Root perforations following endodontics: a case for surgical management

Despite technological advancements in dental instrumentation and techniques, endodontic mishaps remain commonplace. Perforations during access preparation, canal instrumentation, root filling, or preparation of post space are not unusual and instruments may fracture during filing or reaming or when attempting to bypass fractured instruments in the root canal. Many of these complications are hard to avoid due to extreme variations in root canal anatomy, root shapes, curvatures, and canal calcification. Procedural errors impede proper endodontic therapy and increase the risk of treatment failure; as a result, the prognosis is compromised, especially in nonvital teeth or teeth with periradicular lesions. Perforations may lead to short-term or long-term complications (that is, infection, periapical cyst, or granuloma formation); in addition, restorative material may be extruded through the perforation. Clinicians often have difficulty diagnosing and treating root perforations, particularly in posterior teeth (specifically in the area of the mandibular bifurcation); however, such complications do not mean that the tooth must be extracted. This article discusses treatment of perforations near the bifurcation of a mandibular first molar and an apical perforation in a premolar. Both teeth were salvaged via surgery without the use of additional biomaterials.

Levator labii superioris muscle transposition to treat oromaxillary sinus fistula in three horses

OBJECTIVE

To describe surgical transposition of the levator labii superioris muscle to treat oromaxillary sinus fistula in horses.

STUDY DESIGN

Clinical study.

ANIMALS

Three horses with chronic oromaxillary sinus fistula.

METHODS

After severing its tendinous insertion, the muscle belly of the levator labii superioris muscle was retracted and transposed through the oromaxillary sinus fistula. The tendon exited the oral cavity through a full-thickness buccal incision created adjacent to the oral end of the fistula and was then tunneled subcutaneously in a ventral direction before being anchored by sutures to the cheek tissues.

RESULTS

Fistulae healed with few complications and with good cosmetic and functional results.

CONCLUSIONS

Oromaxillary sinus fistula associated with molariform tooth loss in horses can be treated successfully by transposition of the levator labii superioris muscle.

CLINICAL RELEVANCE

Transposition of the levator labii superioris muscle should be considered for resolution of chronic oromaxillary sinus fistula in horses.

Surgical repair of traumatic oronasal fistula in a domestic short-haired cat

A 9-month-old, spayed female domestic shorthair was presented with a suspected traumatic oronasal fistula. Two surgical attempts using mucosal advancement flaps and single layer closure failed, likely due to inadequate blood supply that was potentially exacerbated by excess tension and trauma on the graft.

Complications of mandibular brachygnathism in a North African leopard

A 9-year-old, male North African leopard (Panhtera pardus) presented with mandibular brachygnathism and lingually displaced mandibular canine teeth causing a large left oronasal fistula, rhinitis and nasal discharge, and a right orocutaneous fistula. Surgical closure of the left oronasal defect, bilateral mandibular canine tooth crown reduction, and root canal therapy resulted in a positive clinical outcome. A small recurrent left oronasal fistula and the right orocutaneous fistula healed spontaneously after alleviating the occlusal contact with the mandibular canine teeth. At 12-months postoperatively, clinical signs of oral and dental disease had resolved.

Bioabsorbable root analogue for closure of oroantral communications after tooth extraction: A prospective case–cohort study

OBJECTIVE

To assess the clinical capacity of a bioabsorbable root analog to close oroantral perforations after extraction.

STUDY DESIGN

In this prospective case-cohort study, 20 consecutive patients with oroantral communications greater than 2 mm were treated with a bioabsorbable root analog (RootReplica). Patients were followed up clinically and radiographically for 3 months to monitor the healing process.

RESULTS

Root replicas could be placed in 14 patients, whereas 6 patients required the socket to be covered with a buccal sliding flap. In the latter cases, fragmentary roots or overly large defects prohibited replica fabrication or accurate fitting of the analog, respectively. Healing was uneventful in all patients, and epistaxis, swelling, or pain was observed only in patients treated with flaps.

CONCLUSIONS

The method described is a valuable alternative method with which to close oroantral communications but cannot be performed in all patients because of technical limitations.

The assessment of anesthetic efficacy of ropivacaine in oral surgery

This paper describes the application of ropivacaine, local, amid, long-acting anesthetic in oral surgery. For infiltrative anesthesia, 0.75% of Naropin (ropivacaine) was used in eight patients undergoing various operations (maxillary sinus with oro-antral communication, extraction of upper and lower impacted wisdom teeth, cystectomy, apicoectomy and tooth extraction). The achieved anesthesia in all patients enabled analgesia in the course of the operation, and the expected intraoperative and postoperative bleeding, whereas postoperative analgesia lasted long enough (up to 380 minutes) to prevent the intake of analgesics. Side effects or local reaction on ropivacaine were not detected.

