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7/31/2019 Chandramohan OAF
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ORO-ANTRAL FISTULA
Presented By
Dr. Chandramohan. ChintaIII MDS
Division of Oral and Maxillofacial Surgery
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AETIOLOGY
An oro-antral fistula is an unnatural communication between the
mouth and the maxillary sinus and it can result from several causes, for
example, the extraction of teeth or through massive trauma to the face,
surgery to the maxillary sinus, osteomyelitis of the maxilla, gumma
involving the palate, infected upper implant dentures and as a result of
such rare diseases as malignant granuloma.
The most common cause of an oro-antral fistula is the inadvertent
opening if the maxillary sinus during sinus during the extraction of anupper tooth, for the root apices of the upper canine, premolars and
molars lie in immediate proximity of the floor of the air space. Indeed
apices of adjacent teeth sometimes intrude into the antral cavity and are
only separated from the lining membrane by the socket wall.
Large maxillary sinus are especially at risk to a disruption of the
antral floor, while the accident is less prone to occur in young persons
whose antra have not yet reached adult size. The thickness, too, of the
sinus floor appears to vary from individual to individual as a personal
characteristic. Tooth removal may be difficult and be associated with an
obvious fracture of the antral floor, a fragment of the floor of the
maxillary sinus may be detached together with one or more of its
associated teeth. The most common accident of this nature is a fracture
of the tuberosity together with the upper third and/or second molar, but
any of the maxillary teeth from the canine backwards may be involved.
Rarely the entire floor of the maxillary sinus is detached together with its
associated teeth, the resulting fistula being huge. Displacement of an
upper tooth or root into the maxillary sinus also produces a fistula and in
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this respect the upper third molar tooth and the palatal root of the upper
first molar are especially liable to be involved.
Forceps extraction of a solitary isolated premolar or molar in an
edentulous part of the arch, the root or roots of which are enveloped by
the antral air space, is also prone to cause disruption of the sinus floor.
Rarely the extraction of an upper posterior tooth associated with
periapical disease, e.g., acute periapical abscess, chronic granuloma or
periapical sclerosis may be complicated by antral perforation. The
surgical removal of impacted (e.g. canine, premolar, third molar
supernumerary), submerged or geminated upper teeth certainly carries a
risk of an inadvertent breach of the antrum , as does apicectomy on roots
adjoining the sinus periphery. 'Blind' instrumentation, with out adequate
surgical exposure, in the attempted retrieval of retained apices in the
upper posterior quadrant is likewise a hazardous.
Facial Trauma
Oro-antral fistulae may occur following massive trauma to the
middle third of the facial skeleton, especially if the face is struck by
missiles or if a sharp object is driven through the mouth into the maxillary
sinus. Penetrating injuries-gunshot wounds in particular-may create huge
defects of the sinus walls.
Surgery
The fenestration operation, in effect a partial maxillectomy, whichmay be performed for the eradication of a malignant antral neoplasm, is
responsible for a huge opening into the maxillary sinus, since one-half of
the plate, alveolus and anterior and medial walls may be included in the
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bony removal. The surgical treatment of large or abscessed maxillary
cysts may also be complicated by inadvertent fistula formation.
This necrotic cyst lining breaks down and involves the lining of the
maxillary sinus with which it is in contact and the resultant tissue
destruction may result in a massive fistula into the maxillary sinus.
Malignant Tumours
Malignant tumours of the maxillary sinus may penetrate the lateral
bony wall or erode through the floor of the sinus into the mouth,
producing symptoms referable to the oral cavity including an oroantral
communication. Likewise, neoplasms arising in the upper jaw can, of
course, extend into the sinus above them, leading to fistula formation.
Osteomyelitis
Osteomyelitis of the maxilla in the adult is rare unless there is an
underlying systemic disease such as leukaemia, diabetes, uraemia, etc.,
or the maxillary region has been irradiated in the absence of adequate
drainage for infection. A severe osteitis with bone loss could lead to the
formation of an oro-antral fistula of one or both maxillary sinuses.
