closure of oroantral fistula

Closure of oroantral fistula

Trauma; Preprosthetic Surgery

Mohd Noor A w a n g Department of Oral Surgery, Faculty of Dentistry, University of Malaya

M.N. Awang: Closure o f oroantral fistula. Int. J. Oral Maxillofac. Surg. 1988; 17: 110-115.

Abstract. Oroantral fistula is an uncommon complication in oral surgery. Al- though smaller fistulas of less than 5 mm in diameter may close spontaneously, larger fistulas always require surgical closures. The literature review revealed various procedures for the closure of oroantral fistulas. These procedures may be subdivided into local flap, distant flap and grafting. Procedures involving local flaps are usually adequate to close minor to moderate size defects. Those procedures utilizing the buccal mucoperiosteal flap as the tissue closure include straight-advancement, rotated, sliding and transversal flap procedures; while those involving the palatal mucoperiosteum are straight advancement, rotational- advancement, hinged and island flap procedures. The combinations of various local flaps to strengthen the tissue closure are also being advocated. The advantages and the limitations of these procedures are discussed. Distant flaps and bone grafts are usually indicated in the closure of larger defects in view of their greater tissue bulks. Tongue flaps have superseded extra-oral flaps from extremities and forehead for aesthetic reasons and also in view of their similar tissue replace- ment. Various tongue flap procedures are described. At present, various alloplastic materials such as gold, tantalum and polymethylmethacrylate are infrequently reported in the closure of oroantral fistulas. However, in the light of successful reports over the use of biological materials, collagen and fibrin, in the closure of oroantral fistulas, there seems to be another simple alternative technique for treating oroantral fistulas.

Key words: fistula, oroantral; sinusitis; flaps, oral mucosal

Accepted for publication 20 April 1987)

Perforation of maxillary sinus and leading to the formation of oroantral fistula is a relatively uncommon condition. It may occur as a complication of trauma, surgery, irradiation, infection, cyst or neoplasm. A fistula of more than 5 mm in diameter usually fails to close spontaneously and requires proper surgical closure 36,46.

The closure of oroantral fistulas is one of the more challenging and difficult problems in the field of oral surgery. The literature is full of various techniques ranging from simple to more complex surgical procedures. The choice of each of these procedures is however influenced not only by the size and location of the defect but also by the amount and condition of the tissue available for repair. It was un- animously agreed that, regardless of the surgical technique, successful closure of the oroantral fistula must be preceded by the complete elimination of sinus pathology and the fistulous tract.

The purpose of this article is to review the various surgical procedures of oroantral closure which have been constantly reported in the literature.

The advantages, problems and limitations of these techniques are hi- glighted.

Surgical techniques

The techniques of oroantral closure may be divided into the following procedures:

A. Local flaps; B. Distant flaps; C. Grafts.

A. Local flap procedures I. Buccal flaps

Closure of minor defects can usually be accomplished by local flaps. Such procedures often give excellent func- tional results with minimum morbidity. Various buccal mucoperiosteal flaps have been described: these include rotated flap 5, advancement flap 33'34'42'54'55, sliding flap 39,55 and transversal flap 17,24,44.

Rehrmann's technique is the com- mon buccal flap procedure for closure of minor alveolar fistula 42, (Fig. 1). Having a broad base, it ensures adequate blood supply to the flap. The flap mobility is improved by making

parallel incisions in the periosteum at the base of the flap. TANNER et al. 5° reported 60% success, while KmLEY & KAY 34 achieved 97.2% success using this procedure. This technique is simple and well tolerated by the patient. Denture may be worn immediately since the palatal mucosa is intact. The donor site closes exactly with no raw area left behind for granulation. It has been argued that this method reduces the buccal vestibular sulcus 54,55. WOWERN 55 found out that 40% of the cases have suffered per- manent vestibular reduction. Others 33,34 pointed out that the buccal sulcus re- shapes within 4 to ~8 weeks following the closure. JUSELIUS • KATIOKALLIO 33 indicated this approach in cases where Caldwell-Luc operations have to be per- formed at the same time. They success- fully closed fistula measuring up to 22 x 1 5 mm by this method.

MOCZAIR 39 described a buccal sliding trapezoidal flap procedure for closure of alveolar fistulas (Fig. 2). This technique was later reviewed by WOWERN 55 and HAANAES & PEDERSEN 24. WOWERN 55 pointed out that the change in the vestibular sulcus is negligible by shifting the flap one tooth distally. The disad-

Oroantral fistula 111

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Fig. 1. Rehrmann's buccal advancement flap. The periosteum at the base of the flap is longitudinally incised to facilitate the advancement of the flap.

vantages of this procedure are that it necessitates greater amount of dento- gingival detachment in order to facilitate the shift. This may result in variable degree of periodontal diseases. 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 for the increased scar formation.

Mucoperiosteum overlying an edentulous ridge in the vicinity of the fistula has been utilized in the form of transversal flap (Fig. 3). S c a u c ~ a ~4 described this procedure and found that the buccal vestibular height was not af- fected 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 Schuchardt's method was described by EGYED117. He utilized

Fig. 2. Moczair buccal sliding trapezoidal flap. The periosteum at the base of the flap may be incised (broken lines) to facilitate the distal shift of the flap.

