Based on a case of reconstruction after oncologic resection of the hard palate, the authors document the key technical points for harvesting a posterior-based buccinator myomucosal flap (Bozola's flap), and its limitations and indications after oncologic resection of tumors originating from the oral cavity and/oropharynx.
An 87-year-old patient was referred by his dentist for multiple tooth extractions following pain on the lower right jaw (quadrant 4) and one month of unsuccessful antibiotics treatment. The patient had a medical history of slow progressing myeloma for more than two years with no treatment required, chronic kidney failure and atrial fibrillation. Extraoral examination revealed a right submandibular lymphadenopathy. Intraoral examination revealed severe periodontitis characterized by poor oral hygiene, tooth mobility especially in the molars sectors (score 3 and 4 of Muhlemann) and necrotic gum on quadrant 4. The patient also reported spontaneous loss of teeth. The orthopantomogram (OPT) showed a radiographic bone loss extending to mid third of the roots and beyond. The patient was treated by apixaban and bisoprolol. He had never received biphosphonate or RANK/RANKL inhibitor. The main complaint was pain in quadrant 4. Teeth 45 46 47 were hopeless and their extraction was planned. Extractions were performed with no premedication. After local anesthesia, analgesia was hard to obtain. The extractions revealed a necrotic aspect of the underlying bone and a biopsy was performed looking for osteitis or malignant disease (Fig. 1). Medication-related jaw osteonecrosis was excluded after exhaustive anamnesis. A CBCT was performed to evaluate the extension of the bone necrosis. At this stage it was not informative (Fig. 2). At follow-up appointment two weeks later, a worsening of the wound was observed, with pain preventing alimentation. A new CBCT was performed and showed small radiolucent lesions in the cortical bone surrounding the extraction site (Fig. 2). Surprisingly, histological result was in favor of actinomycosis.
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