Syphilis
Gummata of the palate may result in a massive oro-antral fistula
due to destruction of the intervening bone, and in hereditary or
congenital syphilis any of the lesions normally associated with thesecondary and tertiary forms of syphilis of the nose can also arise and
extend into the mouth.
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Implant Dentures
Destruction of the antral floor in a patient fitted with an upper
implant denture.
Malignant Granuloma
Malignant granuloma is primarily localized to the nose, but may
spread further to involve the palate, pharynx or orbit. When the invasive
process spreads to the palate expansive perforation ulceration may occur
leading to huge fistulae.
SYMPTOMS
The most common symptom is the regurgitation of liquids from the
mouth into the nose. Patient washes the mouth after the extraction has
been completed, passage of fluid from the mouth into the nostril on the
side of the extraction is pathognomonic of an oro-antral fistula. Patients
complained of an immediate escape of fluids from the nose when they
rinsed out their mouths following an extraction. Unilateral epistaxis due toblood in the maxillary sinus escaping through the nasal ostium may also
be an immediate result of fistula formation, escape of air from the mouth
into the nose, an alteration in vocal resonance, an inability to blow out
the cheeks and the passage of air into the mouth on sucking. Smokers
will find that they are unable to draw on a cigarette.
Oro-antral defect was completely occluded by blood clot and it is
only when this plug disintegrates as result of infection that an oro-antral
communication is firmly established. Patients may then present
complaining of a unilateral malodorous nasal discharge (purulent or
mucopurulent), especially when they bend down, or they may experience
a foul, salty or sweetish fetid taste.
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Once a fistula has been created, superimposed infection of the
sinus ensues due to contamination by oral organisms. With a mildsinustitis, the clinical disturbance is often minimal, but a postnasal mucus
drip will often lead to an unpleasant taste which may be accompanied by
a nocturnal cough, hoarseness, earache or catarrhal deafness. This
discomfort is frequently exacerbated on biting, bending, lifting, straining
and by jarring movements, e.g. walking downstairs. They may be an
associated frontal headache, malaise and anosmia. Swallowed pus gives
rise to morning anorexia.
The persistence of a fistula can lead to oblique problems, for
instance, the inadvertent entry into the antrum of food particles, chewing
gum, fluids, impression materials, dressings, packs etc. Any of these
substances may provoke acute or subacute exacerbations of
inflammatory disease.
PHYSICAL SIGNS1. Those presenting immediately after the formation of the fistula.
2. Those relevant to an established oro-antral fistula.
1. The Recently Created Fistula
Most arise as a result of surgery in the immediate vicinity of the
maxillary sinus and this is usually the extraction of maxillary molar or
premolar teeth.
When the roots of the tooth are examined a portion of the bony
floor of the maxillary sinus is seen adhering to the tooth. Fractures of the
maxillary tuberosity where the entire fragment is detached are especially
liable to result in a fistula. Attempted extraction of an upper molar root
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which suddenly disappears as soon as force is applied with an elevator
also denotes its inadvertent displacement into the sinus and the presence
of a coexistent fistula. A similar accident can occur in the attempted
extraction of a partially erupted upper third molar.
Testing to establish the presence of an Oro-Antral Fistula
If the fistula is large it will be obvious on simple inspection, but if
the patency of an oro-antral defect remains in doubt, the nose-blowing
test may be confirmatory. Compression of the anterior nares followed by
gently blowing down the nose (with the mouth open) causes a rise inintranasal pressure, exhibited by a whistling sound as air passes down
the open passage. In addition, escaping air bubbles, blood, mucopus or
pus may appear at the oral orifice. A wisp of cotton-wool held just below
the alveolar opening will usually be deflected by the air stream.
On no account should a suspected pinhole, antral defect at the site
of a recent extraction be explore with an instrument, such as a silver
probe, unless clinical manifestations of a patent communication are
evident. A needless investigation could cause breakdown of a wound seal
and establish a fistula.