Maxillary myxoma: surgical treatment and reconstruction with buccal fat pad flap: a case report

Myxoma is a benign tumor that arises from mesenchymal tissue and is found less commonly in the bone than in soft tissue. The majority of bony myxomas occur in the jaws. When compared with other odontogenic tumors, myxoma of the jaws is a rare entity. Numerous types of treatment have been used for these tumors including simple curettage, enucleation, curettage with peripheral ostectomy, and en bloc resection with or without immediate reconstruction. The buccal fat pad (BFP) is a lobulated mass of fatty tissue in the oromaxillofacial region, which has long been a source of grafts in facial augmentation. A case of an odontogenic myxoma in the left maxillary molar area of a 34-year-old female that was treated by curettage and peripheral ostectomy is presented. The surgical defect was successfully repaired with a pedicled BFP flap.

Dental implant therapy in the treatment of an oroantral communication after exodontia

A new technique in which a dental implant was the ultimate therapy for the treatment of an oroantral communication (OAC) that was created subsequent to the extraction of a maxillary first molar is described. A search of the English-speaking literature has not revealed implant therapy as part of documented modalities for the treatment of an OAC created following dental extraction. The OAC was closed by a sandwich technique that uses two resorbable membrane materials (Bio-Gide, Osteohealth, Shirley, NY) that surround a bone substitute (Bio-Oss, Osteohealth). This procedure, together with additional onlay grafting with the same bone substitute, was used also to regenerate subantral bone to enable the subsequent placement of an endosseous implant after 12 months. An 8-month postoperative radiograph showed creation of a new maxillary sinus bony floor and subantral bone of good quality, and height that can permit the placement of an endosseous dental implant.

[Biphosphonate-associated osteonecrosis of the maxilla. Case report and review of the literature]

In recent years, a growing number of reports in the literature have linked osteonecrosis of the jaw bones with intravenously administered bisphosphonates prescribed for the treatment of hypercalcemia of malignancy due to bone lesions of multiple myeloma or bone metastases in patients with breast or prostate cancer. Furthermore, an association between chronic oral bisphosphonate use in patients with osteoporosis or Paget's disease, and bone necrosis in the mandible or maxilla has been demonstrated in numerous case reports and case series in the last couple of years. Therapeutically, osteonecrosis of the jaws seems to be difficult to treat surgically, often resulting in a recurring or even progressing lesion. In the present case report of a bisphosphonate-associated osteonecrosis of the maxilla in a patient with osteoporosis, the current literature will be discussed, and open research questions and potential problems for our daily dental practice routine will be addressed.

[Soft tissue surgery with the diode laser--theoretical and clinical aspects]

Currently laser light of different wavelengths is used for all kinds of surgical procedures in oral and maxillofacial surgery. In this regard especially the diode laser is mainly used, because of its excellent effects on oral soft tissues. On the basis of various oral soft tissue lesions in 40 patients the benefits of the diode laser in daily practice are demonstrated. Intraoperative and postoperative clinical findings were excellent due to the sufficient cutting abilities, the good coagulation effect and the extremely small zone of thermal necrosis to surrounding tissues. By this the diode laser has proven as an alternative solution to conventional electrosurgery and scalpel. The precise treatment in the contact application mode, which allowed an easier and more controlled guidance of the laser beam, was another advantage of the fiber-assisted laser system. In conclusion the results show that the diode laser is a useful instrument in oral soft tissue surgery.

[Status of mucous membrane of the maxillary sinus in patients with oral-sinus interconnection in different terms after its appearance]

The status of anatomy-morphology of maxillary mucosa depending on the time of interconnection between the maxillary sinus and oral cavity, the size of it and its function were studied. The study was conducted on 25 patients and 20 cadavers. Changes in the mucous membrane of the maxillary sinus in relation to some of factors are discussed.

[Endoscopic treatment of odontogenic cyst with intra-sinusal extension]

Odontogenic cyst is a common lesion that can happen after inflammation of the dental pulp. The therapeutic approach of these cysts is made at dentist's offices, and depending on their extension, they may develop oroantral fistula and chronic sinusitis. The objective of this study is to propose the videoendoscopic treatment of the odontogenic cyst with expression in the maxillary sinus. We made a retrospective study of four cases of cysts of dental origin, with intra-sinusal extension, complicated with oroantral fistula and chronic sinusitis of maxillary sinus after curettage in a dentist's office. We used the videoendoscopic technique through transmaxillary approach to access the intra-sinusal cyst. All the four patients presented resolution of the infectious manifestation and healing of the oroantral fistula, without recurrence within two years of follow-up. Videoendoscopic surgery is a safe and effective method for the management of odontogenic cysts with extension to maxillary sinus, and it may prevent oroantral fistula formation and chronic sinusitis.

