The effectiveness of surgical management of oroantral communications: a systematic review of the literature

BACKGROUND

An oroantral communication (OAC) is a common complication in alveolar surgery that usually occurs as a result of the extraction of maxillary posterior teeth. To avoid further complications, several closure techniques are used; most of them need a flap elevation. Recently, simpler conservative flapless techniques for OAC closure have been described.

OBJECTIVES

To appraise the effectiveness of different techniques for closure of OACs also in comparison to nothing.

SEARCH METHODS

The following electronic databases were searched for randomised controlled trials regarding techniques for closure of OACs: PubMed; SciVerse Scopus; Latin American and Caribbean Health Sciences; The Scientific Electronic Library Online and The Cochrane Library (from January 1949 to August 2014). Unspecific algorithms were chosen in order to maximise search sensibility. Additional manual searching was performed in PubMed related citations, in five journals and in the references of the selected articles. There were no restrictions with regard to publication language.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing techniques for closing oroantral communications to nothing, or different techniques for closing oroantral communications reporting the success rate with at least two months follow-up.

DATA COLLECTION AND ANALYSIS

The screening of eligible studies, the assessment of methodological quality and data extraction were done by two independent reviewers working in duplicate.

RESULTS

The research individuated 1256 publications. After screening, only five articles were assessed for eligibility. Only two RCTs evaluating the effectiveness of techniques for OAC closure fulfilled the inclusion criteria of the present review. One trial including 30 patients assessed whether flapless techniques (resorbable root analogues and haemostatic gauze) could be as effective as the Rehrmann's buccal flap; all the patients were reported as successfully healed in the three intervention groups. Another RCT with 20 patients compared the effectiveness of the buccal fat pad flap (100% success rate) with a sandwich graft with hydroxyapatite crystals within collagen sheaths (90% success rate). The authors found no significant difference.

CONCLUSIONS

There are no RCTs evaluating whether an oroantral communication should be closed or not. There is weak evidence from two RCTs showing good results with five different techniques for closure of OACs (resorbable root analogues, haemostatic gauze, Rehrmann's buccal flap, buccal fat pad flap, sandwich graft with hydroxyapatite crystals). Until sufficiently high quality RCTs are conducted, elevating or not a flap for closure of OACs will be left to the personal choice of the surgeon.

The buccal fat pad flap: an option to prevent and treat complications regarding complex zygomatic implant surgery. Preliminary report

PURPOSE

To evaluate the use of the buccal fat pad flap (BFPF) technique as an option to prevent complications in the treatment of patients with atrophic maxillae rehabilitated after complex zygomatic implant surgery.

MATERIALS AND METHODS

A retrospective study was made of completely edentulous patients submitted to zygomatic implant surgery between May 2005 and November 2007. Patients with severely atrophic maxillae received conventional and zygomatic implants and were followed after the implants were loaded. Preoperative evaluation included panoramic radiography and computed tomographic scans of the maxilla to identify the anatomic conditions and presence of pathology.

RESULTS

Eight male patients with a mean age of 57 years and atrophic maxillae were rehabilitated with zygomatic implants placed using the BFPF technique. The BFPF technique was used in complex situations, including oroantral communication-associated sites, areas that had lost the sinus wall, and extrasinus implant placement. A total of 16 conventional implants, 4 long (21-mm) tilted implants, and 22 zygomatic implants was placed. The patients were rehabilitated with fixed prostheses and were followed for a minimum of 15 months. None of the conventional implants failed and none of the zygomatic implants failed or presented with soft tissue complications.

CONCLUSION

The BFPF presented a high success rate, demonstrating that it is a viable and predictable treatment option to prevent and treat soft tissue complications in complex zygomatic implant surgery.

Buccal fat pad - a simple, underutilised flap

The pedicled buccal fat pad is a reliable flap for the repair of small oral defects. It is durable, easy to harvest and should be considered in settings where access to free flaps is limited and in cases where previous flaps have failed. We discuss a case where this flap was used successfully for closure of an oro-antral fistula. The indications, anatomy and techniques of successful harvest are discussed.

Maxillary odontogenic sinusitis, complicated with cerebral abscess--case report

Maxillary sinus inflammation, when untreated or incorrectly treated, may extend locoregionally, the remaining paranasal sinuses being the first affected anatomical structures. This is why the understanding of the inflammatory pathology of the maxillary sinus, and particularly of the complications it can generate, is extremely important. The purpose of this presentation is to point out that inflammations of the paranasal sinuses are susceptible to develop complications in certain conditions and threaten the patient's life due to the proximity of vital structures. This is the case of a 16 years old male patient who developed a left maxillary and frontal sinusitis, complicated with cerebral abscess. Early detection, multidisciplinary approach and proper indication of surgical treatment, as well as early suspicion of complication, especially in young male adolescents, are extremely important.

