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National Journal of Maxillofacial Surgery
 
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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 140-145  

Buccinator muscle repositioning: A rare case report, short discussion, and literature review


1 Department of Periodontology, Ahmedabad Dental College, Ahmedabad, Gujarat, India
2 Department of Dentistry, Moti Lal Nehru Medical College, Prayagraj, Uttar Pradesh, India
3 Department of Periodontics, Kalinga Institute of Dental Sciences, Bhubaneswar, Odisha, India
4 Department of Periodontics, Pacific Dental College and Hospital, Udaipur, Rajasthan, India

Date of Submission22-Jan-2019
Date of Acceptance07-Jun-2019
Date of Web Publication18-Jun-2020

Correspondence Address:
Dr. Nirma Yadav
Department of Periodontology, Ahmedabad Dental College, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njms.NJMS_8_19

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   Abstract 


Anatomical abnormalities are commonly associated with many problems. Among all anomalies, one is crestal attachment of the frenum or muscle on the alveolar process. Crestal attachment of the buccinator muscle is a rare phenomenon. It may cause various problems in routine oral exercises or restore the edentulous area. The present case report is a case of abnormal buccinator muscle attachment, which was relocated apically by surgical means using an acrylic stent. The healing was uneventful, and significant apical repositioning was observed. The area was then considered for implant placement. An implant was placed, and the long-term results were assured because the patient could maintain oral hygiene well after the muscle repositioning.

Keywords: Acrylic stent, buccinator muscle, edentulous ridge, muscle abnormality, vestibular fornix (depth)


How to cite this article:
Yadav N, Kumar A, Manohar B, Shah M, Shetty N. Buccinator muscle repositioning: A rare case report, short discussion, and literature review. Natl J Maxillofac Surg 2020;11:140-5

How to cite this URL:
Yadav N, Kumar A, Manohar B, Shah M, Shetty N. Buccinator muscle repositioning: A rare case report, short discussion, and literature review. Natl J Maxillofac Surg [serial online] 2020 [cited 2020 Sep 21];11:140-5. Available from: http://www.njms.in/text.asp?2020/11/1/140/287127




   Introduction Top


Buccinator muscle is a thin quadrilateral cutaneous muscle derived from the second arch which forms the lateral wall of the oral cavity. It is formed by mixture of three bundles extended into check from the pterygomandibular ligament to the modiolus. A healthy periodontal complex is the one which is capable of withstanding the stress of mastication, toothbrushing, trauma from foreign objects, tooth preparation associated with crown and bridge, subgingival restorations, inflammation, and frenum pull.[1] A frenum is a fold of mucosal membrane that attaches the lips and cheeks to the alveolar process and limits their movements.[1] Similarly, muscle attachments near the crest of the alveolar bone in edentulous areas or near the marginal tissues in dentate areas may create problems mimicking those of high frenal attachments.

Insertion of buccinator muscle:

  • Forward origin – orbicularis internus of lip
  • Downward (posterior) – with development of face creating a change in vertical dimension due to eruption of deciduous teeth.


Buccinator muscle is overlaid by –

  • Risorius muscle which retracts the angle of the mouth as in grinning
  • Orbicularis oris – encircles the mouth
  • Masseter – elevates the jaw and clenches the teeth
  • And finally, insertion of platysma neck muscle among others.


Buccinator muscle protects the food from accumulating in the buccal pouches, prevents injury to buccal mucosa by compressing the cheek, and salivary glands produce saliva for softening the food and initial digestion.

Most textbooks briefly and superficially describe the role of the buccinator as controlling the bolus during mastication, keeping food between tooth surfaces by “compressing the cheeks,” and preventing injury of the buccal mucosa.[2]

Cohen[1] suggested that the frenum must always be removed when it is so thick and wide that it may interfere with toothbrushing. For the same reason and also for the purposes of appropriate prosthodontic management, coronally attached muscles may require apical repositioning if not resection.

