4/10/2013 1 CLOSURE OF LARGE OROANTRAL FISTULA lh lh Essam Essam Saleh Saleh, MD , MD Prof of ORL Prof of ORL‐H&N Surg. H&N Surg. Alex. University, Egypt Alex. University, Egypt Oroantral Fistula persistent pathological communication between the maxillary sinus and the oral cavity Aetiology Aetiology Aetiology Aetiology The commonest is due to tooth extraction. It is commoner in males. Highest rate in the 3 rd decade Highest rate in the 3 decade. The commonest is in the upper 1 st molar area.
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4/10/2013
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CLOSURE OF LARGE OROANTRAL FISTULA
l hl hEssamEssamSalehSaleh, MD, MDProf of ORLProf of ORL‐‐H&N Surg.H&N Surg.Alex. University, EgyptAlex. University, Egypt
Oroantral Fistula persistent pathological communication between the maxillary sinus and the oral cavity
AetiologyAetiologyAetiologyAetiology
The commonest is due to tooth extraction.
It is commoner in males.
Highest rate in the 3rd decadeHighest rate in the 3 decade.
The commonest is in the upper 1st
molar area.
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In extraction , it is usually due to
Plunging an elevator through the bony floor.
Forcing roots tips or tooth into the sinus.
Penetration while exposing impacted teeth.
Fracture of a segment of the alveolar process.
Aetiology
Destruction of the sinus walls by cyst or tumors.
Erosion of sinus wall by longstanding dentoalveolarinfection.infection.
Faulty implant surgery
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Prolonged periapical infection
Prolonged periapical infection
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Faulty implant surgery
ManifestationsManifestations
Unilateral maxillary sinusitis.
Fetid discharge from the fistula.
Food & water regurge from the nose.
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ManagementManagement
Defects larger than 5 mm usually fail to close Defects larger than 5 mm usually fail to close spontaneouslyspontaneously
Fistula excision
ClosureSoft tissue ± Bony defect
+
Soft tissue ± Bony defect
Maxillary Sinus management
±
ManagementManagement
Soft tissueSoft tissue
Palatal flapPalatal flap Palatal flapPalatal flap Palatal advancement rotation flap.Palatal advancement rotation flap.
Palatal pedicle island flap.Palatal pedicle island flap.
SubmucosalSubmucosal palatal flappalatal flap
BuccalBuccal FlapFlap BuccalBuccal FlapFlap BuccalBuccal advancement flapadvancement flap
BuccalBuccal pad of fat.pad of fat.
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Palatal FlapPalatal Flap
Palatal FlapPalatal Flap
AdvantagesAdvantages Good blood supply Good blood supply
Rotated without tension
Preserves the maxillary vestibular sulcus.
DisadvantagesDisadvantagesgg Raw areaRaw area
Bunching & kinking at flap base.Bunching & kinking at flap base.
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BuccalBuccal FlapFlap
BuccalBuccal FlapFlap
DisadvantagesDisadvantagesooObliteration of the vestibular Obliteration of the vestibular sulcussulcusooDifficult for large defectsDifficult for large defects
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ManagementManagementBony Defect ClosureBony Defect Closure
Why?Why? Oroantral fistulas are cavity dependent
Closure of large defects may fail by soft tissue covering lalone.
Rehabilitation for implants may be needed.
ManagementManagement
Bony Defect ClosureBony Defect Closure Cancellous bone.(Whitney JS et al.)
P l th l l t ( l b h h Polymethylacrylate (Al‐Sibahi A, ShanoonA), hydroxylapatite blocks. (Zide M, Karas N.)
Transplantation of the upper third molar.(Kitagawa Y et al.)
Guided tissue regeneration & absorbable gelatin membrane.(Waldrop TC, Semba SE)
Monocortical bone grafts (Haas R et al.)
Biosorbable root analogue.(Thoma K et al.)
SeptalSeptal CartilageCartilage
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Maxillary Sinus ManagementMaxillary Sinus Management
Traditional management is by g yCaldwellCaldwell‐‐Luc’s operationLuc’s operation and inferior inferior meatalmeatal antrosotomyantrosotomy..
Endoscopic sinus surgery Endoscopic sinus surgery is now the is now the method of choice.method of choice.
Our Management StrategyOur Management Strategy
Dental examination.
ENT examination.
Nasal endoscopy.
Preoperative antibiotics (Macrolides + Metronidazole)
CT scan PNS sinusesCT scan PNS sinuses
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ManagementManagementOur Technique For Large Difficult Our Technique For Large Difficult CasesCases Buccal Pyramidal Flap
Septal Cartilage for Bone Defect
++
±±FESS
BuccalBuccal Pyramidal FlapPyramidal Flap
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BuccalBuccal Flap ModificationsFlap Modifications
PeriostealPeriosteal incisionincision Pyramidal Pyramidal crevicularcrevicular incisionincision
SeptalSeptal cartilagecartilage
ClosurClosuree
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Post Operative CarePost Operative Care
Medications
Antibiotics (Amoxicillin clavulanate + (metronidazole or Clindamycin)
PrecautionsPrecautions opening mouth wide while sneezing
not sucking on a straw / cigarette
id bl i avoid nose blowing
Suture RemovalSuture Removal
10-14 days
PatientsPatients
11 cases, 9 males 2 females
Age : 18‐65 (mean39.5 yrs)g 5 ( 39 5 y )
8 revision surgery.
4 diabetics, 1 irradiated.
Aetiology 9 tooth extraction, 1 primordial cyst 1 faulty implantprimordial cyst, 1 faulty implant.
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ResultsResults
Fistula size 8mm‐3.5 cm (mean 1.4 cm) & involved (mean 1.4 cm) & involved >1 tooth in 3 cases.
2 cases had defect in anterior & inferior wall of the maxillary sinus.the maxillary sinus.
Concomitant FESS was performed in 4 cases.
Fistulas can appear smaller than their Fistulas can appear smaller than their actual sizeactual size
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ResultsResults
Complete closure in 10 cases (91.9%):(91.9%):9 99 9
7 case after 10 days
3 cases closed within 3 weeks.
1 case (9.1%) failed
Follow‐up 1‐60 mon. (mean 17.5 months.)
ConclusionsConclusions
Buccal pyramidal flap is a viable alternative for soft tissue closure of Oroantral fistulafor soft tissue closure of Oroantral fistula.
Septal cartilage for defect closure is a simple, cost‐effective technique that assures an excellent success rate and allows for easier future sinus lift if dental implant is sought.g
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Prolonged periapical infection
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