Clinical Advances in Periodontics Vol. 7, No. 4, November 2017 : Page-215

PRACTICAL APPLICATIONS Extraoral Uses of Autologous Oral Soft Tissue Grafts: A Different Bridge Between Mouth and Body Health Ross I. Gordon,* Andreas O. Parashis,* † and Dimitris N. Tatakis* Focused Clinical Question: Are there any extraoral uses for intraoral soft tissue grafts? Summary: Despite extensive literature on the intraoral uses of soft tissue autografts harvested from oral sites, the peri-odontal literature is lacking information on the extraoral uses of such grafts. The purpose of this article is to review the au-tologous use of certain oral soft tissue grafts for extraoral indications. A literature search revealed that several medical specialties, including otolaryngology, ophthalmology, dermatology, plastic surgery, and urology, have a track record of pos-itive outcomes with the use of free gingival, buccal fat pad, and buccal mucosa grafts for a wide variety of reconstructive procedures at diverse body sites. Conclusions: The numerous successful extraoral uses of oral soft tissue autografts underscore the versatility of these tissues in reconstructive surgery and suggest there is potential for collaboration between periodontal and medical special-ists for the benefit of patients in need of such reconstructions. Broader awareness of these applications of oral soft tissue grafts could help expand their current uses and would allow practitioners to better answer possible patient inquiries. Clin Adv Periodontics 2017;7:215-220. Key Words : Adipose tissue; mouth mucosa; palate; reconstructive surgical procedures; transplantation. Background The periodontal use of intraoral soft tissue grafts has been well documented since the 1960s. 1-6 Before then, flap techniques were developed for various mucogingival in-dications, such as vestibuloplasty. 7 The limitations of flap-based techniques created the need for alternative treatments, thus leading to the development of the free gingival autograft or free gingival graft (FGG) 1 . Over 50 years later, FGGs remain the “gold standard” for gingival augmentation. 8 Besides the palatal masticatory mucosa, the source of FGGs and connective tissue (CT) grafts, other oral soft tis-sues have served as autologous graft donor sites. One such tissue is the buccal fat pad (BFP). 9 Since its first comprehen-sive description in 1801, 10 the BFP has been used to treat oral and maxillofacial defects such as hard and soft palate deformities, oroantral communications, fistulas, and retro-molar deficiencies. 11,12 The BFP has also been used for ves-tibuloplasty and root coverage procedures. 11,12 Despite the voluminous literature on the intraoral uses of these orally harvested soft tissue autografts, 2-6,13 the peri-odontal literature is lacking information on the possible uses of these grafts in several medical specialties, such as otolaryngology, 14 ophthalmology, 15 dermatology, 16 plastic surgery, 17 and urology. 18 Treatment of defects in such dis-parate body areas as the nose, 19 eyelids, 20 vocal cords, 21 * Division of Periodontology, College of Dentistry, The Ohio State Univer-sity, Columbus, OH. † nail bed, 22 and urethra 23 using intraoral soft tissue auto-grafts represents another bridge, albeit a very different one from periodontal medicine, between mouth and body health. The purpose of this article is to review the use of oral soft tissue grafts, specifically FGGs, BFPs, and buccal mucosa grafts (BMGs), for extraoral indications. Search Strategy A targeted search of PubMed, the Cochrane Database, EBSCO, and Scopus using the following terms was initi-ated in November 2015 and updated through October 2016: buccal fat pad graft OR buccal mucosa graft OR free gingival graft OR intraoral soft tissue graft OR mucoper-iosteal graft. Article titles and abstracts were reviewed, and those not pertaining to the topic of extraoral applica-tion were excluded. After identification, related articles were searched for relevant citations. Search Outcome Of the 4,271 retrieved articles, 378 were identified as rel-evant. Among those, 36 representative articles were chosen for inclusion herein. Properties of Oral Soft Tissue Grafts Prevalent in Extraoral Use FGGs FGGs, also called mucoperiosteal, palatal mucosal, or hard palate grafts in the medical literature, are typically har-vested from the palate or other similar tissue quality and adequate quantity areas, e.g., edentulous ridges and the maxillary tuberosity (Figs. 1a and 1b). 1 These grafts consist Clinical Advances in Periodontics, Vol. 7, No. 4, November 2017 Private practice, Athens, Greece. Submitted October 25, 2016; accepted for publication February 20, 2017 doi: 10.1902/cap.2017.160076 215

