soft tissue graft and describes its use in combination with particular bone substitutes for regenerative treatment of peri-implantitis. The final outcome was satisfactory in the patient series, and the technique predictably provided regeneration of the treated lesions.

The BFP has been used in oral and maxillofacial reconstruction for more than three decades, and its application is well documented. Singh et al. reviewed the applications in oral and maxillofacial reconstruction and its potential benefits and limitations, especially its size and applications for the posterior sites of the oral cavity.[16] The donor site, the BFP, is easily accessed through the oral cavity with minimal morbidity, making harvesting a very easy and fast procedure and providing plenty of tissue.

Kablan and Laster discussed in their article the disadvantages and limitations of the pedicled BFP and showed the advantages of the FBFG, especially its use in the entire oral cavity.[35]

The nature of healing of the pedicled BFP in maxillofacial surgery has been widely reported, and the main mechanism is fibrosis and fast epithelialization of the graft.[16],[21],[22],[23]

Autologous FFGs are widely used in cosmetic surgery. FFGs may be taken from different donor sites and transplanted to different recipient sites throughout the body, and it is well-documented that the major healing process of the FFG is fibrosis of the fat tissue.[32] In maxillofacial surgery, the author was the first to investigate and report the clinical and histologic healing process of the FFG. In that report, immature fibrosis was seen 1 month and mature fibrosis of the FBFG was seen 4 months after the surgery.[35]

The fibrosis healing nature of the FBFG may transform thin tissue biotype to thick biotype and improves the soft tissue quality and volume of the recipient site. This was obvious when the FBFG was used during bone augmentation.[35]

In the present case series, the advantages of the FBFG were augmentation of the affected and missed soft tissue around the implants. Furthermore, it was observed that the resulted fibrotic tissue was strongly adhered to the coronal part of the treated implants [Figure 7]a, and in the histological specimen demonstrates mature fibrosis [Figure 7]b. I believe this will maintain the stability of the outcomes for long time, but more follow-up is still required for the treated cases.
Figure 7: Open look at the recipient site 4 months after surgery showed fibrosis healing of the BFFG (a), the histology revealed mature fibrosis with fat tissue remnants (b)

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  Conclusions Top

In this patient series, the Buccal fat pad free graft (FBFG) was a simple procedure that can be performed quickly with minimal morbidity. The donor sites healed very well, without any cosmetic disturbance, making the harvesting of FBFGs a minor and insignificant procedure. The use of FBFGs in the treatment of peri-implantitis enhances protection of the augmented bone particles and augments the soft tissue at the recipient site. The fibrotic healing of the FBFGs improves the clinical attachment level of the soft tissue around the implants and should improve their survival. The mean follow-up period of the current patients was 12 months. Excellent functional and esthetic outcomes were achieved, without recurrence of the peri-implantitis, but additional follow-up is necessary to indicate the long-term reliability of the FBFGs in the treatment of peri-implantitis.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

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