Fig. 3. Transversal flap, (A). Bipedicle flap, (B).

a labial vestibular bipedicle flap to close a fistula in the anterior region (Fig. 3). 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 ap- pears favourable for closure of minor anterior fistula in association with miss-

, ing 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 cases where previous operations have caused considerable scarring in the re- gions where the flaps have to be raised. Such scarred tissues not only reduce the flap mobility but also result in poor healing.

II. Palatal flaps

Various palatal flap procedures based on the greater palatine vessels have been constantly described. These can be classified as straight-advancemenP 2, veau or rotational-advancement 4'13'27'36'46'54, hinged 28,43, and island flap23,25,26,31,32.

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. HERBERT 26 pointed out that, when adequate local tissue is available, palatal mucoperiosteum is the tissue of choice for repair.

Straight-advancement flap (Fig. 4)

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 (Fig. 4) 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 con- gestion. KRUGER 36 suggested a V-shaped excision of the lesser curvature of the flap to minimise folding (Fig. 4). CHOU- KAS 13 left adequate tissue bridge for the placement of the flap underneath this tissue bridge with minimum tension (Fig. 4).

ITO & HARA 29 described a submucosal connective tissue pedicle flap in 1 3 cases of oroantral fistula with success (Fig. 5). Besides having 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

Fig. 4. Straight advancement flap, (A). Pala- tal rotational advancement flap, (B). The kin- king of the flap may be minimised by excision at the lesser curvature of the flap (hatched area) or tunnelling the flap underneath the tissue bridge (area bounded by the broken lines).

Fig. 5. Submucous connective tissue flap, (A). The remaining tissue is returned to the donor site. Island flap based on greater palatine vessels, (B).

112 A w a n g

the epithelial layer of the flap can be returned to the donor site. This procedure gives the patient minimal dis- comfort, and also provides early healing of the wound as there is no raw area left behind for granulation. However, the dissection of the submucous layer is often difficult and requires great care.

The use of a pedicle island flap for surgery in various parts of the body has been documented. However, its use for closure of oroantral defect was only mentioned by HEND~RSEN 25 in 1 974 (Fig. 5). The versatility, simplicity and mobility of the palatal island flap were reasons given by many surgeons for its application in the closure of oroantral fistula 23'z6'31'32. GULLANE ~¢ ARENA 23 have pointed out that approximately 75% of the palate may be pedicled and rotated 180 ° into position to provide 8-10 sq. cm of tissue coverage. HERBERT 26 con- cluded that the size of the defect is not as important as the amount and location of the palatal tissue available for repair. He achieved closure of 3 x 2.3 cm fistula by island flap.

Palatal island flap offers several advantages in closure of large fistula. It is a one-stage local procedure that 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 23 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.

Island flap requires great care during manipulation in order to avoid injury to the vessels. JAMES 31 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 subsequent time.

The mucoperiosteum surrounding the palatal defects has also been utilized for closure of small to moderate size fistulas. Such tissue was designed to

Fig. 6. Hinged flap. The palatal hinged flap is deepithelized.

form a hinged or inversion flap 28,43 (Fig. 6). 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, since the former use only the tissue required to close the fistula.

III. Combined local flaps

An attempt to close larger defects by local flaps often leads to failure. Various double-layer closures utilizing local tissues have been described, providing sufficient tissue bulk. These include the combination of inversion and rotational-advancement flaps ~8,2~,4~, doubled overlapping hinged flaps 43, doubled island flaps 26 and superimposition of reverse palatal and buccal flaps 56 (Fig. 6-9). All these procedures except that described by ZmMBA 56 preserve the buccal vestibular height. It was also argued

Fig. 7. Combined local flaps. Hinged and palatal rotational advancement flap (A & B).

that the buried epithelium in Ziemba's technique may predispose to subsequent pathology 4~. In view of the two donor sites involved, many of these procedures would result in a greater amount of de- nuded areas and increased time of the surgical procedure. BJOKLUND et al. 7 in 1976 reinforced the flap with surgicel and fascia lata. These materials were interposed between the two layers of tissue closure. The authors suggested that the incorporation of these materials could promote fibrosis and subsequent bone formation.

B. Distant flap procedures Tongue flaps

Larger fistulas are technically difficult to close by local flaps in view of the limited tissue bulk. Distant flaps from extremities or forehead have earlier been described for repair of larger defects 6,16,45. However, poor aesthetic effect has led to the withdrawal of these procedures.

Tongue flaps have been formerly described for the reconstruction of lip, cheek and pharyngeal wall. Their application in the closure of palatal fistula were highlighted by GUERRERO-SAN- TOS • ALTAMIRANO 22 in 1966. This flap provides sufficient tissue bulk, and it is extremely pliable which allows suturing of the flap without tension. The donor site can be closed by primary closure. Its versatility and safety have been further emphasized by many authors 19,3°,35,47. In view of the tongue being a mobile struc- ture, many authors favour its immobili- zation to prevent flap dehiscence. GUERRERO-SANTOS ~ ALTAMIRANO 22 fixed the tongue to the upper dental

Fig. 8. Combined local flaps. Inversion flap (A) and palatal rotational advancement flap (B). The hatched area is excised to facilitate the rotation of the palatal flap.