Combined bony closure of oroantral fistula and sinus lift with mandibular bone grafts for subsequent dental implant placement

Sinus lifting and reconstruction of localized alveolar defects are often required after closure of a large oroantral fistula (OAF) to allow for subsequent implant installation. This study describes a combined surgical technique that involves sinus lifting, bony closure, and reconstruction of the alveolar defect at the site of an OAF. The sinus membrane was reconstructed as a continuous layer by combining the residual sinus membrane with a rotated part of oral mucosa around the OAF. Autogenous bone from the chin and/or ramus was grafted into the prepared sinus space and alveolar defect, and the graft was covered by a buccal advancement flap. This technique was used to treat 8 patients who had large OAFs in the posterior maxillary region. The treatment was successful in all cases, and the technique appears to be suitable for large OAFs where implants are subsequently desired.

Technological advances in extraction techniques and outpatient oral surgery

There have been several exciting technological advances in extraction techniques and outpatient oral surgery within the last decade. A variety of new instruments and techniques are revolutionizing the fields of oral and maxillofacial surgery and dentistry. This article reviews the newer innovations in dentistry including the powered periotome, piezosurgery, the Physics Forceps, laser therapy, orthodontic techniques, and use of polyurethane foam.

[Cultivated oral epithelial cells in oral cavity tissue losses treatment with autologous transplantation--case reports]

The rapid development of bioengineering in recent years enables to search for new therapies involving the use of tissue cultures. The aim of this paper is to study and apply the method of keratinocytes culture of mucous membrane on amniotic membrane to cover the losses in the oral cavity.

MATERIAL AND METHODS

In four cases keratinocytes culture on amniotic membrane was applied and transplanted to cover antro-oral fistulas and mucosal and mandibular bone losses.

RESULTS

Histopathological and immunohistochemistrical examinations of the culture were performed. Cytokeratin 14, protein 63, conexin 43 and IgG were indicated.

CONCLUSION

Autologous transplants of epithelial cells on amniotic membrane are a new effective method to cover unhealed tissue losses in oral cavity with the use of modern methods of tissue engineering.

Displacement of a dental implant into the maxillary sinus: report of an unusual complication when performing staged sinus floor elevation procedures

Grafting of the maxillary sinus in both one- and two-stage protocols has become a highly predictable surgical technique for site development and for the placement of implants to support dentures. However, despite the predictability and high success rates reported for dental implants placed either simultaneously with or after a sinus floor elevation (SFE) procedure, complications have been reported. The aim of the following case report is to present an uncommon complication in a staged SFE procedure: the displacement of a dental implant into the maxillary sinus during insertion. As implant dentistry is becoming more and more popular among practitioners, and ever more demanding procedures for initial site development in jaws with bony deficiencies are being introduced into daily practice, the displacement of dental implants into the maxillary sinus during implant placement may become a more frequent complication. Management of this complication is presented, discussed, and evaluated in light of the current literature.

Treatment of oromaxillary fistulae in nine standing horses (2002-2006)

REASONS FOR PERFORMING STUDY

There is minimal published information on equine oromaxillary fistulae that are unrelated to cheek teeth (CT) repulsion or on the conservative treatment of these atypical fistulae.

OBJECTIVES

To report equine oromaxillary fistulae unrelated to CT extraction and describe their management in standing horses.

METHODS

Case details of oromaxillary fistulae of atypical aetiology occurring at 2 referral centres between 2002-2006, including their treatment and response to treatment were examined.

RESULTS

Nine cases of oromaxillary fistula were recorded, mainly in aged horses (median 22 years). Fistulae were associated with CT diastemata in 7 cases, fractured CT in one and a central defect in a worn CT in another. After removing food and exudate from the sinuses, 6 cases were treated successfully by filling the diastema or dental defect with polymethylmethacrylate (PMMA). Following dental extraction, the other 3 cases were treated successfully by use of PMMA alveolar packing.

CONCLUSION

Older horses can spontaneously develop oromaxillary fistulae, usually secondary to CT diastemata. In the absence of apical infection, this disorder can usually be treated successfully in standing horses by treating the sinusitis and sealing the oral aspect of the diastema with PMMA.

POTENTIAL RELEVANCE

Older horses with sinusitis should be assessed for the presence of CT diastemata and oromaxillary fistulae. If detected, these disorders can be treated successfully in the standing horse.

