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Closure of Oroantral Fistula: Trauma Preprosthetic Surgery
Closure of Oroantral Fistula: Trauma Preprosthetic Surgery
Closure of Oroantral Fistula: Trauma Preprosthetic Surgery
M.N. Awang: Closure o f oroantral fistula. Int. J. Oral Maxillofac. Surg. 1988; 17:
110-115.
Perforation of maxillary sinus and The advantages, problems and limi- parallel incisions in the periosteum at
leading to the formation of oroantral tations of these techniques are hi- the base of the flap. TANNER et al. 5 re-
fistula is a relatively uncommon con- glighted. ported 60% success, while KmLEY &
dition. It may occur as a complication KAY34achieved 97.2% success using this
of trauma, surgery, irradiation, infec- procedure. This technique is simple and
Surgical techniques
tion, cyst or neoplasm. A fistula of well tolerated by the patient. Denture
more than 5 mm in diameter usually The techniques of oroantral closure may be worn immediately since the
fails to close spontaneously and re- may be divided into the following pro- palatal mucosa is intact. The donor site
quires proper surgical closure 36,46. cedures: closes exactly with no raw area left be-
The closure of oroantral fistulas is A. Local flaps; hind for granulation. It has been argued
one of the more challenging and diffi- B. Distant flaps; that this method reduces the buccal ves-
cult problems in the field of oral sur- C. Grafts. tibular sulcus 54,55. WOWERN55 found out
gery. The literature is full of various that 40% of the cases have suffered per-
techniques ranging from simple to manent vestibular reduction. Others 33,34
A. Local flap procedures pointed out that the buccal sulcus re-
more complex surgical procedures.
I. Buccal flaps
The choice of each of these procedures shapes within 4 to ~8 weeks following
is however influenced not only by the Closure of minor defects can usually the closure. JUSELIUS KATIOKALLIO33
size and location of the defect but also be accomplished by local flaps. Such indicated this approach in cases where
by the amount and condition of the procedures often give excellent func- Caldwell-Luc operations have to be per-
tissue available for repair. It was un- tional results with minimum morbidity. formed at the same time. They success-
animously agreed that, regardless of Various buccal mucoperiosteal flaps fully closed fistula measuring up to
the surgical technique, successful clo- have been described: these include ro- 22 x 15 mm by this method.
sure of the oroantral fistula must be tated flap 5, advancement flap 33'34'42'54'55, MOCZAIR39 described a buccal sliding
preceded by the complete elimination sliding flap 39,55and transversal flap 17,24,44. trapezoidal flap procedure for closure
of sinus pathology and the fistulous Rehrmann's technique is the com- of alveolar fistulas (Fig. 2). This tech-
tract. mon buccal flap procedure for closure nique was later reviewed by WOWERN55
The purpose of this article is to re- of minor alveolar fistula42, (Fig. 1). and HAANAES& PEDERSEN24. WOWERN55
view the various surgical procedures of Having a broad base, it ensures ad- pointed out that the change in the ves-
oroantral closure which have been equate blood supply to the flap. The tibular sulcus is negligible by shifting
constantly reported in the literature. flap mobility is improved by making the flap one tooth distally. The disad-
Oroantral fistula 111
the epithelial layer of the flap can be that the buried epithelium in Ziemba's
returned to the donor site. This pro- technique may predispose to subsequent
cedure gives the patient minimal dis- pathology4~. In view of the two donor
comfort, and also provides early healing sites involved, many of these procedures
of the wound as there is no raw area would result in a greater amount of de-
left behind for granulation. However, nuded areas and increased time of the
the dissection of the submucous layer is surgical procedure. BJOKLUND et al. 7 in
often difficult and requires great care. 1976 reinforced the flap with surgicel
The use of a pedicle island flap for and fascia lata. These materials were
surgery in various parts of the body has interposed between the two layers of
been documented. However, its use for tissue closure. The authors suggested
closure of oroantral defect was only that the incorporation of these materials
mentioned by HEND~RSEN25in 1974 (Fig. could promote fibrosis and subsequent
5). The versatility, simplicity and mo- bone formation.