Extraoral Uses Of Autologous Oral Soft Tissue Grafts: A Different Bridge Between Mouth And Body Health

Ross I. Gordon, Andreas O. Parashis, and Dimitris N. Tatakis

Focused Clinical Question: Are there any extraoral uses for intraoral soft tissue grafts?

Summary: Despite extensive literature on the intraoral uses of soft tissue autografts harvested from oral sites, the periodontal literature is lacking information on the extraoral uses of such grafts. The purpose of this article is to review the autologous use of certain oral soft tissue grafts for extraoral indications. A literature search revealed that several medical specialties, including otolaryngology, ophthalmology, dermatology, plastic surgery, and urology, have a track record of positive outcomes with the use of free gingival, buccal fat pad, and buccal mucosa grafts for a wide variety of reconstructive procedures at diverse body sites.

Conclusions: The numerous successful extraoral uses of oral soft tissue autografts underscore the versatility of these tissues in reconstructive surgery and suggest there is potential for collaboration between periodontal and medical specialists for the benefit of patients in need of such reconstructions. Broader awareness of these applications of oral soft tissue grafts could help expand their current uses and would allow practitioners to better answer possible patient inquiries. Clin Adv Periodontics 2017;7:215-220.

Key Words: Adipose tissue; mouth mucosa; palate; reconstructive surgical procedures; transplantation.

Background

The periodontal use of intraoral soft tissue grafts has been well documented since the 1960s.1-6 Before then, flap techniques were developed for various mucogingival indications, such as vestibuloplasty.7 The limitations of flap-based techniques created the need for alternative treatments, thus leading to the development of the free gingival autograft or free gingival graft (FGG)1. Over 50 years later, FGGs remain the “gold standard” for gingival augmentation.8

Besides the palatal masticatory mucosa, the source of FGGs and connective tissue (CT) grafts, other oral soft tissues have served as autologous graft donor sites. One such tissue is the buccal fat pad (BFP).9 Since its first comprehensive description in 1801,10 the BFP has been used to treat oral and maxillofacial defects such as hard and soft palate deformities, oroantral communications, fistulas, and retromolar deficiencies.11,12 The BFP has also been used for vestibuloplasty and root coverage procedures.11,12

Despite the voluminous literature on the intraoral uses of these orally harvested soft tissue autografts,2-6,13 the periodontal literature is lacking information on the possible uses of these grafts in several medical specialties, such as otolaryngology,14 ophthalmology,15 dermatology,16 plastic surgery,17 and urology.18 Treatment of defects in such disparate body areas as the nose,19 eyelids,20 vocal cords,21 nail bed,22 and urethra23 using intraoral soft tissue autografts represents another bridge, albeit a very different one from periodontal medicine, between mouth and body health. The purpose of this article is to review the use of oral soft tissue grafts, specifically FGGs, BFPs, and buccal mucosa grafts (BMGs), for extraoral indications.

Search Strategy

A targeted search of PubMed, the Cochrane Database, EBSCO, and Scopus using the following terms was initiated in November 2015 and updated through October 2016: buccal fat pad graft OR buccal mucosa graft OR free gingival graft OR intraoral soft tissue graft OR mucoperiosteal graft. Article titles and abstracts were reviewed, and those not pertaining to the topic of extraoral application were excluded. After identification, related articles were searched for relevant citations.

Search Outcome

Of the 4,271 retrieved articles, 378 were identified as relevant. Among those, 36 representative articles were chosen for inclusion herein.

