[Oro-antral perforations. Desirability of antibiotic support in surgical closure within 24 hours]

OBJECTIVE

The routine use of antibiotics in oro-antral perforations is advocated by a number of authors, in order to prevent post-operative complications such as sinusitis. Our aim was to establish wether the preventive use of antibiotics seams to be indicated in the closure of this perforations.

DESIGN

A retrospective investigation.

SETTING

The department of Oral and Maxillofacial Surgery and Oral Pathology of the Academic Center for Dentistry Amsterdam (ACTA) and the Free University Hospital Amsterdam.

METHODS

In a retrospective study 46 patients have been investigated, 32 males and 14 females, who underwent a surgical closure of an oro-antral perforation in 1995, within 24 hours after its occurrence, in a department of oral and maxillofacial surgery. Twenty-two patients received preoperative antibiotics and 24 patients were treated without the use of antibiotics.

RESULTS

Three (6.5%) patients had a post-operative sinusitis. In the other 43 patients there were no postoperative complications.

CONCLUSION

The preventive use of antibiotics in oro-antral perforations in order to prevent post-operative complications such as sinusitis seams not to be indicated in the closure of this perforations. However, before a final conclusion on this matter can be drawn, a prospective randomized study should be undertaken.

Treatment of oroantral communications after tooth extraction. Is drainage into the nose necessary or not?

Seventy-six patients with oroantral communications after tooth extraction and chronic maxillary sinusitis were treated as follows: bacterial cultures were taken in all of them and maxillary sinuses were irrigated with an antibiotic from the cephalosporin group. Then, in 36 patients, drainage using the Caldwell Luc procedure was performed, including a naso-antral window. In all patients operations were completed by closing oroantral communications with flaps of the mucosa of the alveolar process close to the fistula. Antibiotics according to antibiogram were administered to all patients at least 10 days after surgery. Retrospective comparison between the results obtained in the first group and those in the second group 1, 3 and 6 months after operation was based on objective findings (condition of the oroantral communication, maxillary sinusitis), side effects (pain, numbness of the operated area, headache) and control radiographs (clear maxillary sinus or with mucosal thickening). The study suggests that transnasal drainage is not required in maxillary sinus surgery and in the closure of oroantral communications. Equally good results are achieved by treating with antibiotics and without drainage of the maxillary sinus into the nose.

[Surgical management of oro-cutaneous and pharyngo-cutaneous fistulae]

Pharyngocutan- or orocutan fistulas have been observed in 8.2% of patients after cancer operations at author's clinic. As first therapy the authors used a conservative treatment, and observed a closure in 7 patients while the remaining 5 patients were operated on. From these 5 last cases 3 had large and 2 had mid size fistulas. Four surgically treated patients had radiotherapy, but after conservative treatment their fistulas showed reepithelisation and lack of inflammatory reaction. These fistulas were closed with internal- and external (double) flaps. In all cases the internal flaps were prepared from surrounding tissues of the fistulas while the sternocleidomastoid-, the trapezius- and platysma-myocutan flaps were used externally.

A clinical study on oroantral fistulae

The report presented is an analysis of 98 patients with an oroantral fistula (OAF). The tooth most frequently involved was the upper second molar, followed by the first molar. The highest incidence was seen in the fourth and third decades of life and the lowest incidence in the second decade. In this study, intercurrent sinusitis was the most obvious cause of the chronic oroantral communication. The closure of OAF is one of the more challenging problems in oral surgery. Long-term successful closure of OAF depends on the technique used, the size and location of the defect, and on the presence or absence of sinus disease. Among the several techniques proposed for treatment of OAFs, in the majority of cases, the buccal advancement flap technique was used in this study. The advantages and limitations of the technique are discussed.

Use of the tongue flap for intraoral reconstruction: a report of 16 cases

PURPOSE

This article reports the authors' experience with the use of the tongue flap for intraoral soft tissue reconstruction.

