The OACs and OAFs are a possible complication during the procedures of oral and maxillofacial surgery.
The main etiology for OAC was tooth extraction (92,63–95%) with similar prevalence between right (49%) and left (51%) side4,22.
Most of the authors stated that the commonest site was the first molar region2,23−30.
Other authors, such as Güven31 affirmed that the commonest site was the second molar region while Pourmand et al.32 and Franco-Carro et al.22 observed how OAF was the most common complications after wisdom-tooth removal and the risk of OAF correlated with increasing patient age.
Punwutikorn et al.2 state thar the size of the maxillary sinus is at is greatest during the third decade of life, making this period the one with the highest incidence of OACs. In their study the highest incidence was observed in the age group of 60 and over.
Over time, various techniques have been proposed, among them the buccal advancement flap and buccal fat pad were one of the first described and currently remain among the most widely adopted solutions by surgeons7,8,12.
The most important factors to consider when choosing the OAF closure technique are the size and location, but also the condition of the available tissue9.
Additional evaluation criteria for deciding which technique to use are the quantity and quality of tissue in the affected site and the surgeon's experience33.
Many surgeons choose, as the first line of treatment, buccal advancement flap for the closure of small communication or minor fistula for advantages such as relative simplicity of the surgical technique, adequate blood supply of the flap and the possibility to mobilize adequately the flap. Flap mobility is enhanced and ensured by making parallel incisions in the periosteum at the base of the flap8,9,26,34.
The use of BFP for closure of medium size OAF (diameter between 1 and 4 cm) was described for the first time by Egyedi in 197712. This simple and reliable surgical technique presents several advantages such as excellent blood supply particularly necessary when the receiving site is poorly vascularized, adequate and easy mobilization, good epithelialization of the uncovered fat in the 2–4 weeks post surgery1, 35, the lack of a visible scar at the donor site30,36, high success rate, low patient morbidity1,7,13−15 and regenerative potential of Bichat fat pad through pluripotency cells37. Moreover, the volume of Bichat’s fat pad has larger dimensions in childhood and is relatively consistent in both sexes and persists in the case of weight loss or subcutaneous fat loss38,39.
The main disvantages of BFP are that it can be harvested only once15 and a small depression in the cheek-area may be caused by the procedure, but the contro-lateral fat pad usually does not need excision because asymmetry is not excessive36. Nevertheless, Egyedi12 pointed out that no significant depression in the cheek-area was noticeable.
When correctly dissected and mobilized, the BFP allows to obtain a pedicle graft up to 7 x 4 x 3 cm40. Egyedi12 suggested for the first time the possibility of closing OAF up to 4 cm in diameter, subsequently Tiedeman et al.41 observed how defects up to 3 x 5 cm in size can be covered without compromising its rich vascularity. In the study by Fujimura et al.42 the authors managed to close a defect measuring 6 x 5 x 3 cm.
According to the results obtained by Bhatt et al.19 and Al Nashar et al.21 and supported by other authors, the loss of sulcus depth was statically significant after immediate surgical closure with Rehrmann’s buccal advancement flap as compared to BAF. Moreover, Von Wowern17 showed how in 50% cases the reduction of vestibular height was permanent, corresponding to the extension of the flap. It is therefore recommended to use the BFP where loss of sulcus depth is of concern35,43,44, especially when the site needs to be prepared to receive a prosthesis33,35,43.
Several authors suggest the use of BFP when the Buccal advancement flap or other techniques have failed35,43−47 and when there is the damage of buccal or palatal mucoperiosteum7,35,43.
In the meta-analytic study conducted by Franco-Carro et al.22 few complications related to the use of buccal flaps were noted (15.58%) as well as complications related to the treatment with Bichat fat pad (16.68%).
The study by Alonso-González et al.48 indicates that patients after 6 months were very satisfied (9.1/10) with the BFP treatment and with aesthetic, phonetic and chewing results.
Shukla et al.49 observed how postoperative pain was higher with the use of BFP compared to BAF after the first days. From the 14° day onwards the pain was drastically reduced and from the 21° day no pain was reported by any patient. Postoperative edema is higher with the use of the BFP compared to the BAF, after 21 days the edema has completely resolved in all patients.