Properties of Oral Soft Tissue Grafts Prevalent in Extraoral Use FGGs

FGGs, also called mucoperiosteal, palatal mucosal, or hard palate grafts in the medical literature, are typically harvested from the palate or other similar tissue quality and adequate quantity areas, e.g., edentulous ridges and the maxillary tuberosity (Figs. 1a and 1b).1 These grafts consist of thick keratinized epithelium and different amounts of fibrous CT (lamina propria) and deeper fatty/glandular tissue (submucosa), which vary based on patient/site anatomy and desired dimensions (length and depth of harvesting).24

BFPs

BFPs are bilateral anatomic structures that underlie the zygomatic processes and lie within the buccal and temporal superficial muscles of the face.12 They consist of encapsulated fat masses whose inferior portions extend into the buccal space, making them easily accessible via an intraoral route (Figs. 1c and 1d).25 Although BFPs are not technically intraoral tissues, their extensive intraoral harvest techniques and use as oral flaps warrant their inclusion in this review.11

BMGs

Although the buccal mucosa is frequently inspected for pathology or abnormalities, BMGs are uncommonly used in dentistry. Oral buccal mucosa is pliable and consists of stratified squamous epithelium with slightly vascular underlyingCT(Figs. 1e and 1f),23 has considerably greater surface area than other intraoral grafts, and is easily accessible. These properties make buccalmucosa a desirable source of soft tissue autograft for certain medical applications.23

Clinical Scenarios and Management

Oral Soft Tissue Grafts in Otolaryngology

Due to the proximity of the nose, throat, and ears to the oral cavity, otolaryngology is perhaps the most likely medical specialty to access and use oral grafts. The earliest reported intraoral graft use by otolaryngologists included an FGG applied after anterior tracheal resection due to an invading thyroid carcinoma.14 The authors stated that the FGG was “easy to handle,” provided both lining and supporting tissues for the trachea and proved “very successful.”14

FGGs have served as alternatives to auricular composite grafting for nasal deformity reconstruction, such as alar reconstruction after tumor resection.19 According to reports, FGGs “take well” in most patients, with failures relating to postoperative infection or tissue necrosis.19,26 The range of FGG shrinkage reported in such applications was frequently 11% to 15%, which is slightly less but comparable with FGG shrinkage after intraoral use.1 FGGs have also been used for hypopharyngeal defect correction.27

BFPs have been used primarily as alternative adipose donor sites for vocal cord augmentation. In a study of 10 patients with glottal closure deficiencies, BFPs were harvested, trimmed into 1-mm3 cubes, and injected into vocal cords.21 Most recently, BFPs have also been used for treatment of defects after removal of laryngeal cancers and neoglottal closure28 (Fig. 2).

Oral Soft Tissue Grafts in Ophthalmology

Ophthalmology is probably the medical specialty that first made use of oral grafts. The first published ophthalmic use of oral graft was in 1948, reporting BMG use for eye socket restoration.29 By the 1980s, multiple reports had described FGG use for diverse purposes, including eyelid reconstruction15,30, contracted socket correction31, trichiasis and cicatricial entropion,32,33 and posterior lamellar reconstruction.34 The publication of an FGG-harvesting guide for ophthalmic reconstructive surgery suggests a wide acceptance of FGGs for ophthalmologic use.35

Although not nearly as extensive, there are a few reports of periorbital reconstruction with BFPs36 and BMG use for contracted socket37 and corneal grafts with high success rates38 (Fig. 3).

Oral Soft Tissue Grafts in Dermatology and Plastic Surgery

As a relatively concealed donor site, oral soft tissues have been found useful for esthetic and dermatological needs, notably for lip reconstruction.39 FGGs have been used for repair of “whistling” lip deformities,40 while BFPs have been recently used for lip augmentation with good to excellent long-term esthetic outcomes.41 BFPs have been suggested for midfacial augmentation, facial reconstruction, and as an interpositional graft over the facial nerve to prevent Frey syndrome.25

Oral grafts have also found a niche in the treatment of nail bed defects. Studies describe use of FGGs after subungual exostosis resection,42 severe pincer-nail deformities,43 and onycholysis22 (Fig. 4). Authors investigated post-harvesting palatal healing and discomfort and reported that “retained periosteum caused hypertrophy of the donor site, leading to discomfort, especially in the young patient with a comparatively small defect.”44 It is noteworthy that the representative FGG donor site shown in the article is a 1 1 cm portion harvested directly along the midline of the posterior hard palate.44