Bony palatal necrosis in a diabetic patient secondary to palatal rotational flap

Donor site necrosis is a very rare complication of palatal rotational flaps. The aim of this case report is to present a 43-year-old female, Type I diabetic patient with a chronic oroantral fistula in the right second molar region. The patient had bony necrosis in the donor site following palatal rotational flap operation. The treatment approach and the alternative methods are discussed.

Bony press-fit closure of oro-antral fistulas: a technique for pre-sinus lift repair and secondary closure

PURPOSE

To evaluate the use of intra-oral bone grafts for closing chronic oro-antral fistulas (OAFs), for providing a sound basis for subsequent conventional sinus lifting and for preserving the teeth adjacent to OAFs.

PATIENTS AND METHODS

Twenty-one patients with oro-antral fistulas of variable origin were treated with monocortical bone blocks harvested from the retromolar or interforaminal regions of the mandible. The preoperative treatment, the surgical procedure for both hard and soft tissue closure, and the postoperative management are reviewed in detail.

RESULTS

Press-fit closure for repair of the bony sinus floor was sufficient in 17 patients. Four of them needed additional internal fixation. In all 21 patients adequate closure of the fistulas was obtained, although 3 patients (14.3%) developed wound dehiscences at the grafted sites, which healed by secondary intention. Meanwhile, 3 patients underwent successful sinus lifting.

CONCLUSION

The use of monocortical bone grafts harvested at intra-oral donor sites is a safe and easy technique for repairing defects of the maxilla, especially OAFs in need of secondary closure. It provides a sound basis for subsequent conventional sinus lifting and preserves the teeth adjacent to OAFs.

A new surgical management for oro-antral communication: the resorbable guided tissue regeneration membrane - bone substitute sandwich technique

This paper describes a new technique for the closure of oro-antral fistula/communication, in which both hard tissue (bone) and soft tissue closure is achieved. The sandwich technique utilizes a suitable bone grafting material sandwiched between two sheaths of Biogide (a resorbable membrane) for the hard tissue closure of oro-antral communication post traumatic exodontia. The bone grafting material utilized for this case was Bio-oss. The result obtained was excellent with regeneration of sufficient bony tissue to allow placement of an endosseous implant. This sandwich technique is a simple and excellent technique for the closure of oro-antral communication, especially when subsequent placement of endosseous implant is considered without the need of donor site surgery for bone grafting. The otorhinolaryngologists and oral and maxillofacial surgeons should find this technique very useful in the closure of oro-antral fistulae.

An animal model for oroantral communications: a pilot study with Göttingen minipigs

A pilot study was performed to investigate whether the Göttingen minipig is a suitable animal model for creating and closing oroantral communications (OACs) and to test whether these defects can be closed with a biodegradable polyurethane (PU) foam. In three adult minipigs, an OAC was created on both sides of the maxilla. The left side was closed by a standard surgical buccal flap procedure, the right side by applying a PU foam. The pigs were killed after two weeks, one month and three months, respectively. Postmortem and histological examination showed that an OAC was created in only one of six cases. In the remaining cases, the infraorbital canal was perforated instead of the floor of the maxillary sinus. It was concluded that the Göttingen minipig is not a suitable animal model for OAC investigations. As a result, the closure of OACs with a biodegradable PU could not be evaluated.

Evaluation of different treatments for oroantral/oronasal communications: experience of 112 cases

This retrospective study analyzed the etiologic factors, location and treatments for patients with oroantral or oronasal communications (OAC or ONC). Data analysis extended to gender, age, etiology, location, type of treatment and short-term complications from January 1988 to May 2004. A total of 112 patients with 101 (90%) OAC and 11 (10%) ONC were included. The main etiology for OAC was tooth extraction (95%) with similar prevalence between right (49%) and left (51%) side. For ONC, pathological conditions (27%) and exodontia (27%) were the most prevalent. For the treatment of OAC, suture was the technique most frequently used (60%), followed by buccal fat pad (28%), buccal flap (9%), palatal flap (2%) and one dental transplant (1%). For ONC, the following treatments were used: suture (46%), buccal flap (36%) and palatal flap (18%). Failure to eliminate the communication occurred in six (6%) patients of the OAC group and three (27%) of the ONC group. The results confirm that tooth extraction was the most common etiologic factor for ONC and OAC. Suture, when the communication was small (3-5 mm), and the use of a buccal fat pad (100% successful), when a larger communication existed (>5 mm), seemed to be the two best choices for treatment.