2. Physical signs observed when a Fistula has been present
for a considerable period of time
Sinusitis with repeated attacks of acute mucopurulent rhinitis,
escape of air or fluid through the nostril or the development of a lump onthe gum. The maxillary sinus is usually infected and on inspection of the
suspected orifice of the fistula there is often an unmistakable discharge of
foul-smelling pus. This can usually be demonstrated by occluding the
patient's nose by pinching it with the thumb and forefinger and asking the
patient to blow. If a free descent of pus into the mouth does not occur it
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may be due to the occlusion of the sinus orifice by polyp. If a silver probe
is passed up the fistula into the antrum, the polypoidal mass is pushed to
one side after which a free flow of pus can be expressed into the mouth
on blowing the nose.
Acute sinusitis and there is always tenderness to pressure over
the maxilla, especially immediately below the eye. There may also be
slight flushing of the cheek with oedema of the infra-orbital soft tissues.
Rarely, a patient may complain of earache which could, of course, be
referred from the antrum, but may be attributable to acute otitis media.
Percussion of the upper premolars and molars on the same side as the
infected sinus will frequently elicit pain. By careful examination of the
nose using a nasal speculum and light source, e.g. headlight, nasal
congestion (red, shiny and swollen mucous membrane) in the
neighbourhood of the ostium can be confirmed. Another local sign is the
presence of a trickle of pus of mucopus in the middle.
Inspection of the oropharyx by depressing the posterior aspect of
the tongue with a mouth mirror will often reveal a stream ('curtain') or
trickle of pus or mcuopus tracking down the posterior wall of the pharynx.
It is more common to encounter chronic antral infection in which
the sense of smell may be impaired and foul-smelling mocopus is seen
under the middle turbinate or in the postnasal space. Slight tenderness
may be elicited over the infra-orbital nerve.
For viewing the maxilla, the technique of choice has traditionally
been waters view, however, periapical, occlusal and panaromic dental
radiographs also projects the paradental structures, including the
maxillary sinus. The periapical dental radiograph is the most simple,
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satisfactory method for investigating defects in the floor of the maxillary
sinus for both radiolucent and radioopaque defects. The occlusal view aid
in locating radioopacity medial to the dental arch. The panoramic
radiograph proved to the least useful for evaluating the maxillary sinus3.
The advances in computed topography (CT) Scanning technologies
since the early 1990s have made the imaging of the paranasal sinus
precise. In clinical practice, computed tomography scan can visualized
sinus pathologies more relevant then other imaging modalities. 14
MANAGEMENT OF ORO-ANTRAL FISTULA
An oro-antral fistula must be sealed in order to prevent the escape
of fluids, the entry of other mouth contents into the antrum and to protect
the sinus from oral bacteria.
The immediate treatment following the creation of an oro-
antral fistula
The ideal treatment following the creation of an oro-antral fistula is
to perform an immediate surgical repair, so that primary closure can be
combine with simultaneous antibiotic prophylaxis of sinus infection.
Whether the fistula is complicated by the presence of a tooth or root in
the maxillary sinus.
A buccal flap is then advanced across the gap by incising the
periosteum on its underside, after which it is sutured in position.
The root or tooth may be in close proximity to the point of entrance
and, therefore, can often be removed by the simple expedient of inserting
the nozzle of a powerful sucker into the orifice and withdrawing it. Active
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supportive measures should be instituted. These will include antibiotics
primarily combined with local decongestants and analgesics as required.
Antibiotic Medication
Phenoxymethylpenicillin (Penicillin V) should prove adequate on a
dosage schedule of 250mg. 6-hourly. If the organism appear to be
insensitive to penicillin, a swap would enable another antibiotic to be
selected according to the sensitives, but in practice a broad-spectrum
antimicrobial like ampicillin or oxytetracycline will usually be substituted
on an identical regime to that ordered for the acid-resistant penicillin.
