Case Report Three-Layered Closure of Persistent Oroantral Fistula Using
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Hindawi Case Reports in Dentistry Volume 2019, Article ID 8450749, 5 pages https://doi.org/10.1155/2019/8450749 Case Report Three-Layered Closure of Persistent Oroantral Fistula Using Chin Graft, Buccal Fat Pad, and Buccal Advancement Flap: A Case Report with Review of Literature Shiv Prasad Sharma Specialist Oral and Maxillofacial Surgeon, Zulfi General Hospital, Ministry of Health, King Abdulla Street, 11932, Saudi Arabia Correspondence should be addressed to Shiv Prasad Sharma; [email protected] Received 10 April 2019; Revised 20 July 2019; Accepted 30 July 2019; Published 14 August 2019 Academic Editor: Luis M. J. Gutierrez Copyright © 2019 Shiv Prasad Sharma. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Various techniques have been used for the repair of oroantral fistula (OAF) but majority of them have focused on the soft tissue closure alone, and most of the time, the osseous floor of the sinus was ignored. Existing literature supports that bone grafts supported by Buccal Fat Pad (BFP) heal well without undergoing significant resorption and necrosis. Through this case report, we wish to elaborate on the clinical success of using BFP and autogenous chin graft for simultaneous reconstruction of a large long-standing oroantral fistula with underlying osseous defect. The combination technique can prove beneficial for osseous regeneration of sinus floor and improve chances for future implant prosthetic rehabilitation. 1. Introduction The first clinical application of BFP was described by Egyedi in 1977 where he used it for reconstruction of palatal An oroantral fistula can develop as a sequel of dental extrac- defect following tumor excision [7]. In recent years, Buccal tions, infection, maxillary cyst/tumor excision, persistent Fat Pad (BFP) has been used successfully for closing oral infection/abscess, or radiotherapy [1, 2]. A small oroantral defects due to its reliability and easy harvesting. With a fistula < 3 mm can close spontaneously or by simple figure proper technique of harvest, it can provide a 6×5×3cm of eight suture, but large fistulae > 5 mm need more compli- graft which can cover an area of 10 cm2. The mean thickness cated surgical management [3–5]. It is shown that about 50% is about 6 mm [8, 9]. Care should be taken while harvesting to of patients with unattended OAF will develop maxillary sinus avoid injury to the parotid duct and facial nerve branches. symptoms in 48 hours, and within 2 weeks, 90% will have Ignoring the underlying bony defect can have serious maxillary sinusitis [6]. Early detection and management are consequences with respect to prosthetic rehabilitation. advised to avoid further complications. Simultaneous use of autogenous bone graft for OAF closure Management of established OAF can be classified into is recommended to facilitate good prosthetic treatment. Bone nonsurgical and surgical. Nonsurgical methods employ plac- grafts from different sites have been used. In 1969, Proctor ing materials into the defect to act as a mechanical barrier reported the use of iliac crest graft for large OAF closure without attempting flap closure. Synthetic graft materials, [10]. This of course had the disadvantage of a separate fibrin glue, xenograft, absorbable implants, and acrylic surgical procedure associated with unacceptable donor site splints have all been used. morbidities sometimes. The chin area, retromolar area, Surgical principle involves raising the adjacent or distant tuberosity, and ramus of mandible and zygomatic bone are flap and advancing into the defect, for example, buccal flaps, the preferred alternative donor sites [11]. All the previous palatal flaps, tongue flap, and nasolabial flaps [2]. All these studies have utilized the standard buccal flap (Rehrmann) methods have their own advantages and disadvantages. to cover the graft. We would like to present the successful 2 Case Reports in Dentistry use of autogenous chin graft covered with BFP and closure (fractured root tip). The sinuses showed normal appearance. with BAF in the reconstruction of OAF. The bony defect of size 2×18cmalong the sinus floor was The use of chin grafts in OAF closure has been reported confirmed (Figure 2). with successful outcomes. Haas et al. in their preliminary After correlating the clinical and radiographic findings, study showed successful results with chin grafts [12]. It is surgical closure using buccal advancement flap (BAF)+ important to note that although chin grafts have been used BFP+autogenous bone graft from the chin was planned. with successful results in numerous applications, their use Preoperatively, the patient was started on antral regime in OAF closure has been scarce or may be under reported. (Tab amoxicillin clavulanic 625 mg+metronidazole 500 mg+ It provides high quality bone which is easy to harvest and Tab ibuprofen+Tab chlorpheniramine 4 mg + nasal decon- can be