The Transverse Cervical Vessels as Recipient Vessels for Previously Treated Head and Neck Cancer Patients

BACKGROUND

A major challenge in head and neck reconstruction in patients with a "frozen neck" is the limited availability of recipient vessels including the carotid artery system. The aim of the present study was to investigate the suitability of the transverse cervical vessels as recipient vessels for free flap reconstruction in head and neck cancer patients.

METHODS

Thirty-three sides of necks in 26 patients requiring free flap reconstruction were explored. The presence, location, and size of the transverse cervical vessels were documented.

RESULTS

Two arteries (6 percent) and four veins (12 percent) were unavailable. Eight arteries (24 percent) and two veins (6 percent) had a diameter of less than 2 mm, 23 arteries (70 percent) and 18 veins (55 percent) had a diameter of 2 to 3 mm, and nine veins (27 percent) were larger than 3 mm. The contralateral neck was explored because of the lack of suitable ipsilateral vessels in six patients (23 percent). The transverse cervical vessels were unsuitable on both sides in two patients (8 percent). All the available transverse cervical vessels were found to be free of disease. Moderate scarring in the supraclavicular region was present in two cases. All flaps survived without vascular events.

CONCLUSIONS

The transverse cervical vessels were thus suitable as recipient vessels in 92 percent of patients and should be the first choice in difficult head and neck reconstructions.

[Surgical correction of oroantral fistulas with integration of mandibular bone]

OBJECTIVE

The goal of this study was to formulate a proposal for an alternative surgical technique for treating >3 mm oroantral fistulas by integration of mandibular bone, in an attempt to decrease complications due to its invasive nature.

MATERIAL AND METHODS

An observational, descriptive and longitudinal cohort study was carried out in the Maxillofacial Oral Surgery Department in the Specialty Hospital of the 21st Century National Medical Center of the Mexican Institute of Social Security in Mexico City. Sample patients with a diagnosis of oroantral fistula from January 1984 to December 1999 were selected. Surgical correction under general anesthesia was performed with the integration of mandibular osseous graft. Patients were followed postoperatively for 4 years.

RESULTS

Of the 22 patients, 13 were male and 9 female, and all were between 25 and 45 years old (average: 35.5 years). They were treated by application of osseous external mandible graft. In most cases, the graft was covered with a sliding mucoperiosteal flap, two were covered with a racquet-type flap and one only one procedure was Von Lagenbeck type because the nasal floor was involved. None of the patients refused the graft. All patients were followed postoperatively, both clinically and radiologically, for 4 years.

DISCUSSION

Oroantral communication control is difficult because of mouth fluids, mixed bacterium and a humid environment that promotes development of infection. Therefore, the solution is complicated. As a consequence, it is thought that a simple technique such as the use of mandible graft, which offers advantages over others that are performed such as the application of calotte, rib, iliac crest, and perone grafts, but also implies double surgery in distant anatomic areas with particular complications in each one and a longer surgical time.

CONCLUSIONS

Whatever the etiology of the oroantral communication, the fistulas must be treated immediately after diagnosis. Treatment protocol must be established according to the size and location and presence or absence of infectious process. Successful treatment is achieved by this process.

Management of Arsenic Trioxide Necrosis in the Maxilla

Historically, pulp-necrotizing agents were commonly used in endodontic treatments. They act quickly and devitalize the pulp within a few days. However, they are cytotoxic to gingiva and bone. If such an agent diffuses out of the cavity, it can readily cause widespread necrosis of gingiva and bone, which can lead to osteomyelitis of the jaws. Although the use of arsenic trioxide can cause severe damage to surrounding tissues, producing complications, it is still used in certain areas in the world. This article presents and discusses two cases of tissue necrosis and their surgical management. These cases showed severe alveolar bone loss in the maxilla, which affected the patients' quality of life and limited the restorative possibilities. As dentists, we should be aware of the hazardous effects of arsenic trioxide and should abandon its use. Because of its cytotoxicity, there is no justification for the use of arsenic trioxide in the modern dental practice.

Technique for in-office cranial bone harvesting

PURPOSE

This is a report of a technique of cranial bone harvesting suitable for the outpatient setting.