Local Decongestants
Vasoconstrictor nose drops (sprays) and inhalations to encourage
the drainage of pus and secretions. The ideal decongestant will not
interfere with ciliary action, but merely produce shrinkage of the
antronasal mucous membrane and aeration of the sinus. Ephedrine Nasal
Drops (0.5 per cent) instilled intranasally every 3 hours.
When the nose is clear following the decongestant drops or spray,
stem inhalation helps by encouraging drainage; it also tends to thin the
mucus and have a soothing effect. Menthol and Benzoin Inhalation is an
old favourite and the instructions are to add a teaspoonful to a pint of hot
(not boiling) water and inhale the vapour for 10 minutes at least twice a
day.
Analgesics
Aspirin soluble tablets (1-3 tablets up to four times daily), Aspirin,
Phenacetin and Codeine Tablets (1-2 tablets up to four times daily) are
usually sufficient to control the pain.
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Antral Lavage
Once pus accumulated in copious amounts in the antrum an
integral part of remedial treatment is the establishment of surgical
drainage. For dependent drainage is best achieved through the fistulous
orifice in the antral floor which lies below the meatal level. Sometimes,
however, the oral end of the communication may be partially or
completely blocked by herniated antral mucosa, a polyp or mucosal cyst
excised in order to permit free drainage. A slit like opening on the gum
must be enlarged, preferably to conform with the existing diameter of the
bony defect. A bacterial culture of the resultant discharge is most useful
for sensitives if an antibiotic has not already been given. If necessary the
sinus should be washed out with warm sterile normal saline at regular
intervals (e.g. bi-weekly) until a clear return is obtained.
Temporary Therapeutic Measures before Surgical Closure
Pack
The ribbon gauze pack is positioned at the entrance to the socket,
overlying both the orifice and brim and held securely by a simple
structure framework.
Denture Plate
The construction of a well-fitting upper base plate with a flange
extension to cover the artificial opening is another sensible precautionary
measure if surgical repair of the fistula is to be deferred. The appliance
should not penetrate the fistula but merely provide a barrier to the
inadvertent entry of food particles. Before taking the impression the hole
should be occluded with a piece of tulle gras or Cellophane, so that there
is no danger of forcing impression material into the sinus space.
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Treatment of Delayed Cases
1. Treatment of an Oro-antral Fistula seen within 24 hoursof the Accident.
If an oro-antral fistula is referred within 24 hours of its occurrence,
the edges of the wound are fresh and surgically clean and it should be
closed immediately, after which the usual postoperative treatment of
nasal drops, inhalations and antibiotics is instituted. A defect
uncomplicated by concurrent deflexion of tooth or root into the antrum
can usually be closed by a buccal flap and sutured under local analgesia.
2. Treatment of Cases seen more than 24 hours after the
Injury.
After a period of 24 hours has elapsed the soft-tissue margins of
the fistula are often infected and successful primary closure is less likely.
If early surgery is impracticable, it is preferable to defer the operation
until the gingival edges of the fistula have healed soundly, i.e. in
approximately three weeks. Prophylactic treatment consisting primarily
of antibiotics along with local decongestants and analgesics should,
however, be prescribed immediately.
Treatment of an Oro-Antral Fistula which has been present for
more than a month:
On examination pus can be seen discharging from a fistula into the
mouth. The flow of pus is increased when the patient blows his nose or
when the clinician holds the nose and instructs the patient to blow. Some
persons complain of a unilateral nasal discharge whenever they bend
down, and the fistulous track may be continually bathed of offensive pus.
If the free flow of pus is impeded by a narrow orifice at the oral end of
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the fistula, the patient will experience acute antral pain infra-orbitally
and in the alveolus on the affected side. Drainage of the maxillary sinus
should be re-established through the fistula by enlarging it surgically, and
the sinus should be gently irrigated daily with normal saline until the
washings are clear.