PATIENTS AND METHODS

From May 1992 to December 1996, 16 patients were treated with a tongue flap for reconstruction of a variety of intraoral soft tissue defects. Ages ranged from 16 to 65 years with a mean of 39.6 years.

RESULTS

The procedure was successful in 15 patients. There were six complications: one total necrosis, four partial necroses, and one infection. Partial necrosis and infection were well controlled by conservative treatment.

CONCLUSION

Use of the tongue flap is a versatile method for reconstruction of a variety of intraoral soft tissue defects.

Surgical endodontics of upper molars: relation to the maxillary sinus and operation in acute state of infection

Findings in 200 cases of root resection of first maxillary molars showed perforation to the sinus in half of the cases. In 42% of the cases, the first maxillary molar had root resection performed in a subacute or acute state of infection. Only two cases developed postoperative sinusitis. Antibiotic treatment was indicated preoperatively in 3% and postoperatively in 5%. Postoperative symptoms, such as pain and swelling, were usually moderate, possibly because of a nontraumatizing operation technique, a careful removal of infected tissue, and a good drainage by loose suturing.

Sinusitis of dental origin

Acute or chronic sinusitis may be odontogenic. Bacteria involved in odontogenic sinusitis are specific organisms associated with the teeth (Streptococcus sanguis, Streptococcus salivarius, Streptococcus mutans, anaerobic germs). They are often secondary to an intrasinus foreign body following periodontitis. The treatment is both naso-sinusal and dental. Cysts of the maxilla can also invade the sinus. In particular, radiculo-dental cysts (periapical) must be surgically excised, in some cases associated with a middle meatotomy. Finally, one should look for oro-antral fistulae. The surgical technique for its closure should take into account the reversibility of the sinus lesions.

Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery

The preparation and use of platelet gel, an autologous formulation of fibrin glue, are described. The unique features of this biologic sealant are that it is derived from autologous blood collected in the immediate preoperative period by the anesthesiologist, it contains a high concentration of platelets, and it can be used in patients who are not candidates for blood bank donation. Platelet gel has been used successfully in the area of reconstructive oral and maxillofacial surgery in conjunction with ablative surgery of the maxillofacial region, mandibular reconstruction, surgical repair of alveolar clefts and associated oral-antral/ oral-nasal fistulas, and adjunctive procedures related to the placement of osseointegrated implants.

Closure of a post-traumatic maxillary defect. A case report

A case of successful closure of a large maxillary defect is presented, using a free bone graft, rigid fixation and hydroxylapatite particles.

Oroantral fistula: a complication of transantral ligation of the internal maxillary artery for epistaxis

Transantral ligation of the internal maxillary artery (IMAX) is a well-described option for surgical management of posterior epistaxis not controlled by anterior and posterior packing. Advocates for this procedure argue that it reduces the morbidity, length of hospital stay and financial cost associated with prolonged nasal packing. The procedure is carried out through a Caldwell-Luc approach and the IMAX is clipped in the pterygomaxillary fossa. Fashioning of a nasoantral window is optional and its inclusion usually depends on the integrity of the sinus ostium. The commonest complications of transantral IMAX ligation occur when local structures including the inferior orbital and anterior superior alveolar nerves are damaged. The incidence of oroantral fistula following IMAX ligation is very low but those cases reported have been associated with the failure to create a nasoantral drainage window. We report two cases of persistent oroantral fistula complicating transantral internal maxillary artery ligation. No nasoantral window was fashioned in either of these cases.

Use of buccal fat pad to repair intraoral defects: review of 30 cases

The buccal fat pad has been frequently used for the closure of oro-antral and oro-nasal communications. There are a few studies in the literature reporting its use in defects secondary to tumoral resections. In this paper we consider both the anatomical basis and the surgical technique. We also review 30 cases, used for the repair of 15 defects due to tumoral resections, 8 to maxillary cysts, 6 to communications and 1 secondary to a postraumatic defect. It has been successful in 28 of the 29 patients, with a complete epithelization of the flap, even in 4 cases with partial necrosis of the pad. It is an acceptable type of reconstruction, versatile and of a simple surgical technique. However, its use is limited to small or medium defects, being sometimes scarce.