MATERIALS AND METHODS

Bone scrapers are used for the harvesting of cranial bone shavings with the patient under intravenous sedation or general anesthesia.

RESULTS

Graft volumes larger than that usually obtainable from intraoral sites and the tibia have been harvested utilizing this technique. In a series of 8 first patients, the largest volume of bone obtained was 14 cc with no complications related to the donor sites. These cases include the following types of pre-implant reconstructive procedures: large unilateral sinus grafting, bilateral sinus grafting/guided-bone regeneration of an entire alveolar ridge, inlay grafting of the alveolus, inlay grafting in association with distraction osteogenesis, subnasal grafting, alveolar cleft grafting, closure of large oroantral defects combined with sinus grafting, and grafting of an grossly atrophic mandible with simultaneous placement of dental implants via the submental approach.

CONCLUSION

This is a safe bone harvesting technique providing an alternative source of autogenous bone graft.

The Buccal Fat Pad in the Closure of Oro-Antral Communications: An Illustrated Guide

This article is intended as an illustrated, step-by-step guide in the use of the pedicled buccal fat pad in the closure of oro-antral communications. The advantages and disadvantages of its use are discussed, along with its basic anatomy.

Inferior meatal antrostomy: is it necessary after radical sinus surgery through the Caldwell-Luc approach?

PURPOSE

In the Caldwell-Luc (CWL) operation, an antrostomy at the inferior meatus is created surgically to promote sinus drainage. This inferior meatal antrostomy (IMA) has been criticized because of the need for an additional time, early loss of the sinusotomy, injury to the nasolacrimal duct, epistaxis from the sphenopalatine artery, and deviation from the normal sinus physiology. This trial was undertaken with specific attention to the question: Is it necessary to perform antrostomy at the inferior meatus after radical sinus surgery through the CWL approach?

MATERIALS AND METHODS

Thirty-three patients with a dental origin of sinus disease indicating the CWL operation were entered into this trial. They were treated in blocks of 3, in which IMA was not performed in the first and second patients of each successive block. Only the third patient of each block had IMA performed. Cheek swelling, infection, and failure to relieve the patient's symptoms were the criteria for comparison between patient groups. Cheek swelling was measured by the eye-mouth line and the ear-nose line on the second and fourth day after surgery.

RESULTS

At no time was there a statistically significant difference in cheek swelling between the treated groups (P >.05). No infection or failure of treatment was encountered. However, some patients in both groups had numbness or paresthesias of the cheek, upper lip, upper front gingiva, and teeth. These complaints were transient and lasted for several weeks.

CONCLUSION

Based on our findings, it does not seem necessary to perform antrostomy at the inferior meatus, provided the patient has a patent osteomeatal complex and no anatomic abnormalities.

[Oroantral perforations]

Some risk factors in relation to the occurrence of an oroantral perforation are discussed in the light of the existing literature. Factors relevant for the diagnosis and the treatment of an oroantral perforation, are discussed. Small perforations probably heal without problems, provided that the alveolus is deep enough and a blood clot will form without disturbance. Some pros and cons of buccal and palatal transposition flaps for closing clinically significant oroantral perforations, are discussed.

Use of pedicled buccal fat pad in the closure of oroantral communication: analysis of 75 cases

OBJECTIVE

This report evaluates the use of pedicled buccal fat pad for closure of oroantral communications.

METHOD AND MATERIALS

Seventy-five patients were treated with pedicled buccal fat pad. Fifty-two were treated immediately after tooth extractions. The remaining 23 had chronic oroantral communication and were treated similarly after irrigation of the maxillary sinus with saline for 7 days.

RESULTS

The 6-month follow-up revealed uneventful healing in all of the patients. Though partial necrosis of the flap was observed in three patients, this did not effect the final healing. Total necrosis of the flap was not noted.

CONCLUSION

The use of pedicled buccal fat pad is an acceptable and reliable alternative in acute or chronic oroantral communications management and may even be used as a first treatment choice by experienced surgeons.

Use of the Serratus Anterior Free Flap to Treat a Recurrent Oroantral Fistula

We describe the successful use of the serratus anterior free muscle flap to obliterate a recurrent oroantral fistula in a 39-year old male who 19 years before this surgery had sustained a high velocity impact to his right face with multiple subsequent corrective surgeries. There was no complication from the serratus anterior free flap surgery and no postoperative scapular winging. The serratus anterior muscle is a versatile flap and ideal for various defects. It should be considered for obliteration of oroantral fistulas when no local or regional tissue is available because of previous surgery or trauma.