SURGICAL PROCEDURES
The technique of oro-antral closure may be divided into the flowing
procedures.
A. Local Flaps
B. Distant Flaps
C. Grafts
Local Flap procedures
1. Buccal Flaps - These include
- Rotated Flap
- Advancement Flap
- Sliding Flap
- Transverse Flap
Buccal Flap Operation
Buccal flap operation, originally described by von Rehrmann in
1936. The upper buccal sulcus at the reflection is richly vascularized and
before commencing the operation about 1 ml. Of local analgesic solutionshould be injected into the muco-alveolar fold to reduce local capillary
bleeding by vasoconstriction. This measure minimizes bleeding at the
time of operation, reduces the risk of a postoperative haematoma which
could possibly imperil the suture line and helps to define tissue planes.
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Incision is made around the fistulous track 3-4 mm. marginal to the
orifice. A No. 11 scalpel blade is used and the entire epithelized tract
together with any associated antral polyps is dissected out and discarded.
The edge of the gum bordering the defect is freshened. If, to improve
flexibility, the free end of the proposed flap needs to be longer than the
width of the delineated defect, then crest-or-ridge or gingival margin
extensions are placed on each side. Next, two divergent incision are
made with a No. 15 blade from each side of the oro-antral orifice up into
the buccal sulcus for a distance of 2.5 cm. or more. These incisions are
made down to bone and carried well above the reflection. Thisimplements the principle that the base of the flap should be broader than
the tip so that an adequate blood supply reaches the free margin. Some
limitation of the width of the flap base must inevitably occur when there
are teeth present on each side of the fistula, but it must never be so
narrow that vascularization of the apex is impaired, leading to sloughing.
It is of incidental importance that when extending the oblique incision
into the cheek, care must be taken to avoid injury to the parotid papilla or
duct. In its unaltered state the buccal mucoperiosteal flap cannot be
stretched because of the inelastic nature of the limiting membrane-the
periosteal component. However, if the flap is raised and turned over
reveal its undersurface, a horizontal relasing incision made as high as
possible through the taut periosteum will allow advancement of the
buccal tissues.
Before suturing the flap across the bony opening, the maxillary
sinus should be carefully inspected for evidence of infection, If the
maxillary sinus is empty and the mucosa healthy-looking, the wound can
be closed. However, if it contains polypoid masses or other diseased
tissues, these should be removed with Luc's forceps before repairing the
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fistula. The remainder of the lining membrane in such cases should not be
sacrificed unless irreversibly damaged, for this tissue is capable of repair
and regeneration. If the orifice of the fistula is not sufficiently wide to
enable polyps and pathological tissue to be removed, then it can be
enlarged by using Jansen-Middleton bone nibblers. If it is considered
undersirable to enlarge the original bony defect, then a routine Caldwell-
Luc approach should be made into the sinus for this purpose. The antrum
should then be gently irrigated with warm sterile normal saline and the
mucoperiosteal flap sutured into position across the opening of the fistula
with interrupted black silk sutures. If necessary, the wound edges can betrimmed to improve adaptation and ensure accurate coaption.
Postoperatively the patient should have antibiotic cover with
phenoxymethylpenicillin or a suitable alternative for 5 days and use nasal
drops and inhalations five times a day for a week. The patient should be
restricted to a soft diet to avoid the implantation of irritant food particles
along the suture line. Instructions should be given to the patient to avoid
sneezing, exploring the wound with the tongue or deliberately sucking air
or fluid through it. Nose-blowing is also prohibited since, in the early
stages, not only does it create back-pressure on the suture line before
consolidation is complete, but it also invites the risk of surgical
emphysema for air may be forced through the periosteal gap which is
then a freeway to the soft tissues of the cheek. If the patient wears a
denture care must be taken tot avoid injury to the swollen cheek tissues.
Sutures should not be removed earlier than 10-14 days post-operatively.