The buccinator muscle may pose problems similar to thick, wide, and crestally attached frenum in the region of molars near its origin over the jaw bones. It is usually described as having predominantly horizontal fibers arising from the pterygomandibular raphe and from the alveolar bone of the maxilla and mandible and running anteriorly to interdigitate with the fibers of the orbicularis oris in the corner of the mouth, which composes the mobile and adaptable portion of the cheek.[2],[3]

The superior constrictor muscle, buccinator muscle, and orbicularis oris muscle function as a unit in the acts of swallowing, blowing, sucking, pronouncing vowels, chewing, and coughing. The buccinator and orbicularis oris play a major role in beginning the swallow by producing a peristaltic-like wave of contraction, originating in the oral cavity and passing pharyngeally. The buccinator usually initiated the sequence followed quickly by the orbicularis oris.[3] Furthermore, Kang et al.[4] have described a tentative physiological role, suggesting that they act as a dilator of the parotid duct, as the buccinator muscle fibers extend to the terminal portion of the duct.


   Case Report Top


A 23-year-old female patient was referred to the department for the management of a mandibular partial edentulous area having high muscle attachment. The patient was being considered for an implant placement for missing mandibular right first permanent molar (Teeth no. 46). The high muscle attachment was considered to be an impediment for proper implant placement and in maintaining proper oral hygiene. The patient's main chief complaint was difficulty in chewing food because of the missing tooth and food lodgment due to high muscle attachment in the mandibular region (46).

Intraoral examination and medical history

On examination, patient medical history was unremarkable, with no report of incidents of trauma and infections. On examination, the patient was a well-built, well-nourished, well-oriented, and mentally sound adult. No medical history and no extraoral abnormalities were detected. The patient did not indulge in tobacco or alcohol chewing habit.

Intraoral examination showed good oral and periodontal hygiene. Tooth no 46 was missing, and the extraction was done because of the decayed teeth. The height and width of the edentulous ridge were maintained. On retracting the cheek, a frenum-like band of soft tissue attached at the crest of the edentulous ridge was observed. On closure examination, anatomic reference points and the nature of the attached tissue revealed that it was the buccinator muscle whose attachment was abnormal. The origin of the attachment extended to the crest of the alveolar ridge. The vestibular depth was almost nonexistent in that area [Figure 1].
Figure 1: Fan-shaped buccinator muscle attachment at the crest of the alveolar ridge

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The attachment of the muscle leads to the difficulty in movements of the toothbrush, leading to suboptimal oral hygiene. The attachment would have definitely created a space problem for the implant placement and, because of the food impaction in that area, may further worsen the situation. A decision to reposition the attachment apically was undertaken. Muscle repositioning treatment was discussed with the patient. The patient accepted the apical repositioning with an acrylic stent treatment option and gave written consent.

Investigations

Routine blood investigations were carried out and were found within normal limit.

Treatment

An alginate impression of the lower arch was taken, and a cast was made in dental stone. It was decided to construct an acrylic surgical stent, as a periodontal dressing would not have stayed in proper apical position due to counteracting forces created by high muscle attachment. Approximating the anticipated loss of tissue resulting from the surgical procedure, the patient's cast was marked and scored to ensure close contact of the acrylic surgical stent with the alveolar ridge [Figure 2]. A passive fit of the acrylic surgical stent was checked in the patient's mouth, and the final adjustments were made. The stent was then smoothed and highly polished to minimize the accumulation of plaque [Figure 3].
Figure 2: Acrylic surgical stent was prepared on the cast

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Figure 3: Smoothed and highly polished acrylic surgical stent with the final adjustments

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Local anesthetic (2% lignocaine with 1:80,000 epinephrine) was administered, and a crestal incision was made, keeping the incision slightly buccal [Figure 4]. The incision was extended anteriorly two teeth and posteriorly distal to the last molar. The muscle attachment was detached from the crest, and dissection was continued inferiorly for approximately 1 cm–2 cm. Deeper to that, the dissection continued apically keeping the periosteum intact. The vestibular depth and muscle repositioning were checked by retracting the cheek [Figure 5]. After adequate depth was achieved, the surgical area was irrigated with normal saline, the bleeding controlled, and the surgical stent stabilized in the surgical area [Figure 6].
Figure 4: Crestal incision was made slightly buccal

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Figure 5: Surgical detachment of buccinator and vestibular extension

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Figure 6: Bleeding controlled and the surgical stent stabilized in the surgical area