Palatal rotation-advancement flap for delayed repair of oroantral fistula: a retrospective evaluation of 63 cases

OBJECTIVE

To review our 17-year clinical experience with delayed oroantral fistula repair by palatal rotation-advancement flap, and to report its advantages, disadvantages, and complications.

STUDY DESIGN

The records of 63 patients with late oroantral fistula treated by palatal rotation-advancement flap from 1984 to 2002 were reviewed. Eleven had undergone unsuccessful closure with a buccal flap. Data recorded were patient age and sex, cause of fistula, signs and symptoms, interval from appearance of fistula to repair, fistula size, radiographic appearance, method of repair, and immediate and late complications.

RESULTS

There were 35 women and 28 men aged 21 to 71 years (mean 50.3 years). Surgery was performed 3 months to 20 years after injury (mean 1.8 years). Twenty-four patients had acute maxillary sinusitis and 39 had chronic sinusitis. The main causes of oroantral fistula were extraction of the second and first molars and pathological lesions within the sinus. Average fistula size was 2.3 cm x 1.6 cm. Fifty-one repairs were preceded by Caldwell-Luc operation. All fistulas were successfully closed with the palatal rotation-advancement flap, with minimal complications on long-term follow-up.

CONCLUSION

The palatal rotation-advancement flap is recommended for the late repair of oroantral fistula owing to its good vascularization, excellent thickness and tissue bulk, and easy accessibility; it also allows for the maintenance of the vestibular-sulcus depth. It is particularly indicated in cases of unsuccessful buccal flap closure.

A preliminary study of monocortical bone grafts for oroantral fistula closure

Sinus floor elevation has become a standard procedure in patients affected by severe maxillary atrophy, before implant placement, provided that the maxillary sinus is intact and uninfected. In the case of an oroantral fistula, simple soft tissue closure may interfere with the process of elevating the Schneiderian membrane. Total regeneration of the bony sinus floor is necessary to prevent disruption of the sinus membrane. In this study, 5 patients with oroantral fistulae of different causes were treated with autogenous monocortical bone blocks harvested from the chin. Press-fit closure for bony repair of the basal maxilla was sufficient in 3 of them. Two patients needed additional internal graft fixation. In the meantime, the 3 aforementioned patients underwent a successful sinus lift procedure. The use of a monocortical bone block for the closure of an oroantral fistula is recommended before internal sinus augmentation.

Treatment of oroantral fistula:experience with 27 cases

PURPOSE

To review patients with chronic oroantral and oronasal fistula who underwent surgical correction.

MATERIAL AND METHODS

Twenty-seven patients with chronic oroantral and oral fistula who underwent surgical correction in the Hacettepe University Faculty of Medicine Department of Otorhinolaryngology Head and Neck Surgery between 1968 and 2001 were reviewed retrospectively.

RESULTS

Local mucosal flaps were used for surgical correction. The underlying factors were tooth extraction in 13 patients (48%), tumor in 5 (18.5%), osteomyelitis in 3 (11%), Caldwell-Luc procedure in 2 (7.5%), trauma in 2 (7.5%), dentiginous cyst in 1(3.7%), and correction of septal perforation in 1 (3.7%). Among the fistulas, 23 were oroantral, 3 were oroantronasal, and 1 was oronasal, respectively. Two patients required revisional repairment. The surgical procedure failed in 1 diabetic patient and 3 patients with prior history of external radiotherapy.

CONCLUSION

Tooth extraction was the most common etiologic factor, and malignancy should be excluded in all patients. The outcome may not be satisfactory in patients with systemic disease and in patients with history of radiotherapy. Multiple surgical interventions may be necessary only on rare occasions.

Use of third molar transplantation for closure of the oroantral communication after tooth extraction: a report of 2 cases

OBJECTIVE

This clinical report introduces a promising and unique method for the immediate closure of the oroantral communication (OAC) after tooth extraction: the use of the transplanted third molar with closed apices.

STUDY DESIGN

In 2 adult patients, OAC caused by the extraction of an upper molar was immediately closed by using a transplanted third molar with complete root formation. After tooth extraction at the recipient site, OAC with perforated mucosa of the sinus floor was confirmed and the donor third molar was transferred to the prepared recipient socket. Endodontic therapy of the transplanted third molar began at 3 weeks after surgery, and prosthetic treatment was completed at 5 months after the operation. These 2 patients were carefully observed both clinically and radiographically.

RESULTS

Closure of the OAC was successfully performed, and the transplanted teeth became fixed with the passage of time in these 2 patients. Root resorption did not occur, and good functional results were obtained without any complications.

