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Large Oroantral Fistula Repair Using Combined Buccal and Palatal Flaps: a Case Series Ahmed N 48 Original article Large oroantral fistula repair using combined buccal and palatal flaps: a case series Ahmed N. Abdelhamid, Tamer Youssef Department of Otorhinolaryngology, Faculty of Aim Medicine, Ain Shams University, Cairo, Egypt The aim was to detect the efficacy of combined buccal advancement and Correspondence to Ahmed N. Abdelhamid, palatal rotational flaps in closure of large oroantral fistulas (OAFs) after dental MD, 6th Nile Valley Street, Hadayek Alkoba, extraction. Cairo 11331, Egypt. Materials and methods Tel: +201012053054; fax: 0224343309; e-mail: [email protected]/ A 3-year prospective study was conducted between February 2014 and May 2017. [email protected] A total of 11 patients with large OAF after dental extraction were included in the study. Seven patients developed OAF after dental extraction of the maxillary first Received 18 July 2017 Accepted 20 November 2017 molar teeth, whereas two patients developed an OAF after dental extraction of the second maxillary premolars. The last two patients developed an OAF after dental The Egyptian Journal of Otolaryngology 2018, 34:48–54 extraction of the second maxillary molars. Results Closure of the defect was achieved in 10 cases, whereas only one case had failure. In addition to postoperative pain, swelling, and reduction of the vestibular sulcus, one patient experienced postoperative nasal adhesions between the nasal septum and inferior turbinate. Conclusion A combined buccal and palatal flap is efficient in closure of large delayed OAF secondary to dental extraction. Further study is required to assess new bone formation after repair of large OAF using this technique. Keywords: buccal advancement flap, combined flaps, maxillary tooth extraction, oroantral fistula, palatal rotational flap Egypt J Otolaryngol 34:48–54 © 2018 The Egyptian Journal of Otolaryngology 1012-5574 Introduction Materials and methods The oroantral fistula (OAF) is a pathological Patients communication between the oral cavity and the This is a prospective study. A total of 11 maxillary sinus. Like any fistula, it is lined by patients experienced delayed large OAF after epithelium arising from the oral mucosa and/or from dental extraction. This study was conducted in the antral sinus mucosa, which, if not removed, could the Otorhinolaryngology Department, Faculty of inhibit spontaneous healing [1]. Medicine, Ain Shams University Hospitals, between February 2014 and May 2017. They were operated OAF is a common complication following posterior under general anesthesia. Preoperative computerized maxillary dental extraction owing to the close tomography (CT) of the paranasal sinuses (coronal and relationship between the floor of the maxillary sinus axial thin cuts) was done for all patients. The study and the root apices of the molar teeth and premolars. protocol was explained to the patients in detail, and an The incidence of OAF after dental extraction varies informed written consent was obtained from all the from 0.3 to 3.8% [2]. patients involved in this study, including the use of their lesion photographs, CT photographs, operative OAF must be closed as it causes contamination of video recordings, and follow-up photographs. the maxillary sinus from the oral cavity resulting Preoperative treatment of sinus infection and in sinusitis, in addition to communication of perioperative strict control of blood glucose level for the oral cavity squamous epithelium with the diabetic cases were ensured. pseudostratified columnar ciliated respiratory cells of the maxillary sinus [3]. Many options for the closure of the fistula exist including soft tissue This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which with or without bony closure. In this study, we allows others to remix, tweak, and build upon the work assessed the closure of large OAF using combined noncommercially, as long as the author is credited and the new buccal and palatal flaps. creations are licensed under the identical terms. © 2018 The Egyptian Journal of Otolaryngology | Published by Wolters Kluwer - Medknow DOI: 10.4103/ejo.ejo_59_17 Large oroantral fistula repair Abdelhamid and Youssef 49 Ethical approval (2) Patients experiencing renal or hepatic diseases. All procedures performed in studies involving human participants were in accordance with the ethical Surgical technique standards of the institutional and the national research After induction and oral endotracheal intubation, committee and with the 1964 Helsinki declaration and its along with amoxicillin plus clavulanic acid injection, later amendments. This study did not have any influence the mouth was opened using the Boyle-Davis mouth on patient management. Application of the classification gag (surgical holdings; manufacturer of surgical system in each case was by formal recognition of what was instruments; UK). Excision of the fistula was done already implemented regularly in clinical practice. by making a circular incision with a 2-mm margin Inclusion criteria around the OAF, and the