Oral Soft Tissue Grafts in Urology

Oral grafts, mainly BMGs, have received extensive attention in urological surgery, especially for treatment of urethral strictures, where the natural patency of the urethra is compromised at one or more segments.45 The first published report on the use of BMGs for urethral repair in 199218 was quickly followed by numerous reports that have substantiated the effectiveness of BMGs for urethral reconstructions.23,45,46 Despite the lack of randomized clinical trials, systematic reviews have concluded that BMGs display many of the characteristics of an ideal graft for urethral reconstruction and, when properly used, can provide predictable outcomes.46 Furthermore, the post-BMG success rates of urethral reconstruction support BMG as the first-choice graft over the most common alternative (penile skin graft).45

BMGs have also been used to treat congenital urological malformations, such as repair of hypospadias and epispadias. 47,48 Furthermore, BMGs have been used for treatment of Peyronie disease, a condition marked by abnormal penile curvature due to scarring; significantly improved erectile function and 90% partner satisfaction during long-term follow-up have been reported.49

Discussion

FGGs, BFPs, and BMGs have found use in many unexpected environments. Table 1 lists extraoral procedures where oral grafts have demonstrated acceptable outcomes. Periodontists aware of the extraoral uses of oral soft tissue grafts will be prepared to answer possible questions from patients. The oral cavity represents a uniquely accessible source of versatile soft tissues, ranging from thick, durable tissue (FGG) to fatty, malleable tissue (BFP) to thin, flexible tissue (BMG). These attributes have led several medical specialties, including otolaryngology, ophthalmology, dermatology, plastic surgery, and urology, to establish a track record on the use of oral soft tissue grafts for a wide variety of reconstructive procedures to manage conditions ranging from eyelid deformities to erectile dysfunction.

The extraoral use of oral soft tissue autografts is not without limitations. Reported limitations include harvestable graft size,46 thickness,45 and long-term stability.45 Additionally, these grafts are susceptible to postoperative complications,45 such as infection and necrosis.19,26 The apparent lack of interdisciplinary approaches on this topic, evidenced by the largely independent development of the medical literature on oral soft tissue harvesting,34,43 seems to have resulted in harvesting complications that are typically avoided in the periodontal setting.44

Although not often stated explicitly, the reviewed articles suggest that the primary surgeon, especially in the case of otolaryngologists, was the one performing the oral graft harvesting. Reports of interdisciplinary approaches are limited; one dermatologic application stated that, in support of the dermatologist, the oral graft harvesting was performed by an otolaryngologist.50 The apparent lack of engagement of periodontists suggests there is untapped potential for collaboration between periodontal and medical specialists for the benefit of patients in need of such procedures.

Conclusions

The numerous successful extraoral uses of oral soft tissue autografts underscore the versatility of these tissues in reconstructive surgery and suggest there is potential for future collaboration between periodontists and physician colleagues for the benefit of patients in need of such reconstructions. Broader awareness of these applications of oral soft tissue grafts could help expand their current uses and would allow periodontal practitioners to better answer possible inquiries from patients.

Acknowledgment

The authors report no conflicts of interest related to this study.

CORRESPONDENCE:

Dr. Dimitris N. Tatakis, Division of Periodontology, College of Dentistry, The Ohio State University, 305 W. 12th Ave., Columbus, OH 43210. E-mail: tatakis.1@osu.edu.

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Division of Periodontology, College of Dentistry, The Ohio State University, Columbus, OH.

† Private practice, Athens, Greece.

Submitted October 25, 2016; accepted for publication February 20, 2017

doi: 10.1902/cap.2017.160076

Read the full article at http://onlinedigeditions.com/article/Extraoral+Uses+Of+Autologous+Oral+Soft+Tissue+Grafts%3A+A+Different+Bridge+Between+Mouth+And+Body+Health/2909021/445120/article.html.

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