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Postoperative instructions were explained to the patient, and a course of antibiotics and analgesics were given for 5 days. The patient was recalled after 7 days for reevaluation [Figure 7]. The stent was retained in position for 15 days to allow complete healing with regular normal saline irrigations and oral hygiene instructions. The area healed uneventfully without any complication. Adequate vestibular depth was achieved after 2 months of healing [Figure 8], there was the significant gain in vestibular depth, and the muscle was relocated to an apical position, thus allowing the toothbrush head to be positioned properly for maintenance of proper oral hygiene. The implant placement was done after 3 months of complete healing.
Figure 7: One week postoperative

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Figure 8: Two months postoperative

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   Discussion Top


The oral cavity is always a challenging anatomical area for every dentist or practicing specialty oral and dental surgeons due to its close proximity relationship with numerous structures such as glandular, soft tissue, and osseous. The pterygomandibular raphe is fibrous band which serves as an origin point for buccinator and superior constrictor muscle.[5] The buccinator (Latin word means trumpet player), also known as trumpet muscle, is an important muscle in mastication, which forms the anterior part of the cheek or the lateral wall of the oral cavity, and it is well known that it helps in mastication by maintaining bolus position. The buccinator muscle in inclusion with the orbicularis oris and superior constrictor muscle performs the function as follows:

  • Helps in pushing back food on the occlusal surface, swallowing, smiling, and blowing
  • Helps in sucking and pronouncing bowel
  • Chewing and coughing.


In the year 2006, Kang et al.[4] have described a tentative physiological role, suggesting that they act as a dilator of the parotid duct, as the buccinator muscle fibers extend to the terminal portion of the duct. In normal condition, buccinator muscle fibers are attached in the region of molar or premolar region. The malposition of buccinator muscle in the oral cavity can create problems in speech along with difficult and slurred functioning due to its rare aberrant attachment on the vestibular region or inappropriate anatomic location attachment. It originates from three areas as follows:

  1. Alveolar process of the maxilla and fibrous structure
  2. Alveolar process of the mandible and fibrous structures
  3. Pterygomandibular raphe with one more muscle superior pharyngeal constrictor muscle of the pharynx.


Various reasons can be for buccinator abnormal anatomical locations, in which few are as follows:

  • Can be due to iatrogenic injury during or postoperative traumatic extractions in patients with decreased alveolar height
  • Loss of soft tissue
  • Loss or decreased vestibular height due to any periodontal disease or gingival recession
  • Atrophic alveolar ridge
  • Can be due to hyperactivity of buccinator (presumably thickening it and putting pressure on the underlying hard tissues).[6]


In our reported case, negligible vestibular depth after traumatic extraction along with less attached gingiva on buccal aspect and almost crestal positioning of mucogingival junction precluded proper positioning of the toothbrush.[3],[6] Treatment for buccinator reposition is a combination of frenectomy and vestibular extensions. Gingival augmentation would have also been another option for buccinator reposition, as the American Academy of Periodontology[7],[8] recommends that gingival augmentation procedures should be performed to prevent soft-tissue damage in the presence of alveolar bone dehiscence during natural or orthodontic tooth eruption, to halt progressive recession of the gingival margin, to improve plaque control and patient comfort around teeth and implants, and to increase the insufficient dimension of gingiva in conjunction with fixed or removable prosthetic dentistry.

In a anatomical study done by Kang et al. in the year 2006[4] on buccinator muscle fibers (based on anterior to exterior position) extending to the terminal portion of parotid duct and finally concluded that muscle fibers extend in three different locations which are as follows:

  1. Type I was originating from the anterior and posterior aspects of the duct and extended to the terminal portion of the parotid duct
  2. In Type II, buccinator muscle fibers originated from the anterior aspect of the duct and inserted into the anterior aspect of the duct
  3. In Type III, buccinator muscle fibers originated from the posterior aspect of the parotid duct and ran posteriorly to the duct.


As Bradin[9] reported, “for vestibular extensions to be successful, pack should be in position for at least 3 weeks. Many cases fail because packs cannot be maintained. The pack should go down to the area of depth required and be maintained. Packs are frequently displaced in an incisal direction, while they are still setting and this will interfere with the desired result. Aids in pack retention such as wire ligature, copper bands, or stents can be employed at various times.”

Hur done a observational study in the year 2017 and concluded that the connecting fascia between the buccinator and tendons of the temporalis and the inferior fibers of the buccinator that were attached to the deep tendon of the temporalis could assist in coordination of the movements of the mandibular region and the mouth angle in the timing and strength of contraction of the muscles during mastication, facial expression, and speech.[10]

Z-plasty technique is a technique widely used in plastic surgery for the improvement of functional and cosmetic appearance of scars. This technique is nowadays used in dermatological procedures such as ectropion, lip alignment, and bifid earlobe.