MOCZAIR4described a buccal sliding trapezoidal flap procedure for
closure of alveolar fistulas. The disadvantages of this procedure are that
it necessitates greater amount of dentogingival detachment in order to
facilitate the shift. This may result in variable degree of periodontal
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disease. Thus, this procedure is suitable for the edentulous patient. In
addition, the distal shifting of the flap leaves a raw area on the mesial
aspect which accounts of the increased scar formation.
Mucoperiosteum overlying an edentulous ridge in the vicinity of the
fistula has been utilized in the form of transversal flap. SCHUCHARDT5
described this procedure and found that the buccal vestibular height was
not affected following the closure of the fistula. Unfortunately the design
of this flap does not offer greater mobility and it also results in a raw area
over the donor site following the closure.
A modification of SCHUCHARDTS method was described by
EGYEDI 6. He utilized a labial vestibular bipedicle flap to close a fistula in
the anterior region. This flap has an advantage in that it obtains bilateral
blood supply. In addition the donor site can be closed exactly by primary
closure. This method appears favourable for closure of minor anterior
fistula in association with missing anterior teeth. However the procedure
reduces the labial sulcular height and also results in the presence of two
pedicles on top of the alveolus.
Buccal flap procedures are relatively simple to perform. The blood
supply to these flaps is good. However, these flaps require careful
manipulation as they are thin. Their application may be limited in case
where previous operations have caused considerable scarring in the
regions where the flaps have to be raised. Such scarred tissues not only
reduce the flap mobility but also result in poor healing.
Buccal fat pad
Buccal fat pad (BFP) was mentioned for the first time by Heister in
1732 and better described by Bichat in 1802. However, it was described
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only as an anatomic element. Egyedi15 was the first to report use of the
BFP in oral reconstruction for the closure of oro-antral and oro-nasal
communications.
BFP lies in the masticatory space between the buccinator muscle
and masseter muscle, and it is wrapped within a thin fascial envelope.
Anatomically, BFP consists of three independent lobes: anterior,
intermediate and posterior. Some authors describe it as a central body
with four process: buccal, pterygoid, superficial and deep temporal. Each
lobe is encapsulated by an independent membrane and a natural space
between them. The blood supply to the BFP derives from buccal and deep
temporal branches of the maxillary artery, from the transverse facial
branch of the superficial temporal artery and from some small branches
of the facial artery.
BFP mean volume is approximately 10ml and weights 9.3gms15. it is
capable of covering defects of about 4cm in diameter15. BFP flap is
epithelialised in 4 6 weeks. Before epithelialisation, an initial phase of
granulation is observed, probably because fat tissue is replaced with
granulation tissue and it is covered by stratified parakerototic stratified
squamous epithelium migrating from the margin of the flap15.
BFP has many possible functions16. filling and allowing slippage of
fascial spaces between mimetic muscles; enhancement of intermusclar
motion, separating muscles of mastication from one another; to
counteract negative pressure during suction in the newborn; protection
and cushion of neurovascular bundles from injuries.
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Advantages
It is a simple and easy flap to use
It has a rich blood supply.
Its epithelialisation is complete within 6 weeks.
Morbidity and failure rate is very low.
It is well accepted by the patient, and it can be associated with other
pedicle flaps.
Disadvantages
Can only be used once
Limitation of oral opening due to scar retraction and by the loss of
separation of the muscles of mastication from each other.
Mouth exercises are used post operatively to improve mouth
opening.
Surgical approach
Incision through the superior vestibular sulcus. The incision cuts
mucosa and buccinator fibres, exposing the maxillary periosteum and the
BFP. Its fascia is severed, and the fat pad is placed into the mouth by
pulling it and by pushing the check skin under the zygomatic arch. The
flap is pulled with tissue forceps and rotated or transferred onto the
defect and sutured with no tension. Physical therapy was recommended
for 4 to 6 weeks after the surgery.
II. Palatal flaps
Various palatal flap procedures based on the greater palatine
vessels have been constantly described. These can be classified as
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Striaght-advancement7
Rotational advancement
Hinged8 and
Island flap.