CONCLUSIONS

Tooth transplantation of a mature third molar for closure of the OAC is a simple and excellent method because the transplanted tooth not only closes the communication to the maxillary sinus, but it also satisfactorily functions at the recipient site during mastication, even in adult patients.

Implant surgery: the management of soft tissues

Soft tissue healing plays a significant role in determining the outcome of implant and other osseous surgery. A variety of methods is required to accomplish primary soft tissue closure. These include the techniques of undermining; free grafting, both full and split thickness; and pedicle grafting. Preprosthetic surgery, which includes the correction of high muscle attachments and vestibular deficiencies, involves the use of broad spectrum grafting modalities in order to create an appropriate environment for the placement of implants.

Bilateral oroantral fistulas following devitalization of teeth by arsenic trioxide: a case report

Although it is well known that prolonged application or leakage of arsenic trioxide can cause severe damage to the periodontal tissues, the substance is still used by some dentists. This paper describes a case of arsenical necrosis of the jaws affecting the right and the left side of the maxilla. As a result of leakage into the tissues of an arsenical paste from the pulp chamber of endodontically treated teeth, bilateral oroantral fistula (OAF) occurred. It is concluded that there is no justification, whatsoever, for the use of arsenic in modern dental practice. In the following case, buccal advancement flap and submucosal palatal island flap techniques were used for to close the OAF. The submucosal palatal island flap technique resulted in successful closure of the OAF.

Long-term results of the application of solvent-dehydrated bone xenograft and duramater xenograft for the healing of oroantral osseous defects: a pilot experimental study

The aim of this study was to investigate the long-term effects of the use of human cadaveric solvent-dehydrated bone graft and duramater as a barrier membrane for the treatment of oroantral communication. Standard oroantral osseous defects were created in five minipigs. Subjects received cancellous bone graft in the form of block or microchips, duramater or a combination of bone and membrane. Uneventful healing was achieved in all of the subjects, clinically including the control site which did not receive any material. The operated bone segments were evaluated both by radiological and histological examinations after 6 months. Radiological evaluation was carried out using bone density analysis software and histological evaluation made by light microscopy. Radiological and histological results revealed that bone grafting of oroantral osseous defects improved the bone quality. However, application of duramater did not change this activity, both alone or combined with bone grafts. Within the limits of this experimental study, although solvent-dehydrated bone grafts were found superior and could be applied for the healing of osseous oroantral defects, resorbable membranes did not contribute to this process.

Repair of oroantral communications in the third molar region by random palatal flap

Various palatal flap procedures based on the greater palatine vessels have been advocated for the repair of oroantral communications (OACs). However, when the defect is located in the third molar region, difficulty is encountered in using the palatal flap because rotation is hindered by the vascular pedicle. In this study, we used random palatal flaps to repair OACs in the third molar area in 21 patients. The vascular pedicles were ligated and severed in all cases in order to evaluate whether it was necessary to preserve the greater palatine vessels when using the palatal rotation flap (PRF). The repair was successful in 16 cases (76.2%). The length/width ratio of the flap was the most important factor determining the outcome. The ratios were 2.23 +/- 0.12 and 2.40 +/- 0.14 in the success and failure groups, respectively and their difference was statistically significant (P<0.05). Other clinical parameters such as age, gender, antral infection, tooth displacement into the sinus and duration of the communication had no influence on the outcome (P>0.05). The study showed that the PRF with the appropriate length/width ratio can safely be used in a random fashion. This provided another option in the repair of oroantral communications of difficult locations such as in the tuberosity area.

Use of the buccal fat pad in maxillary and sinus grafting of the severely atrophic maxilla preparatory to implant reconstruction of the partially or completely edentulous patient: technical note

PURPOSE

To examine the use of the buccal fat pad (BFP) for correction of maxillary osseous defects, preliminary to dental implant reconstructions, and to present patients in whom this technique was used.

MATERIALS AND METHODS

The blood supply of the BFP was investigated with a special laser Doppler flowmetry fiberoptic probe in situ before herniation and after placement of the pedicled BFP over maxillary bone grafts.

RESULTS

The possibility of using the BFP pedicle flap to provide an immediate blood supply to a recipient site was confirmed, as it promotes rapid neo-vascularization of the grafted material over which it is placed. No complications were seen in the present patients.

DISCUSSION

The BFP has an additional protective function of providing for a multiple-layer wound closure over all types of maxillary bone grafts, thereby preventing graft exposure and enhancing success.

CONCLUSIONS

With its high blood flow, the BFP may offer protection and early blood supply to maxillary and sinus bone grafts.

