Comparison Between Buccal Fat Pad Flap and Buccal Advancement Flap for Closure of Oroantral Fistula: A Systematic Review

Abstract

Purpose: The aim of the present study was to evaluate the success rate of two different surgical techniques used to close oroantral fistula.

Material and Methods: A systematic Review was conducted based on the PRISMA guideline. Selected reports from electronic databases (PubMed, LILACS, Semantic Scholar, Cochrane Library, Rutgers University Library and Europe PMC) for studies conducted from 1959 to 2021 were initially evaluated. The inclusion criteria were recent English-language studies, all human studies and studies comparing buccal fat pad (BFP) and buccal advancement flap (BAF).

The research individuated 1455 records. After screening, only 4 studies were assessed; 1 retrospective study and 3 comparative studies.

Results: The pooled RR was significant, showing a probability of success of Buccal Advancement Flap slightly lower than the Buccal Fat Pad Flap for closure of an oroantral fistula (RR 0.914, 95% CI: 0.836 - 0.998). Heterogeneity between the included studies was absent (I2 0.0%, P=0.452).

Conclusion: Both techniques are safe, simple and with a high success rate. BFP is ideal in the closure of oroantral fistulas of more than 5 mm, when it is necessary to preserve the depth of the vestibular sulcus or when the buccal advancement flap fails.

Introduction

Oroantral communications (OACs) occasionally occur during oral and maxillofacial surgery. Usually, an OAC less than 2 mm in diameter will close spontaneously, but when a defect of more than a 3 mm is present, or there is inflammation in the antrum or periodontal region, the opening often persists and requires surgical closure ^1,2.

Immediate closure of OACs, preferably within 24 to 48 hours, is recommended to minimize the risk of maxillary sinusitis and the development of a fistula³.

Oroantral fistula (OAF) is an epithelialized communication between the oral cavity and the maxillary sinus which has its origin from the extraction of upper molars as the most common etiologic factor (incidence between 0.31% and 4.7%), followed by cysts, tumors, trauma, osteonecrosis, implant failure, dehiscence following failure in atrophied posterior maxilla and other pathological entities^4,5.

Several methods of surgical OAC repair have been described. The treatment strategies for OACs that we found in literature were divided into the following groups by Visscher’s classification⁶: autogenous soft tissue grafts, autogenous bone grafts, allogenous materials, xenografts, synthetic/metals closure, and other techniques, in 2018 new techniques were included in this classification by Parvini et al⁷.

The most common and oldest surgical technique used for the closure of minor OAF is the buccal advancement flap (BAF), also known as the Rehrmann flap, for the adequate blood supply, simplicity, versatility and high success rate^8,9.

Another common technique for the closure of OAF is to use buccal fat pad (BFP), an anatomical structure identified by Heistern in 1732 such as “molar gland”¹⁰, the adipose nature of this structure was described by Bichat in 1801 and since that time it was commonly called “Bichat’s fat pad” ^10,11.

The use of BFP for closure of medium size OAF was described for the first time by Egyedi¹² in 1977 for its various advantages such as simple surgical procedure, high success rate, adequate mobility, good epithelialization of the uncovered fat, potential source of stem cells and rich vascularity (derived from the buccal and deep temporal branches of the maxillary artery, transverse facial branches of the superficial temporal artery, and small branches of the facial artery)^1,7,13−15.

Materials And Methods

Discussion

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%) side^4,22.

Most of the authors stated that the commonest site was the first molar region^2,23−30.

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 surgeons^7,8,12.

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 flap^8,9,26,34.

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 surgery^{1, 35}, the lack of a visible scar at the donor site^30,36, high success rate, low patient morbidity^1,7,13−15 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 loss^38,39.

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 concern^35,43,44, especially when the site needs to be prepared to receive a prosthesis^33,35,43.

Several authors suggest the use of BFP when the Buccal advancement flap or other techniques have failed^35,43−47 and when there is the damage of buccal or palatal mucoperiosteum^7,35,43.

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.

Results

Three studies highlighted a lower probability of success of BAF than BFP. Only the study of Rashid et al.²⁰ reported opposite results. Nevertheless, study-specific relative risks resulted non-significant. However, the pooled RR was significant, showing a probability of success of BAF slightly lower than BFP for closure of oroantral fistula (RR 0.914, 95% CI: 0.836–0.998). Heterogeneity between the studies was absent (I² 0.0%, P = 0.452).

Figure 2. Forest Plot; Comparison Between Buccal Fat Pad Flap and Buccal Advancement Flap.

Conclusion

No randomized clinical trials (RCTs) meeting the selected inclusion criteria were identified in this systematic review. Furthermore, the number of patients treated in the different studies was quite small and no further studies were implemented on a larger number of patients.

Considering the risk of bias estimated in the study as moderate-high, the interpretation of the results must be carefully considered.

The choice of the technique to be used must be evaluated on the basis of factors such as the clinical experience of the surgeon, the specific conditions of the patient and the advantages / disadvantages of the chosen technique.

Both techniques are safe, simple and with a high success rate. BFP is ideal in the closure of oroantral fistulas of more than 5 mm, when it is necessary to preserve the depth of the vestibular sulcus or when the buccal advancement flap fails.

Declarations

FUNDING

There was no founding for this article. 

CONFLICTS OF INTEREST

The authors declare no conflicts of interests.

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