Although palatal tissue is less elastic, it is thicker than the buccal
tissue. The abundant blood supply in the palatal tissue promotes
satisfactory healing to the flap. Procedures involving palatal flaps do not
affect the buccal vestibular height. It is for these reasons that many
surgeons favour the palatal flap procedures for closure of small to
moderate size defects.
Straight-advancement flap does not offer much greater mobility
for lateral coverage. Thus, it is suitable for closure of minor palatal or
alveolar defect. Palatal rotational-advancement flap provides adequate
mobility and tissue bulk to the flap. However, it requires the mobilization
of large amount of palatal tissue, and it often kinks following the rotation
of the flap which may predispose to venous congestion. CHOUKAS left
adequate tissue bridge for the placement of the flap underneath this
tissue bridge with minimum tension.
ITO & HARA described a submucosal connective tissue pedicle
flap. Besides have abundant blood supply, the connective tissue flap is
extremely elastic, enabling it to be rotated without tension. Another
advantage of this flap over the whole thickness flap is that epithelial layer
of the flap can be attached to the donor site. This procedure gives the
patient minimal discomfort and also provides early healing of the wound
as there is no raw area left behind for granulation. However, the
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dissection of the submucous layer is often difficult and requires great
care.
Palatal island flap offers several advantages in closure of large
fistula. It provides a flap with an excellent bulk, blood supply and
mobility. This technique uses only the tissue required to close the defect.
Necrosis of the palatal bone of the donor site is not a problem with this
procedure as there is ample blood supply from the nasal mucosa. This
procedure is suitable for closure of posterior fistula as the island flap is
pedicled on the greater palatine vessels. These vessels will be stretched
if the flap is advanced too far anteriorly, and thus its application is limited
in closure of anterior defect. GULLAN & ARENA described a
modification of island flap to obtain approximately 1 cm extra length of
the flap by freeing the vessels at the greater palatine foramen. This
provides an additional mobility for anterior advancement of the flap.
The mucoperiosteum surrounding the palatal defects has also been
utilized for closure of small to moderate size fistulas. Such tissue was
designed to form hinged or inversion flap. The procedure is simple to
perform with minimum morbidity. Both island and hinged flaps leave a
small raw area for granulation compared to that of rotational-
advancement whole thickness flap.
III Combined local flaps
An attempt to close larger defects by local flaps often leads to
failure. Various double-layer closure utilizing local tissues have been
described, providing sufficient tissue bulk. These include the combination
of inversion and rotational-advancement flaps9, doubled overlapping
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hinged flaps8,doubled island flaps and superimposition of reverse palatal
and buccal flaps.
B. Distant flap procedures
Tongue flaps
Larger fistulas are technically difficult to close by local flaps in veiw
of the limited tissue bulk. Distant flaps from extremities or forehead have
early been described for repair of larger defects. However, poor aesthetic
effect has led to the withdrawal of these procedures.
Tongue flaps have been formerly described for the reconsturction
of a cheek and pharyngeal wall. Their application in the closure of palatal
fistula were highlighted by GUERRERO SANTOS & ALTAMIRANO 10 in
1966. This provides sufficient tissue bulk, and extremely pliable which
allows suturing of the flap without tension. The donor site can be closed
by primary closure.
The anteriorly based partial thickness dorsal tongue flap has a
disadvantage in that it requires restrictive tethering of the mobile tongue
during healing. However, this is not a problem with the posteriorly based
full thickness lateral tongue flap. Since the base of this latter flap is
situated in the less mobile anterior 1/3 rd of the tongue. Mouth function
and appearance is much improved with the posteriorly based full
thickness lateral tongue flap.
C. Graft procedures
1. Bone
The use of an autogenous cancellous bone in the closure of palatal
defect is a well known procedure. COCKERILAM et al. in 1976
suggested that, when a conservative method fails or when the size of the
defect is too large, bone graft should be indicated in the closure.
