Oroantral communicating defects can arise secondary to dental infection, osteomyelitis, sequelae of radiation therapy, trauma, or the removal of maxillary cysts or tumors. These defects are often observed after tooth extraction in patients who have severe sinus pneumatization [2]. The extraction of maxillary posterior teeth is the most common reason of the defect because of the proximity of the apices of the bicuspids and molars to the antrum and the thinness of the antral floor (ranging from 1 to 7 mm).
The sizes of oroantral defects vary from small (1 to 2 mm in diameter) to large (over 5 mm in diameters) fistulae [2,3,4]. Although the size, location, and etiology differ from case to case, the soft tissue defect with difficulties in wound healing is an important feature. An oroantral defect less than 2 mm in diameter will usually close spontaneously, but when the defect exceeds 3 mm3, or there is inflammation in the antrum or periodontal region, the defect often persists and leads to chronic maxillary sinusitis. Various methods for closure of the defect have been reported, including a pedicled graft of the buccal fat pad [5, 6].
Since the introduction of the buccal fat pad for reconstruction of a maxillary defect in 1977 [1], many applications have been studied and introduced. A pedicled buccal fat pad can be used for epithelialization without additional skin graft procedures. Buccal fat pads have many advantages over other types of flaps [7, 8]. The surgical procedure is simple and has shown a high success rate in various applications [9, 10]. The rich vascularity of the buccal fat pad is an advantage when it is used in a poorly vascularized recipient site. Many studies have reported a high success rate (95%) using buccal fat pad procedures because of the high vascularity of the flap and its proximity to the recipient site. In addition, the surgical procedure for grafting is straightforward [11,12,13].
In the present cases, the large defects were successfully covered using buccal fat pads. Without the pedicled flap, large defects may not be covered by soft tissue. In case 1, primary closure of the gingiva was possible without reconstruction. However, the inner area of surgery could not be covered with well-healed epithelium without reconstruction and could not be supported by bony tissue due to resorption of bony tissue. Without reconstruction, the defect would remain and wound dehiscence would have developed. According to the follow-up examination and the radiologic data, the defect did not progress to fistula or become the source of chronic sinusitis. After the surgical reconstruction, the defect was successfully epithelized and bony defects were well covered without signs of inflammation or patient discomfort. In case 2, the defect was too large to be sutured primarily. Therefore, the pedicled buccal fat pad was used to cover the defect and primary closure was mostly achieved. At the follow-up visit after surgery, no evidence of dehiscence or recurrence was observed. In case 3, primary closure was impossible after surgical removal of a recurrent ameloblastoma lesion. Therefore, the pedicled buccal fat pad was harvested to cover the defect. The wound was exposed due to failure of gingival closure; however, the exposed fat pad was well epithelized on the operation site. The surgical wound healed perfectly without any complications. In summary, reconstruction using a pedicled buccal fat pad had the following advantages: straightforward harvest, immediate closure of the oroantral communicating defect, short surgery time, and reduced financial cost.
In conclusion, the buccal fat pad for reconstruction of large oroantral defects is a useful and straightforward alternative method for the reconstruction of various-sized surgical defects of the maxillary posterior area and even for large oroantral defects. Furthermore, reconstruction surgery using a pedicled buccal fat pad can prevent many complications that may lead to chronic inflammation of operative site and can promote epithelization of the defect site. These findings support the use of the buccal fat pad for reconstruction in the oral and maxillofacial region.