A modified technique of using the tongue tip for closure of large anterior palatal fistula

Anteriorly based dorsal tongue flaps are the most commonly used flaps for closure of difficult palatal fistulae. The author presents a patient in whom the palatal defect was thought to be too big to be closed by the standard tongue flap. The tongue tip was divided into equal dorsal and ventral flaps, and both flaps were used to reconstruct the palatal defect. Technical considerations, and advantages and disadvantages of the procedure are discussed.

Inadequate implant angulation resulting from oroantral fistula: case report

Successful implant surgery is largely dependent on good treatment planning and careful surgery. A complete treatment plan must encompass both surgical and prosthetic considerations for the implant restoration. Some compromised implants are restorable, and the result can be acceptable if they can be adjusted into a more ideal position. The goals of the segmental osteotomy are the preservation of a healthy dental unit, the creation of a more ideal environment for dental restoration and occlusal reconstruction, the optimization of cost effectiveness, and the minimization of edentulous space. The purpose of this study is to present the segmental maxillary osteotomy to reposition the alveolar segment with its implant that was in a highly compromised situation.

Oronasal fistula repair

Oronasal fistula is a relatively common complication associated with maxillary canine tooth extraction, problematic healing of maxillectomy, and repair of secondary cleft palate in small animals. Regardless of the clinical scenario associated with oronasal fistula, therapy requires surgical treatment. Principles for surgical repair of oronasal fistula include development of mucosal flaps with excellent vascular supply to transpose over the defect to restore continuity of the nasal and oral cavities. The specific surgical technique may vary but includes either single or double mucosal flaps. Oronasal fistula refractory to multiple attempts at surgical repair may be obturated by using a prosthodontic device.

Soft tissue surgery in the oral and maxillofacial region

The practice of dentistry is most often perceived as the treatment of the hard tissues of the oral region, specifically the teeth and jaws. However, there are many disorders and conditions involving surgical treatment of the soft tissues that extend to the adjacent and associated structures of the oral and maxillofacial surgery region.

Application of the buccal fat pad in oral reconstruction

PURPOSE

This report evaluates the use of the buccal fat pad in reconstruction of defects of the hard and soft palate.

PATIENTS AND METHODS

Twenty-nine patients with different indications (oroantral fistula, tumor of the hard and soft palate, posterior fistula in cleft patients, covering of bone transplants in augmentation procedure) were treated with a pedicled buccal fat pad without lining. The maximum reconstructed defect was 5.5 x 4 cm.

RESULTS

All inserted fat grafts healed well without any aesthetic disturbances. The surface of the fat converted to normal mucosa.

CONCLUSIONS

Use of the buccal fat pad is a safe and easy method to reconstruct defects in the posterior maxilla and soft palate. Good vascularization, ease of access, and minimal donor site morbidity make it a reliable soft tissue graft.

Team approach for closure of oroantral and oronasal fistulae

Oroantral and oronasal fistulas present with a broad range of causation, size, duration, and extent of infection involving the nose and paranasal sinuses. Accurate diagnosis of the extent of the disease with appropriate radiographic evaluation will guide the surgeon to select an approach that addresses all of the infected sites. When significant sinus disease is found, an endoscopic approach to restoring drainage in all of the involved sinuses can promote predictably successful closure of oroantral and oronasal fistulas. The multispecialty team approach to this disease, with the concomitant management of the sinusitis and fistula closure, is a significant advance in the successful management of this chronic condition.

Three-layer closure of an oroantral-cutaneous defect

Reconstruction of oroantral defects, which are usually caused by tumor resection, is challenging. These defects become an even more difficult problem when they comprise multiple layers including oral mucosa, subcutaneous tissue, muscle and skin. This paper describes such a case in which a three-layer closure using a palatal flap, a buccal fat pad flap and a local skin flap was successfully performed.

The use of the pedicled buccal fat pad (BFP) and palatal rotating flaps in closure of oroantral communication and palatal defects

The use of the buccal fat (BFP) and palatal rotating flaps for the closure of oro-antral communication and reconstruction of palatal defects was compared clinically. The BFP proved to be consistently successful in closing oro-antral fistulae and palatal defects resulting from tumour resection, preserving the normal anatomical architecture of the oral mucosa. No denuded area requiring secondary granulation was required as in the case of palatal flaps. In addition, no facial disfigurement was observed on the operated side. BFP is considered a reliable, convenient method for closure of palatal defects and closure of oro-antral communication. It can also be considered as a reliable back-up procedure in the event of failure of other techniques.