<p>The therapeutic approach for buccosinusal fistula (BSF) requires careful consideration of factors such as infection status, bone defect size, and epithelialization. The literature describes three primary treatment options: vestibular flap, buccal fat pad, and palatal flap. This study aims to report a clinical case of recurrent BSF after five surgical interventions and review current literature on treatment modalities. A 42-year-old female patient underwent extraction of the upper left first molar, followed by alveolar bone grafting, evolving into buccosinusal communication (BSC). Over 45 days, she underwent five surgical interventions using the vestibular flap technique, which failed to prevent epithelialization and led to aesthetic and functional complications, such as facial asymmetry and displacement of the parotid papilla. As an alternative, a rotated split palatal flap was employed. After six months of follow-up, complete closure of the BSC was observed, with no signs of sinus pathology or raw areas at the donor site, indicating satisfactory healing and successful treatment. Literature shows that while vestibular flaps are commonly used, they often fail in large or recurrent defects due to tension and limited vascularization. Buccal fat pads offer good coverage but may not suffice for extensive areas. Palatal flaps stand out for their robust blood supply from the greater palatine artery, thicker tissue, and high success rates, particularly in previously treated cases. Thus, they are strongly indicated for refractory BSF cases. The palatal flap is an effective, reliable alternative for BSF management, especially in complex cases.</p>