Chronic sinusitis associated with the use of unrecognized bone substitute: a case report

Bone grafts are used for bone augmentation to ensure optimal implant placement. However, this procedure may sometimes cause sinusitis. The case of a 44-year-old woman with the diagnosis of recurrent and chronic sinusitis of her right maxillary sinus with a history of dental implant surgery is presented. After several attempts with normal standard sinusitis therapy, unrecognized bone substitute was removed from the sinus cavity, which finally led to resolution of the sinusitis. This case reiterates the importance of a careful examination, consultation, and second opinion for the selection of optimal treatment.

Development of an oro-antral fistula following sinus elevation surgery: a case report on management using platelet-rich plasma

The aim of this case report is to present the use of platelet-rich plasma (PRP) in the management of an oro-antral fistula occurring as a complication of lateral wall sinus augmentation. Currently, platelet-rich plasma is being used in periodontal and oral surgical practices in a wide variety of applications. The patient in this case report developed an oro-antral fistula following sinus augmentation. This was treated using platelet-rich plasma combined with a flap approach. Following clinical healing, three single-stage implants were placed and restored. Clinical and histologic results are discussed in relation to clinical management, wound healing, and regenerative outcomes of treatment. The patient has been followed up for six years.

Oroantral fistula and genian mucosal flap: a review of 25 cases

The oroantral fistula is a pathological connection between the maxillary sinus and with the oral cavity. The condition mostly follows dental extraction.

Aim

To present the experience of 25 cases.

Material and methods

Retrospective cases between 1996–2000. The ORL examination included nasal or sinusal endoscopy, a CT scan and histopathological analysis.

Results

Twenty-five cases were found: ten 2nd molar cases, eight 1st molar cases, six 2nd premolar cases, and one canine case. All patients underwent a Caldwell-Luc operation plus excision of the epithelium lining the fistula, that was then completely covered by a flap of mucosa rotated from the genian region.

Discussion

In cases of major fistulae a bone autograft taken from the anterior sinus wall was used. Bacterial cultures (n=19) revealed streptococus pneumoniae (13), haemophillus influenza (6), Moraxella catharralis (2) and staphylococus aureus (2). Aspergillus niger was found in one case presenting as a “fungic ball”.

Conclusions

The only case of surgical failure, after 30 days postoperatively, was reoperated, using a bone graft. After a 6-month follow up all of the patients progressed satisfactorily, including the reoperated patient.

Single photon emission computerized tomography and histological evaluation in the validation of a new technique for closure of oro-antral communication: an experimental study in pigs

Various bone regeneration techniques have evolved recently but controversies regarding vascularization and integration of such bone grafting techniques have led occasionally to animal experiment to validate such techniques. The objective of this study was to evaluate the evidence of vascularization and osseo-integration of a new bone regeneration technique utilized for the closure of oro-antral communication (OAC) by an experimental model in which Single Photon Emission computerized Tomography and histological studies were conducted in pigs. We conclude that the sandwich technique used for the closure of OAC results in a vascularized new bone formation which eventually osseo-integrate with the surrounding bone. Also, this experimental study confirmed that autogeneous bone graft was superior to xenografts when used within the sandwich unit.

Closure of oroantral communication with buccal fat pad flap in zygomatic implant surgery: a case report

The scientific literature has demonstrated the use of the buccal fat pad (BFP) flap to cover bone grafts in the correction of maxillary osseous defects and in the closure of oroantral communications. The use of the pedicled BFP flap to provide an immediate blood supply to a recipient site is recommended to provide closure of oroantral communications. The author presents a case report of zygomatic implant surgery in which the BFP flap technique was used in the closure of an oroantral communication caused by maxillofacial surgery.

Alveolar cleft closure by distraction osteogenesis with skeletal anchorage during consolidation

Intraoral distraction osteogenesis (DO) has been widely used for the reconstruction of various dentoalveolar defects. However, its use in the management of alveolar clefts is relatively new. This method allows the closure of the cleft via the regeneration of new alveolar bone and attached gingiva through the distraction of a dento-osseous segment. It eliminates the need for a donor site for autogenous bone grafting and possible graft failure. However, the relatively long consolidation period required for the use of intraoral DO devices may result in soft tissue irritation that would compromise patient cooperation, especially in children. In the case presented, the intraoral DO technique was used for the treatment of a unilateral residual alveolar cleft and an implant was subsequently placed in the regenerated bone. A miniplate was also placed to serve as a skeletal anchor to enable the early removal of the distractor device. The distractor was removed before the beginning of the consolidation phase.

