The aim of this study was to compare the clinical results of pedicled buccal fat pad flap (PBFPF) with the standard buccal flap in the closure of oro-antral fistula (OAF). Twenty-two patients aged 25–56 years with oro-antral communication were randomly divided into two groups using Rand List 1.2 software. In group 1, OAF was treated with the classic buccal sliding flap and in group 2 a pedicled buccal fat pad was used. All patients were visited 48 h, 1 week and 1 month after surgery for assessment of primary (success of surgery) and secondary outcomes (pain, swelling, maximum mouth opening (MMO) reduction). Both methods were equally successful for the closure of OAF. The pain score was statistically greater in the experimental group ( U = 9, P = 0.001). MMO was statistically less in the experimental group 2 and 7 days after surgery ( P < 0.001). 1 month after surgery, no statistically significant difference was found in MMO between the two groups ( P = 0.09). In general, the PBFPF group had more pronounced swelling than the control group. Despite the statistical evidence, none of the patients complained of pain and swelling following the PBFPF procedure.
Oro-antral communication or fistula (OAF) is common following the removal of posterior maxillary teeth because of their close relationship to the maxillary sinus . Surgical closure of an antral perforation is indicated if the opening is greater than 4–5 mm at the time of injury, if a sinus disease is present whatever the size of the opening, and if the communication is persistent .
The most common surgical technique for closure of an acute oro-antral perforation is the buccal flap procedure described by R ehrmann . Great care must be taken to develop the flap with the correct undermining and horizontal periosteal releasing incisions to create a watertight closure without tension. Although it is a simple and versatile flap, which allows a simultaneous Caldwell-Luc operation, it has some disadvantages, of which the permanent reduction of vestibular height is the most important and could be a problem for edentulous patients requiring a prosthesis . Various techniques including local and distant flaps and grafts have been described for the closure of oro-antral communication, but most of them have potential disadvantages which preclude their widespread use in routine surgical practice .
Recently, a pedicled buccal fat pad flap (PBFPF) has been increasingly used in the repair of oro-antral communication. The procedure was introduced by E gyedi . The main reported disadvantage for this flap is the unpredictable limitation in mouth opening . When a surgical technique is selected it should be compared with the usual standard techniques. The aim of this study was to compare the clinical results of PBFPF with the standard buccal flap in the closure of oro-antral communication.
Materials and methods
22 patients aged 25–56 years with a chief complaint of oro-antral communication were included in this double-blind randomized clinical trial study. All the patients were referred to the Department of Oral and Maxillofacial Surgery in the Faculty of Dentistry, Tabriz University of Medical Sciences (Tabriz, Iran) from 2006 to 2008. After completing a consent form, the patients were randomly divided into two groups using Rand List 1.2 software. In group 1, oro-antral communication was treated with a classic buccal sliding flap and in group 2 a PBFPF was used based on the method used by H anazawa et al. . Subjects with any systemic problems affecting the healing process, smoking habits, drug and alcohol abuse, previous sinus disease, history of sinus surgery, presence of intra-antral foreign bodies and need for a Caldwell-Luc procedure were excluded from the study. Computed tomography and panoramic views were used to exclude patients with intra-sinus pathology or foreign bodies. All the patients were operated on within 7 days of fistula formation and those who were scheduled for the surgery after 48 h, underwent sinus lavage with normal saline for 3 days to reduce the odds of any suspected contamination. Local anaesthesia in both groups was administered via posterior and middle superior alveolar nerve blocks and greater palatine nerve block using two 1.8-ml dental cartridges containing 2% lidocaine and 1:80,000 epinephrine (Darupakhsh, Tehran, Iran). The fistula was exposed using a standard trapezoid buccal flap in both groups ( Fig. 1 ). The mesio-distal and bucco-palatal dimensions of the bony defect were measured with a periodontal probe after conservative removal of existing polyps ( Fig. 2 ). In group 1 (control), the area was closed by sliding the buccal flap over the fistula and suturing the flap to the undermined palatal mucosa using horizontal mattress sutures (3.0 chromic gut) ( Fig. 3 ). Periosteal hatches and palatal alveolar bone reduction were used as needed. In group 2 (experimental) the buccal fat pad was delivered to the surgical area using a small vertical incision at the depth of periosteal pocket as described by H anazawa et al. . The pedicled fat was gently transmitted over the defect avoiding excessive traction and sutured to the surrounding tissue with 3.0 chromic gut sutures ( Fig. 4 ). The elevated buccal mucoperiosteal flap was sutured in its original position to minimize the reduction of buccal sulcus depth. Postoperative care was the same in both the groups, including oral antibiotics (co-amoxyclav 625 mg, tid), systemic and local decongestants and analgesics (ibuprofen 400 mg, qid) for 7 days. The patients were instructed to eat soft meals for 10 days and to protect the repaired area.
All the patients were visited 48 h, 1 week and 1 month after surgery to assess the primary (success of surgery) and secondary outcomes (pain, swelling and reduction in mouth opening). Surgery was considered successful in the absence of wound dehiscence 1 week after the operation and negative nose blowing 1 month later. Postoperative pain was measured by patients’ rating 12 h after surgery using a visual analogue scale (VAS) of 100 units on a three-point scale with: 0–34 as mild pain, 35–64 as moderate pain and 65–100 as severe pain. The patients were also asked to mark the degree of their pain on a graphic rating scale.
According to the technique used by Chukwunke et al., postoperative swelling was evaluated by multiplication of two measurements: tragus–commisure and lateral cantusn–gonial angle lines and compared with the preoperative values at 48 h and 1 week postoperatively using the following formula :
Postoperative value − preoperative value Preoperative value × 100 = % of facial swelling