epithelial tract and any The study included patients with a large OAF (>5mm inflammatory tissue (like granulation tissue) within in diameter) with the following criteria: the opening were completely excised (Fig. 2). (1) After dental extraction for dental caries. Two divergent cuts were made from each end of the (2) More than 3 weeks of presentation (delayed). fistula extending into the vestibule. Then drilling of the (3) Maxillary sinusitis evident by preoperative CT of alveolar ridgewas doneallaroundthefistula(Fig.3).The the paranasal sinuses (Fig. 1). trapezoidal buccal mucoperiosteal flap was reflected from the alveolar process and the lateral wall of the A total of 11 patients were included in this study. Seven maxilla releasing it to the gingivolabial sulcus, taking ’ patients experienced OAF following extraction of the care not to injure Stenson s duct (Fig. 4). first molar, two patients after extraction of second molar, and another two patients after extraction of A full-thickness mucoperiosteal palatal rotational flap the second premolar. The diameter of the OAF of adequate width (to cover the defect) was harvested ranged from 8 to 13 mm. with a viable greater palatine artery at its base posteriorly (Fig. 5). The buccal advancement flap Exclusion criteria was sutured to the palatal rotational flap, ensuring a The exclusion criteria included the following: watertight closure with 4-0 vicryl sutures (Fig. 6). Lastly, middle meatal antrostomy has been done (1) OAF owing to any maxillary sinus pathology like a endoscopically for all cases with good irrigation of benign or a malignant tumor. the maxillary sinus with isotonic saline. Figure 1 (A, B): coronal, (C): axial Preoperative CT scan showing a right oroantral fistula with alveolar bone defect associated with right maxillary sinusitis. 50 The Egyptian Journal of Otolaryngology, Vol. 34 No. 1, January-March 2018 Figure 2 Figure 5 Oroantral fistula filled with granulation tissue. Harvest of the Palatal rotational flap with pulsating viable greater palatine artery. Figure 3 Figure 6 Suturing of buccal and palatal flaps together. Patientswereinstructedtoavoidgettinghardfoodonthe operated side for 2 weeks postoperatively, tongue rolling over the suture line for 1 week, and nose blowing or Drilling the edge of the fistula. sneezing with a closed mouth for 2 weeks. Clinical assessment of the patients was done at 1, 2, 4, and 12 Figure 4 weeks, postoperatively (Fig. 7). Technical notes for a successful repair of OAF are as follows: (1) Tension-free advancement of the buccal and palatal flaps is important. (2) Proper treatment of any sinus infection is a must with adequate nasal irrigation. (3) Elimination of any diseased bone. (4) Complete excision of the fistulous tract. (5) Palatal flap: (a) The anterior extension of the flap must exceed Buccal advancement flap. the diameter of the bony defect. (b) It must have a sufficient length to allow its lateral Amoxicillin plus clavulanic acid (1 g twice daily) was rotation without exerting tension on its base with given for 7 days postoperatively along with analgesics, resultant kinking of its blood supply, and also whereas isotonic nasal saline wash was done for 1 month. make the incisions with a gentle curve to Large oroantral fistula repair Abdelhamid and Youssef 51 Figure 7 Figure 8 Follow up (2 weeks postoperatively with closure of the defect). eliminate the need for a back-cut on the palatal Extracted tooth in relation to oroantral fistula formation. RM1 = right flap which is done to avoid its kinking [1]. 1st molar; RM2 = right 2nd molar; LM1 = left 1st molar; LPM2 = left 2nd premolar. Statistical methods Data were analyzed using Stata version 14.2 (StataCorp maxillary posterior teeth. If not identified and LLC, College Station, Texas, USA). Normality of treated properly, a large OAC may develop numerical data distribution was examined using the into OAF. OAF is a pathological epithelialized Shapiro–Wilk test. Normally distributed numerical data communication between the oral cavity and the were presented as mean±SD and range. Categorical data maxillary sinus. It is a frequent complication that were presented as number and percentage. occurs most commonly after dental extraction of the maxillary molar and premolar teeth owing to the projection of the root of teeth within the maxillary Results sinus or the proximity of the root apices to the sinus A total of 11 patients were included in this study, with floor. This epithelialization usually occurs when the age range from 33 to 50 years and a mean age of 42 years. OAC persists for at least 48–72 h. Moreover, chronic Only one patient had a previous history of failed primary periapical infection of the posterior maxillary teeth is a closure of the fistula done by the referral dentist. predisposing factor for OAF after tooth extraction [4]. The diameter of the OAF in this study ranged from Within few days, transmission of micro-organisms 8 to 13 mm, with a mean of 11 mm. Seven patients from the oral cavity to the antrum causes maxillary experienced OAF after first maxillary molar extraction, sinusitis.
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