Osteonecrosis of the jaws associated with use of risedronate: Report of 2 new cases

Use of various bisphosphonates has been associated with the development of osteonecrosis of the jaws (ONJ). At least 865 cases of ONJ attributed to these agents have been reported in the English-language literature. Approximately 96% of these published cases were seen with administration of the intravenous agents pamidronate and zoledronate, whereas only 26 cases have been associated with oral bisphosphonates, 25 of them with alendronate. Only a single case of ONJ associated with the oral bisphosphonate risedronate has been previously cited. We report 2 cases of ONJ attributed to risedronate administration. The patients developed osteonecrosis 15 and 24 months after treatment for osteopenia. A regimen of antibiotics and chlorhexidine mouthrinse resolved the osseous defect in the mandible caused by complete exfoliation of a lingual torus in 1 patient. The other patient required sequestrectomy, repeated courses of antibiotics, surgical debridement, and steroids to promote closure of an oroantral fistula and management of sinusitis after bone grafting and implant placement in the posterior maxilla. A demographic profile of reported oral bisphosphonate users affected by ONJ is also provided. With the millions of patients receiving various oral bisphosphonates for osteopenia and osteoporosis, health care practitioners should be aware of the potential for the onset of osteonecrosis and familiar with its management.

Clinical applications of autologous cryoplatelet gel for the reconstruction of the maxillary sinus. A new approach for the treatment of chronic oro-sinusal fistula

The authors report their clinical experience regarding an original method of surgical repair of oro-sinusal communications. From September 1999 to December 2003, 13 patients (7 male and 6 female patients; mean age: 52 years, range: 24-68 years) underwent surgical repair of an oro-antral fistula by means of cryoplatelet gel: in three patients, it was mixed with bioglass granules; in two, it was mixed with Bioss; in three, it was mixed with particulate bone extracted by means of a bone grafter from the oral cavity close to the operative site, with addition of demineralised bovine bone; in three, it was used together with porose hydroxyapatite, and in two patients the cryoplatelet gel was used only. No postoperative complication was reported; primary wound healing was achieved within seven to nine days. A bony orthopantoscintigraphy was performed a few months following the operative procedure, showing an active osteogenic process. In eight patients, a CT was performed after 8 to 12 months from the operation, showing a normal pneumatization with reconstruction of the floor of the maxillary sinus. Although preliminary, these findings seem to suggest that the use of bioengineered materials coupled with growth factors and osteoprogenitor cells may represent a valuable alternative to autologous bone transplantation for the reconstruction of the maxillary sinus.

Endoscopic surgical treatment of chronic maxillary sinusitis of dental origin

PURPOSE

Chronic maxillary sinusitis of dental origin (CMSDO) is a common disease that requires treatment of the sinusitis as well as of the odontogenic source. We present our surgical experience performing contemporary treatment of the odontogenic source and endoscopic sinus surgery (ESS) in patients with CMSDO.

PATIENTS AND METHODS

Seventeen patients with CMSDO underwent contemporary treatment of the odontogenic source and ESS. Five patients presented chronic oroantral fistula (OAF); 5 patients presented odontogenic cysts occupying the maxillary sinus; 2 patients had inflammatory cysts of the molars; 2 patients had maxillary sinus infection secondary to peri-implantitis; 3 patients had foreign bodies pushed through the root canal into the sinus. The first surgical step was the treatment of the odontogenic source. The second step was ESS with opening and calibration of the maxillary natural ostium.

RESULTS

Foreign bodies were extracted from the sinuses through the endonasal approach. No major complications after ESS were observed. The average time for ESS was +/-25 minutes. Good distant results without symptoms and complete closure of the fistula were obtained in all patients.

CONCLUSION

When significant sinus disease is found, an endoscopic approach to drainage in all of the involved sinuses can promote predictably successful closure of OAF. The endoscopic approach to chronic maxillary sinusitis of dental origin is a reliable method associated with less morbidity and lower incidence of complications.

Retrieval of a root fragment from the maxillary sinus--an appreciation of the Caldwell-Luc procedure

A 30-year-old man presenting for routine extraction of a carious upper left first permanent molar subsequently underwent the retrieval of a palatal root that had been displaced into the maxillary sinus. This paper illustrates the principles of the Caldwell-Luc procedure and highlights the issues and management of acute oro-antral communication associated with a displaced root into the sinus. This paper was presented at the Clinical Excellence in Patient Care Symposium, Dunedin on 29 September, 2006.