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WHITNEY et al7advocated bone grafts in cases where there is need to
recontour the alveolar ridge. Soft tissue coverage may be accomplished
by palatal flaps, buccal flaps or tongue flaps. Closure of the defect by
bone not only ensures strength to the flap but also replaces the defect
with similar tissue. This technique has been reported as greatly
successful. The disadvantage of this method is that it requires an
additional surgical procedure to obtain a bone graft. This increases the
length of the procedure and morbidity. A single stage and simpler
surgical procedure of obtaining a bony closure was described by
BRUSATI in 1982. He took the bone from the lateral wall of the antrumand had it pedicled on the periosteum to close the alveolar defect. The
disadvantage of his procedure is that the buccal vestibular height was
reduced as a result of the use of the buccal flap as a soft tissue coverage.
This method is suitable for closure of fistula situated in the buccal or
alveolar area, where the bone which is pedicled on the periosteum can
readily be advanced into the required position.
II. Alloplastic materials
Various alloplastic materials have been used in the past for the
closure of oroantral fistula. These include gold foil, gold plate, tantalum
plate, soft polymethylmethacrylate and lyophilized collagen. Gold is
seldom available and expensive. The insertion of the alloplastic materials
is a simple procedure and does not require raising of a large amount of
local tissue. The procedure does not affect the buccal vestibular height.
There is no raw area left behind for granulation following the closure. The
use of collagen has an advantage over the other materials in that it does
not require removal prior to complete healing as it probably becomes
incorporated in the granulation tissue.
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References
1. H.C. KILLEY and L.W. KAY. The maxillary sinus and its dental
implications.
2. AXHAUSEN. Methodik des verschlusses van Defekten in alveolar for
Satzoberkiefer. Deutsche manatschrift for zahnekam. 48: 193-196. 1930.
3. WOWERN. N.V. Treatment of oroantral fistula.. Arch otolaryngal.
96; 99-104, 1972.
4. MOCZAIR, L NUOVO. methodo operatiopela chirsura dele fistole del
seno mascellase di origina oentale. Stomatol (Roma). 28. 1087-1088,
1930.
5. SCHUCMARDI.K. METHODIK DES VERSCHILUSSES VON DEFEKTEE
Alvealor forsate zahnlose oberkiefer, Dtsch. zahn mund kieferheick 17:
366-369-1953.
6. EGYEDI. P. The bucket-handle flap for closure of fistulas around the
premaxilla. J. Maxillofac. Surg. 4: 212-210-1976.
7. WNITNEY.J.H.S HAMNER et al, The use of cancellous bone for
closure of oroantral fistula and oronasal defect. J. oral Surg. 38-679-
681, 1980.
8. RINTALA. A couble overlapping hinged flap to close palatal fistula.
Scand. J. Plast. Reconstr. Surg. 5, 91-98-1971.
9. QUAYLE.A. Double flap technique for closure of oronasal and
oroantral fistula. BJOMFS, 19-132-137.1981
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10. GUERERO-SANTOS, et al, The use of Lingual flaps in repaire of
fistula of hard plate. Plast. Recrost. Surg 38, 123-128, 1966.
11. AL SIBAHI, A. & Al- BADR. Closure of oroantral fistula. J. oral
maxillofac. Surg 40, 165-166,1982.
12. MOHD NOOR AWANG, Closure of oroantral fistula, Int. JOMFS, 17,
110-115. 1988.
13. CARLOS A. PEREZ, et al, Diagnostic radiology of maxillary sinus
defects. J. oral surg oral med oral pathol. 66,507-512-1988.
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study. Laryngoscope 113,205-209, 2003.
15. EGYEDI P. Utilization of the buccal fat pad for closure of oro-
antral/nasal communications. J. Maxillofac surg, 5: 241-244, 1977.
16. GIUSEPPE COLELLA, The buccal fat pad in oral reconstruction.
British Journal of plastic surgery, 57: 326-329, 2004.
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