bility of the palatal island flap were rea- Fig. 6. Hinged flap. The palatal hinged flap
sons given by many surgeons for its ap- is deepithelized. B. Distant flap procedures
plication in the closure of oroantral fis-
tula 23'z6'31'32. GULLANE ~ ARENA23 have Tongue flaps
pointed out that approximately 75% of Larger fistulas are technically difficult
the palate may be pedicled and rotated form a hinged or inversion flap 28,43(Fig. to close by local flaps in view of the
180 into position to provide 8-10 sq. 6). The procedure is simple to perform limited tissue bulk. Distant flaps from
cm of tissue coverage. HERBERT 26 con- with minimum morbidity. Both island extremities or forehead have earlier
cluded that the size of the defect is not and hinged flaps leave a small raw area been described for repair of larger de-
as important as the amount and lo- for granulation compared to that of ro- fects 6,16,45.However, poor aesthetic effect
cation of the palatal tissue available for tational-advancement whole thickness has led to the withdrawal of these pro-
repair. He achieved closure of 3 x 2.3 flap, since the former use only the tissue cedures.
cm fistula by island flap. required to close the fistula. Tongue flaps have been formerly de-
Palatal island flap offers several ad- scribed for the reconstruction of lip,
vantages in closure of large fistula. It is cheek and pharyngeal wall. Their appli-
III. Combined local flaps
a one-stage local procedure that pro- cation in the closure of palatal fistula
vides a flap with an excellent bulk, An attempt to close larger defects by were highlighted by GUERRERO-SAN-
blood supply and mobility. This tech- local flaps often leads to failure. Various TOS ALTAMIRANO22 in 1966. This flap
nique uses only the tissue required to double-layer closures utilizing local tis- provides sufficient tissue bulk, and it is
close the defect. Necrosis of the palatal sues have been described, providing suf- extremely pliable which allows suturing
bone of the donor site is not a problem ficient tissue bulk. These include the of the flap without tension. The donor
with this procedure, as there is ample combination of inversion and rotation- site can be closed by primary closure. Its
blood supply from the nasal mucosa. al-advancement flaps ~8,2~,4~, doubled versatility and safety have been further
This procedure is suitable for closure overlapping hinged flaps 43, doubled is- emphasized by many authors 19,3,35,47. In
of posterior fistula as the island flap is land flaps 26 and superimposition of re- view of the tongue being a mobile struc-
pedicled on the greater palatine vessels. verse palatal and buccal flaps 56 (Fig. ture, many authors favour its immobili-
These vessels will be stretched if the flap 6-9). All these procedures except that zation to prevent flap dehiscence.
is advanced too far anteriorly, and thus described by ZmMBA56 preserve the buc- GUERRERO-SANTOS ~ ALTAMIRANO 22
its application is limited in closure of cal vestibular height. It was also argued fixed the tongue to the upper dental
anterior defect. GULLAN & ARENA23 de-
scribed 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 ad-
vancement of the flap.
Island flap requires great care during
manipulation in order to avoid injury
to the vessels. JAMES31 suggested that the
sectioning of the island should be done
last, so that if such injury occurs the
flap can still be used as a rotational-
advancement flap or returned to its
original site and closure done at a sub-
sequent time.
The mucoperiosteum surrounding Fig. 8. Combined local flaps. Inversion flap
the palatal defects has also been utilized (A) and palatal rotational advancement flap
for closure of small to moderate size Fig. 7. Combined local flaps. Hinged and (B). The hatched area is excised to facilitate
fistulas. Such tissue was designed to palatal rotational advancement flap (A & B). the rotation of the palatal flap.
Oroantral fistula 113
AN & BROWN5~in 1983 suggested a back- tissue coverage. This method is suitable
cut incision at the base of the flap to for closure of fistula situated in the buc-
improve the mobility of the flap. This cal or alveolar area, where the bone
flap can be expanded to provide a large which is pedicled on the periosteum can
area of coverage by making a serirs of readily be advanced into the required
longitudinal incisions (Fig. 11). position (Fig. 12).
failed. The posteriorly based full thick- Reconstruction of major defects of the
ness lateral tongue flap has been shown palate. Plast. Reconstr. Surg. 1956: 17:
to be superior to the anteriorly based 105-109.
