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Case Report:

A CASE REPORT OF ORO –ANTAL FISTULA TREATED WITH A COMBINATION

TECHNIQUE OF BUCCAL ADVANCEMENT FLAP AND BUCCAL FAT PAD

1 Dr Gopal Sharma, 2 Dr Jaya Mukherjee , 3Dr Bhagyashree Purandare

1Head of department, Dept of Oral medicine and Radiology, YMT Dental college , Kharghar, Navi Mumbai

2Postgraduate studies, Dept of Oral medicine and Radiology, YMT Dental college , Kharghar, Navi Mumbai

3Postgraduate studies, Dept of Oral medicine and Radiology, YMT Dental college , Kharghar, Navi Mumbai

Corresponding author : Dr Jaya Mukherjee

Abstract :

The oroantral fistula (OAF) is a pathological communication between the oral cavity and the maxillary sinus; depending on

the location it can be classified as alveolo-sinusal, palatal-sinusal and vestibulo-sinusal. Oro-antral communications may

develop as a complication of dental extractions, but may also result from accidental or iatrogenic trauma, neoplasm or

infection . An oroantral fistula which is smaller than 2 mm frequently closes spontaneously. A 28 years old healthy male

reported to the outpatient department of hospital for evaluation of pus discharging fistula distal to left upper first molar. A

surgery was planned for the removal of displaced root segments and closure of the fistula. A Caldwell luc approach was used

to remove the roots and the closure of oro antral fistula was done by using double layer technique with buccal fat pad and a

buccal advancement flap. The sutures were then placed. The treatment of oronatral fistula through the use of buccal

advancement flap and buccal fat pad is a simple and complete method which enables several uses in most of cases.

Keywords : Coroantral fistula

Introduction : The oroantral fistula (OAF) is a

pathological communication between the oral

cavity and the maxillary sinus; depending on the

location it can be classified as alveolo-sinusal,

palatal-sinusal and vestibulo-sinusal.1 Oro-antral

communications may develop as a complication of

dental extractions, but may also result from

accidental or iatrogenic trauma, neoplasm or

infection.2,3 An oroantral fistula which is smaller

than 2 mm frequently closes spontaneously.

However, when the defect is bigger or when there

is inflammation, maxillary sinus or periodontal

region infection, such fistula demands surgical

treatment for its complete closing.4 This article

reports a case of a oro-antral fistula successfully

treated with a double layer technique using buccal

fat pad and buccal advancement flap and removal

of displaced roots of molar from the antrum.

Case Report : A 28 years old healthy male

reported to the outpatient department of hospital for

evaluation of pus discharging fistula distal to left

upper first molar. The patient gave history of

traumatic extraction of upper left second molar 2

months back. He had discomfort in the region of

the extraction socket. Soon after, expression of a

yellowish foul smelling discharge followed from

the socket, the patient reported for the dental check

up .The patient reported that the crown was

fractured while extraction. The patient also

reported of foul smelling discharge from nose

while drinking water. The intra oral examination

revealed that the left upper second molar was

absent. Purulent material from the fistula was

observed distal to left maxillary first molar. A

provisional diagnosis of oro-antral fistula was

given based on the history and examination.

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The patient was advised for a orthopantomograph

OPG and cone beam computed tomography CBCT.

The radiographs revealed oro antral communication

with displacement of two roots into maxillary

sinus.

FIG 1- PREOPERATIVE

A surgery was planned for the removal of displaced root segments and closure of the fistula. A Caldwell luc

approach was used to remove the roots and the closure of oro antral fistula was done by using double layer

technique with buccal fat pad and a buccal advancement flap. The sutures were then placed.

FIG 2- SURGERY FOR CLOSURE OF FISTULA

Routine postoperative instructions with prescription of antibiotics and analgesics were given to the patient. The

patient was warned against blowing the nose for 2 weeks. The post operative CBCT showed maxillary antrum

clear of the root stumps.

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FIG 3 –POSTOPERATIVE

The patient was followed-up for duration of 2 months periodically at the regular intervals to evaluate for any

postoperative complication. Complete epithelisation was observed after 6 weeks. No post operative

complications were evident.

I

FIG 4-POSTOPERATIVE HEALING

DISCUSSION

The primary closing of oro-antral fistulas in 48

hours presents a 90 to 95% success rate, and such

rate falls to 67% when the closing is secondary.5,6

Numerous surgical methods have been described

for treatment of oro antral fistulas, although only a

few have been accepted in daily practice. The

buccal fat pad is an encapsulated, rounded,

biconvex specialized fatty tissue which is distinct

from subcutaneous fatty tissues. It is located

between the buccinator muscle medially, the

anterior margin of the masseter muscle and the

mandibular ramus and zygomatic arch laterally

7,8,9,10. The advantages of pedicled buccal fat pad

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(BFP) include ease of harvesting, simplicity,

versatility, low rate of complications, and quick

surgical technique. The blood supply of the buccal

fat pad is not affected due to its displacement, once

it is gripped and replaced between the flap and the

maxillary wall. It is worth noting that the use of

BFP with buccal advancement flap (combination

technique) in the literature is scarce.11,12 It provides

more stability, can be used to cover BFP and as

additional tissue for closure where there is a

deficient BFP for closure.

CONCLUSION

The treatment of oronatral fistula through the use

of buccal advancement flap and buccal fat pad is a

simple and complete method which enables several

uses in most of cases.

REFERENES

1. Borgonovo, Andrea Enrico, Frederick Valerio Berardinelli, Marco Favale, and Carlo Maiorana.

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Publishing Ltd; 1987.

3. Yilmaz T, Suslu AE, Gursel B. Treatment of oroantral fistula: experience with 27 cases. Am J

Otolaryngol. 2003 Jul-Aug;24(4):221-3

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10. Samman N, Cheung LK, Tideman H. The buccal fat pad in oral reconstruction. Int J Oral Maxillofac

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communications and formulation of a rational approach. J Maxillofac Oral Surg. 2010;9:13–8.

Date of submission: 21 January 2014, Date of provisional acceptance: 14 Feb 2013

Date of Final acceptance: 22 March 2014 Date of Publication: 07 April 2014

Source of support: Nil; Conflict of interest: Nil

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