In the specialty of periodontics, Z-plasty technique is used for the improvement of denture-bearing areas and most commonly used in tongue ankylosis, frenectomy, etc., and for improvement of buccinator muscle, we, as a periodontist, find this technique to be more suitable for this reported case.

Moreover, choosing the same technique used in the aforementioned case report was because of the following:

  • Achievement of proper alignment and symmetry of buccinator muscle
  • Minimum chances of reoccurrence
  • Minimum chance of postoperative complications
  • Excellent healing and prognosis.


  • The other techniques which can be used

  • Laser surgery with acrylic stent
  • Electrosurgery with acrylic stent.



   Conclusion Top


In general, buccinator muscle is not considered as the muscle of facial expressions, but this muscle is well developed in musicians who play a brass instrument, and many other muscles overlie and few intermingle with buccinator muscle, so it is involved in facial expression with all other muscles. Role of custom fabricated surgical acrylic stent in surgical correction (either by surgical blade or laser or electrocautery) of buccinator muscle was to prevent the erroneous reattachment of muscle fibers.

Various techniques[11],[12] have been proposed for increasing the vestibular height which are as follows:

  • Vestibuloplasty using skin grafts (free gingival or split thickness) preferred
  • Various epithelization techniques (less effective)
  • Use of surgical acrylic stents.


Inappropriate attachment of buccinator muscle can raise many problems as follows:

  • Lack of oral hygiene
  • Faultless prosthodontics treatment
  • In mastication
  • Speech and chew movements.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Cohen ES. Atlas of Cosmetic and Reconstructive Periodontal Surgery. 3rd ed. Hamilton: BC Decker Inc.; 2007. p. 247.  Back to cited text no. 1
    
2.
Standring S, Borley NR, Collins P, Crossman AR, Gatzoulis MA, Healy JC, et al., editors. Gray's Anatomy. Vol. 40. Spain: Churchill Livingstone Elsevier; 2008. p. 487.  Back to cited text no. 2
    
3.
Perkins RE, Blanton PL, Biggs NL. Electromyographic analysis of the “baccinator mechanism” in human beings. J Dent Res 1977;56:783-94.  Back to cited text no. 3
    
4.
Kang HC, Kwak HH, Hu KS, Youn KH, Jin GC, Fontaine C, et al. An anatomical study of the buccinator muscle fibres that extend to the terminal portion of the parotid duct, and their functional roles in salivary secretion. J Anat 2006;208:601-7.  Back to cited text no. 4
    
5.
Law CP, Chandra RV, Hoang JK, Phal PM. Imaging the oral cavity: Key concepts for the radiologist. Br J Radiol 2011;84:944-57.  Back to cited text no. 5
    
6.
Dutra EH, Caria PH, Rafferty KL, Herring SW. The buccinator during mastication: A functional and anatomical evaluation in minipigs. Arch Oral Biol 2010;55:627-38.  Back to cited text no. 6
    
7.
D'Andrea E, Barbaix E. Anatomic research on the perioral muscles, functional matrix of the maxillary and mandibular bones. Surg Radiol Anat 2006;28:261-6.  Back to cited text no. 7
    
8.
Ainamo A, Bergenholtz A, Hugoson A, Ainamo J. Location of the mucogingival junction 18 years after apically repositioned flap surgery. J Clin Periodontol 1992;19:49-52.  Back to cited text no. 8
    
9.
Bradin M. Precautions and hazards in periodontal surgery. J Periodontol 1962;33:154-63.  Back to cited text no. 9
    
10.
Hur MS. Anatomical connections between the buccinator and the tendons of the temporalis. Ann Anat 2017;214:63-6.  Back to cited text no. 10
    
11.
Dorfman HS, Kennedy JE, Bird WC. Longitudinal evaluation of free autogenous gingival grafts. A four year report. J Periodontol 1982;53:349-52.  Back to cited text no. 11
    
12.
Thoma DS, Benić GI, Zwahlen M, Hämmerle CH, Jung RE. A systematic review assessing soft tissue augmentation techniques. Clin Oral Implants Res 2009;20 Suppl 4:146-65.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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