17. Egyedi, P.: The bucket-handle flap for
partial thickness dorsal tongue flap.
closure of fistulas around the premaxilla.
Alloplastic materials may not be eas-
J. Maxillofac. Surg. 1976: 4: 212-214.
ily available, and are costly compared 18. Fickling, B. W.: Oral surgery involving
to the use of flap procedures. Works maxillary sinus. Ann. R. Coll. Surg. 1957:
), / on the use o f collagen and fibrin have 20: 13-25.
received particular attention. This is be- 19. Golden, G. I., Mentzer, R. M., Fox, J.
cause these materials are biologically W., Futrell, J. W. & Edgerton, M. T.:
competent and they are easy to use. Basket suspension as an adjunct to
Fig. 13. Buccal osteoperiosteal flap. The bone tongue flap closure of the hard palate.
from the lateral wall of the sinus is pedicled Cleft Palate J. 1976: 13: 350-354.
on the periosteum and rotated to cover the References 20. Goldman, E. H., Stratigos, G. T. & Ar-
defect. The soft tissue coverage is ac- thur, A. L.: Treatment of oroantral fistula
complished by the buccal advancement flap. 1. Akin, R. K., Walter, P. J. & Boos, E. by gold foil closure. J. Oral Surg. 1969:
J.: Repair of large palatal defects with a 27: 875-876.
cancellous bone graft. J. Oral Surg. 1977: 21. Gordon, N. C. & Brown, S. L.: Closure
advantageous in cases where there are 35: 402-404. of oronasoantral defects. Report of case.
limited available local tissues for repair 2. A1-Sibahi, A. & A1-Badri, A.: Closure of J. Oral Surg. 1980: 38: 600-605.
as a result o f considerable scarring of oroantral fistula using gold plate. Iraqi 22. Guerrero-Santos, J. & Altamirano, J. T.:
these tissues. The use of h u m a n fibrin Dent. J. 1975: 4: 2-4. The use of lingual flaps in repair of fis-
3. A1-Sibahi, A. & Ameen, S.: The use of tulas of the hard palate. Plast. Reconstr.
seal may predispose to the transmission
soft polymethylmethacrylate in the clo- Surg. 1966: 38: 123-128.
of viral hepatitis. A l t h o u g h it is care-
sure of oroantral fistula. J. Oral Maxillo- 23. Gullane, P. J. & Arena, S.: Palatal island
fully controlled by the manufacturer, fac. Surg. 1982: 40: 165-166. flap for reconstruction of oral defects.
such a complication could not be ruled 4. Ashley, R. E. A.: A method of closing Arch. Otolaryngol. 1977: 103: 598-599.
out entirely. antroalveolar fistulae. Ann. Otol Rhinol. 24. Haanaes, H. R. & Pedersen, K. N.: Treat-
Laryngol. 1939: 48: 63~635. ment of oroantral communication. Int. J.
5. Axhausen, G.: Zur Methodik des Versch- Oral Surg. 1974: 3: 124-132.
Summary lusses von Defekten im Alveolarforsatz 25. Hendersen, D.: Palatal island flap is clo-
Closure of oroantral fistula may often Oberkiefer. Deutsche Monatschrift J~r sure of oroantral fistula. Br. J. Oral Surg.
