Chandramohan OAF

download Chandramohan OAF

of 24

Transcript of Chandramohan OAF

  • 7/31/2019 Chandramohan OAF

    1/24

    ORO-ANTRAL FISTULA

    Presented By

    Dr. Chandramohan. ChintaIII MDS

    Division of Oral and Maxillofacial Surgery

  • 7/31/2019 Chandramohan OAF

    2/24

    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

    2

  • 7/31/2019 Chandramohan OAF

    3/24

    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

    3

  • 7/31/2019 Chandramohan OAF

    4/24

    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.

    4

  • 7/31/2019 Chandramohan OAF

    5/24

    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.

    5

  • 7/31/2019 Chandramohan OAF

    6/24

    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

    6

  • 7/31/2019 Chandramohan OAF

    7/24

    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

    7

  • 7/31/2019 Chandramohan OAF

    8/24

    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,

    8

  • 7/31/2019 Chandramohan OAF

    9/24

    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

    9

  • 7/31/2019 Chandramohan OAF

    10/24

    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.

    10

  • 7/31/2019 Chandramohan OAF

    11/24

    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.

    11

  • 7/31/2019 Chandramohan OAF

    12/24

    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

    12

  • 7/31/2019 Chandramohan OAF

    13/24

    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.

    13

  • 7/31/2019 Chandramohan OAF

    14/24

    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

    14

  • 7/31/2019 Chandramohan OAF

    15/24

    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

    15

  • 7/31/2019 Chandramohan OAF

    16/24

    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

    16

  • 7/31/2019 Chandramohan OAF

    17/24

    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.

    17

  • 7/31/2019 Chandramohan OAF

    18/24

    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

    18

  • 7/31/2019 Chandramohan OAF

    19/24

    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

    19

  • 7/31/2019 Chandramohan OAF

    20/24

    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

    20

  • 7/31/2019 Chandramohan OAF

    21/24

    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.

    21

  • 7/31/2019 Chandramohan OAF

    22/24

    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.

    22

  • 7/31/2019 Chandramohan OAF

    23/24

    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

    23

  • 7/31/2019 Chandramohan OAF

    24/24

    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.

    14. RAHUL K.SHAH et al, Paransal sinus development A radiographic

    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.

    24