Fig. 9. Combined local flaps. Reverse palatal (A) and buccat advancement flap, (B). The palatal and buccal periosteum of the donor sites are intact.

arch and lip. GOLDEN et al. 19 used sup- portive 'basket ' , while KRtJCI~INSK~q 35 sutured lateral border of the tongue to the maxillary premolars. STEINI-IAUSER 49 advocated maxillomandibular fixation in his cases.

The anteriorly based partial thickness dorsal tongue flap 47 (Fig. 10) 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 posterior 1/3rd of the tongue (Fig. 11). Mouth function and appearance is much improved with the posteriorly based full thickness lateral tongue flap 12,5~. The reported complication involving necrosis of the flap following the use of this flap is minimal. VAUGrI-

AN & BROWN 5~ in 1983 suggested a back- cut incision at the base of the flap to improve the mobility of the flap. This flap can be expanded to provide a large area of coverage by making a serirs of longitudinal incisions (Fig. 11).

C. Grail procedures I. Bone

The use of an autogenous cancellous bone in the closure of palatal defect is a well known procedure. COCKERHAM et al. 14 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 (Fig. 12). WmTNEY et al? 3 advocated bone grafts in cases where there is need to recontour the alveolar ridge. Soft tissue coverage may be accomplished by palatal flaps ~,3°, buccal ftaps 8,9,14,4°,53 or tongue flaps 3°. 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 1° in 1982. He took the bone from the lateral wall of the antrum, and 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

Oroan t ra l f i s t u l a 113

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 (Fig. 12).

II. Al l plastic materials

Various alloplastic materials have been used in the past for the closure of oroantral fistula (Fig. 13). These include gold foiF °,37, gold plate 2,15,48, tantalum plate H, soft polymethylmethacrylate 3 and lyophilized collagen 38. 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 be- comes incorporated in the granulation tissue 38.

A simple non-surgical technique by application of lyophilized fibrin seal (human) - Tissucol ® to the defect described by ZTmcIc et al. 57 in 1985. This material forms clot after reacting with a solution ofthrombin, calcium chloride and aprotinin. The resultant whitish elastic gel clot of increasing strength ad- heres firmly to the defect wall. The authors achieved complete closure of the defects within 1 month by single application of Tissucol ®. This method does not require raising the flap. Thus, it is

Fig. 10. Anteriorly based partial thickness dorsal tongue flap. The donor site is closed by primary closure. After 2-3 weeks, the pedicle is divided and the proximal portion is returned to the donor site.

Fig. 11. Posteriorly based full thickness lateral tongue flap. The broken lines show the back cut incision to improve the flap mobility. Longitudinal incisions into the muscle layer to expand the flap.

Fig. 12. Bone graft shown in cross section. The excess bone is trimmed to the level of the defect. The palatal rotational advancement flap is used as its tissue coverage, (A), The alloplastic material is being inserted under the surrounding mucoperiosteum, (B).

114 Awang

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Fig. 13. Buccal osteoperiosteal flap. The bone from the lateral wall of the sinus is pedicled on the periosteum and rotated to cover the defect. The soft tissue coverage is accomplished by the buccal advancement flap.

advantageous in cases where there are limited available local tissues for repair as a result o f considerable scarring of these tissues. The use of human fibrin seal may predispose to the transmission of viral hepatitis. Al though it is care- fully controlled by the manufacturer, such a complication could not be ruled out entirely.

Summary

Closure of oroantral fistula may often be a difficult problem presenting a chal- lenge to the oral surgeon. The review of the literature revealed many surgical techniques that have been advocated to close varying degrees of oroantral defects. Assessment o f local and general factors of the patient have to be care- fully made prior to the selection of the technique. It is further emphasized that complete elimination of sinus infections, excision of the fistulous epithelial tract and proper postoperat ive care are equally important , leading to the success of the closure.

Local mucoperiosteal flaps are often indicated in closure of small to moderate size defects because they are simple to perform and well tolerated by all pa- tients. The reduction o f buccal vestibular height following the closure by buccal flap procedures has received much criticism. Local flaps are utilized in both single- and double-layer closures. A double-layer closure not only improves the strength o f the flaps but also mini- mises contraction and risk o f infection. The strength o f the double-layer closures has been further improved by the incorporat ion of surgical and fascia lata.

Distant flaps and bone grafts are sig- nificant in closure o f large defects or in cases where local flap procedures have

failed. The posteriorly based full thickness lateral tongue flap has been shown to be superior to the anteriorly based partial thickness dorsal tongue flap.

Alloplastic materials may not be eas- ily available, and are costly compared to the use of flap procedures. Works on the use o f collagen and fibrin have received particular attention. This is because these materials are biologically competent and they are easy to use.

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Address: Mohd Noor Awang Department o f Oral Surgery Faculty of Dentistry University o f Malaya 59100 Kuala Lumpur Malaysia

closure of oroantral fistula

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