Zahnheilkunde. 1930: 48: 193-196. 1974: 12:141 146.
be a difficult problem presenting a chal-
6. Bakamjian, V.: A new technique for pri- 26. Herbert, D. C.: Closure of a palatal fis-
lenge to the oral surgeon. The review
mary reconstruction of the palate after tula using mucoperiosteal island flap. Br.
of the literature revealed many surgical radical maxillectomy for cancer. Plast. J. Plast. Surg. 1974: 27: 332-336.
techniques that have been advocated to Reconstr. Surg. 1963: 31: 103-108. 27. Hiranadani, L. H. & Kamdar, H. N.:
close varying degrees of oroantral de- 7. Bjoklund, A., Kock, H. J. & Petterson, Treatment of chronic oroantral fistula by
fects. Assessment o f local and general K. I.: A new method of strengthening complete palatal flap. J. Laryngol. Otol.
factors of the patient have to be care- palatal closure defect of the hard palate. 1961: 75: 744-746.
fully made prior to the selection of the Acta Otolaryngol. 1976: 82: 147-150. 28. Hynes, W.: Fistula in the hard palate fol-
technique. It is further emphasized that 8. Boyne, P. J. & Sand, N. R.: Secondary lowing cleft surgery. Br. J. Plast. Surg.
complete elimination of sinus infections, bone grafting of residual alveolar and 1957: 15: 377-384.
palatal defects. J. Oral Surg. 1972: 30: 29. Ito, T. & Hara, H.: A new technique for
excision of the fistulous epithelial tract
87-90. closure of oroantral fistula. J. Oral Surg.
and proper postoperative care are 9. Broude, R J. & Waite, D. E.: Secondary 1980: 38: 509-512.
equally important, leading to the suc- closure of alveolar defects. Oral Surg. 30. Jackson, I. T.: Closure of secondary pala-
cess of the closure. 1974: 37: 829-832. tal fistula with intra-oral tissue and bone
Local mucoperiosteal flaps are often 10. Brusati, R.: The use of an autogenous grafting. Br. J. Plast. Surg. 1972: 25:
indicated in closure of small to moder- osteoperiosteal flap to close oroantral fis- 93-105.
ate size defects because they are simple tulas. J. Oral Maxillofac. Surg. 1982: 40: 31. James, R. B.: Surgica closure of large
to perform and well tolerated by all pa- 250-251. oroantral fistula using a palatal island
11. Budge, C. T.: Closure of oroantral open- flap. J. Oral Sur~. 1980: 38: 591-595.
tients. The reduction o f buccal vestibu-
ing by the use of tantalum plate. ,L Oral 32. Janakarajah, N.: The island flap in the
lar height following the closure by buc-
Surg. 1952: 10: 32-33. closure of palatal and cheek defect. J.
cal flap procedures has received m u c h 12. Carlesso, J., Mondolfi, P. & Flicki, E.: Pergigian Universiti Malaya 1983: 1:
criticism. Local flaps are utilized in both Hemitongue flaps. ['last. Reconstr. Surg. 47 51.
single- and double-layer closures. A 1980: 66: 574-577. 33. Juselius, H. & Katiokallio, K.: Closure
double-layer closure not only improves 13. Choukas, N. C.: Modified palatal flap of antroalveolar fistulae. J. Laryngol.
the strength o f the flaps but also mini- technique for closure of oroantral fis- 1971: 85: 387-393.
mises contraction and risk o f infection. tulas. J. Oral Surg. 1974: 32:112-113. 34. Killey, H. & Kay, L.: An analysis of 250
The strength o f the double-layer clo- 14. Cockerham, S., Wood, W. H. & Lind, K.: cases of oroantral fistulas treated by buc-
Closure of a large oroantral communi- cal flap operation. J. Oral Surg. 1967: 24:
sures has been further improved by the
cation by bone grafting. J. Oral Surg. 726-739.
incorporation of surgical and fascia 35. Kruchinskyi, G. V.: New method of pala-
1976: 34: 1098-1100.
lata. 15. Crolius, W. E.: The use of gold plate for tal defect repair. Acta Chir. Plast. 1972:
Distant flaps and bone grafts are sig- closure of oroantral fistula. Oral Surg. 14: 23-27.
nificant in closure o f large defects or in 1956: 9: 836-837. 36. Kruger, G. O.: Textbook o f Oral & Maxil-
cases where local flap procedures have 16. Edgerton, M. T., Jr. & Zovickian, A.: lofacial Surgery, 6th edition, ed. C. V.