used without any significant donor site morbidity. gestant) for 5 days. The grafts from different origins show varied rates of miner- The entire procedure was performed under local anesthe- alization. In an interesting study by Schlegel et al., chin bone sia (2% lignocaine with 1 : 80000 adrenaline) using Posterior grafts were found to be superior in terms of mineralization Superior Alveolar block supplemented by infiltration+greater over a 6-month period [13]. palatine nerve block. The fistulous tract was excised in a Several techniques have been utilized to reconstruct the circumscribed manner along the defect. A modified buccal bony defect. Most of the published articles are in the form mucoperiosteal flap was elevated in trapezoidal outline start- of a case report or case series. There is a lack of large prospec- ing from the mesial and distal end of the fistulous opening. tive randomized studies comparing the reliability and out- The periosteum was incised along the posterior aspect of comes of these existing methods. Kapustecki et al. in their the flap to identify BFP. Gentle blunt dissection was done series of 20 cases used autogenous grafts from symphysis to harvest the BFP till we obtained the sufficient amount of mandible (14 patients) and external oblique line (6 patients) fat to cover the graft and the defect. Next, the cortical bone covered with PRF (Platelet Rich Fibrin) membrane [14]. graft was harvested from the chin of size matching the defect. They observed successful fistula closure along with restora- The graft was press fit into the defect and did not require tion of adequate alveolar width and height in preparation screw fixation. Then, the BFP was mobilized to cover the for future prosthetic solutions. In their series of 21 cases graft, and finally, the mucoperiosteal flap was repositioned reconstructed with bone grafts from mandibular symphysis and sutured in place (Figures 3 and 4). This way, 3-layered and retromolar areas, Watzak et al. realized a complication closures were performed to reconstruct the bony as well as rate of 14.3% in the form of wound dehiscence, which healed soft tissue defect. The patient was put on nasogastric tube by secondary intention [15]. feed till the time of suture removal. Mucosalisation of the Er et al. performed two-layered closure with simulta- fat pad was noticed at follow-up visits after 1 week and 1 neous bone grafting using graft from different intraoral sites month later (Figures 5 and 6). [16]. They noted wound dehiscence in 20% of their patients. The patient was observed for signs of infection, dehis- It can be realized that wound breakdown can result from cence, and necrosis. Postoperative radiograph showed bone inadequate two-layered closure. Ahmed and Askar showed graft well in place (Figure 7). No significant complication favorable results with the coverage of bone graft with buccal was noted in the follow-up appointments. Both the pri- mucoperiosteal flap [17]. In a 10-month follow-up case, mary site and the bone graft donor site healed without Weinstock et al. demonstrated the additional benefit of the any dehiscence. three-layer closure with bone graft, buccal fat, and buccal advancement flap [18]. The two layers over the graft not only 3. Discussion provide added support but also give a well vascularized bed for the success of the graft. The commonest cause for the development of OAF includes Table 1 summarizes various studies demonstrating the dental extractions of posterior teeth (molars, premolars) due use of different modalities addressing the osseous defect asso- to close proximity of the root apices to the sinus floor. Fre- ciated with OAF. quencies of such occurrences have been reported to be between 0.31% and 4.7% [19]. Based on its location, the fistula 2. Case Presentation can be alveolosinusal, palatosinusal, or vestibulosinusal [20]. Ever since its first clinical use by Egyedi in 1977, BFP has A 45-year-old male patient, chronic smoker, reported to us gained popularity and rightly so because of its advantages: with the chief complain of leakage of liquids through his nose rapid epithelialization, excellent reliable blood supply, ana- while drinking. Otherwise, he was asymptomatic. He under- tomically favorable position, ease of harvest, low rate of com- went extraction of his tooth number 16 about 6 months back plications, and minimal to no donor site morbidity. elsewhere. On clinical examination, there were no signs and Problems that we can come across mainly at the time of symptoms suggestive of acute maxillary sinusitis. Intraorally, harvesting BFP are perforation or shrinkage. Egyedi advo- a fistulous opening round in shape with normal surrounding cated covering the fat pad with split skin graft to overcome mucosa and an obvious bony defect was seen along the max- these issues, but Tideman et al. have shown that BFP was illary alveolus molar region (Figure 1). No active discharge capable of self-epithelialization within 3-4 weeks of its inset was present.