Oroantral .fistula 115
MOSBY, 1984. St. Louis, Toronto, lose oberkiefer. Dtsch. Zahn Mund Kiefer- Highmore. J.A.M.A. 1920: 75: 867-869.
291-293. heilk. 1953: 17: 366-369. 53. Whitney, J. I-I. S., Hamner, W. B., Elliot,
37. Mainous, E. G. & Hammer, D. D.: Surgi- 45. Skolniek, E. M., Yee, K. F. & Keyes, G. M. D. & Tucker, D. F.: The use of cancel-
cal closure of oroantral fistula using gold R.: A flap reconstruction in major sur- lous bone for closure of oroautral fistula
foil technique. J. Oral Surg. 1974: 32: gery of the head & neck. Laryngoscope and oronasal defect. J. Oral Surg. 1980:
528-530. 1976: 86: 1584-1587. 38: 679-681.
38. Mitchell, R. & Lamb, J.: Immediate clo- 46. Skolnick, E. M., O'Neill, J. V. & Bairn, 54. Wowern, N. V.: Treatment of oroantral
sure of oroantral fistula with collagen im- H. M.: Closure of oroantral fistula. Lar- fistula. Arch. OtolaryngoL 1972: 96:
plant. A preliminary report. Br. Dent. J. yngoscope 1979: 89: 844-845. 99-104.
1983: 154:171 173. 47. Smith, T. S., Schaberg, S. J. & Collin, J. 55. Wowern, N. V.: Closure of oroantral fis-
39. Moczair, L.: Nuovo methodo operatiop- T.: Repair of the palatal defect using a tula with buccal flap. Rehrmann versus
ela chisura delle fistole del seno mascella- dorsal pedicle tongue flap. J. Oral Maxil- Moczair. Intr. J. Oral Surg. 1982: 11:
se di origina dentale. Stomatol (Roma). lofac. Surg. 1982: 40: 670-673. 156-165.
1930: 28: 1087-1088. 48. Steiner, M.: Oroantral closure with gold 56. Ziemba, R. B.: Combined buccal and re-
40. Proctor, B.: Bone graft closure of larger plate. J. Oral Surg. 1952: 18: 514-515. verse palatal flap for closure of oroantral
or persistent oromaxillary fistula. Lar- 49. Steinhauser, E. W.: Experience with dor- fistula. J. Oral Surg. 1972: 30: 722730.
yngoscope 1969: 79: 822-825. sal tongue flap for closure of defect of 57. Ztajcic, Z., Todorovic, L. J. & Petrovic,
41. Quayle, A. A.: Double flap technique for the hard palate. J. Oral Maxillofac. Surg. V.: Tissucolin closure of oroantral com-
closure of oronasal and oroantral fistula. 1982: 40: 787-789. munication. A pilot study, lnt. J. Oral
Br. J. Oral Surg. 1981: 19: 132-137. 50. Tanner, H., Royer, R. Q. & McBean, J. Surg. 1985: 14: 444-446.
42. Rehrmann, A.: Eine methode zur Schlies- B.: Chronic oroantral fistulas. J. S. Calif.
sung von Kieferhohlenperforationen. Dt- Dent. Assoc. 1964: 32: 200-207. Address:
sch. Zahnarztl. Z. 1936: 39: 11361139. 51. Vaughan, E. D. & Brown, A. E.: The Mohd Noor Awang
43. Rintala, A.: A double overlapping hinged versatility of the lateral tongue flap in the Department o f Oral Surgery
flap to close palatal fistula. Stand. J. Pla- reconstruction of defect of the oral cavity. Faculty of Dentistry
st. Reeonstr. Surg. 1971: 5: 91-95. Br. J. Oral Surg. 1983: 21: 1-I0. University o f Malaya
44. Schuchardt, K.: Methodik des Verschlus- 52. Welty, C. F.: Closure of fistolus opening 59100 Kuala Lumpur
ses von Defekten im alveolarforsate zahn- through alveolar process in the antrum of Malaysia