Use of the buccal fat pad as a pedicle graft

A technique was developed to use the pedicle buccal fat pad as method for closing an oro-antral communication. The buccal fat pad is situated in the posterior part of the maxilla and bounded by the pterygopalatine fossa, buccal muscle, and masseter muscle. It is supplied by blood from small branches of the maxillary artery, the superficial temporal artery, and the facial artery. Generally, the buccal fat pad can be easily reached by a horizontal incision over the periosteum near the maxillary third molar. As much as 60 x 50mm2 can be obtained. For reconstructive surgery, the buccal fat pad is suitable for closing the sinus near the hard and soft palate and naso-oral fistulae. In our case, graft tissues after surgery healed satisfactorily, began to epithelialize at two weeks after operation, and appeared with normal mucous-like changes at about one month. Thus, the pedicle buccal fat pad is a safe, simple, convenient, and effective grafting method, if it is applied to appropriate cases.

Radiographic comparison of osseous healing after maxillary sinusotomy performed with and without a periosteal pedicle

OBJECTIVE

To assess the postoperative fate of bone trapdoors in patients with a trapdoor in the facial wall of the maxillary sinus that was replaced after removal of sinus disease.

STUDY DESIGN

Twenty patients were studied. In 10 patients (group A) the trapdoor was made as a free bone graft; in the other 10 patients (group B), an osteoperiosteal trapdoor was made. The postoperative fate of bone trapdoors was studied by means of computed tomography.

RESULTS

In group A there was poor bony consolidation at the trapdoors' junction with the surrounding bone and a significantly reduced density of the osteotomized bone. In two of the group A patients there was a partial loss of the trapdoor. In group B, however, bony consolidation took place in that all the trapdoors were completely connected again to the surrounding bone and there was no reduction of the bone density.

CONCLUSION

The results indicate that a trapdoor with a periosteal pedicle appears to be more reliable than one without a periosteal pedicle.

Anteriorly based palatal flap for closure of large oroantral fistula

A technique for closure of large oroantral fistula as a lateral transposition flap with an anteriorly based palatal flap is described. Mucoperiosteum of the posterior third of the hard palate, which is more yielding, is raised to bridge large defects without leaving any considerable exposed raw area. The technique is particularly useful in the correction of defects at the tuberosity region.

Orthognathic surgery for the cleft lip and palate patient

A thoughtful staged reconstruction for the cleft lip and palate patient is the preferred approach. The primary lip and palate repair performed during infancy and early childhood provides the foundation for normal speech, occlusion, facial appearance, and self-esteem. A long-term negative effect of these early surgical interventions is a significant incidence of maxillary growth restriction that produces secondary deformities of the jaws and dentition. This article reviews the variations in presentation, surgical and orthodontic techniques, and the results that we have achieved in patients born with a cleft who underwent primary repair in childhood, had a jaw deformity and malocclusion in adolescence, and underwent orthognathic surgery combined with orthodontic treatment for facial reconstruction and dental rehabilitation.

Application of the interseptal alveolotomy for closing the oroantral fistula

PURPOSE

This article describes a new application of the interseptal alveoplasty to close oroantral fistulae caused by dental extraction. The surgical technique is described, and its advantages are compared with those of other techniques.

MATERIALS AND METHODS

The technique was used to treat eight patients with comparatively small fistulae in the soft tissue, approximately 1 to 5 mm wide.

RESULTS

All fistulae were successfully closed.

CONCLUSION

It is proposed that the technique provides greater flexibility in the treatment of fistulae. In addition, because there is a bony base, this promotes more successful healing than other commonly used procedures.

[The adipose Bichat bolla flaps in repair of oroantral fistulas]

The Authors review Literature concerning surgical treatment of oro-antral fistulas. After a brief discussion concerning the anatomy of the Bichat bulla, the Authors present two clinical cases of oro-antral fistulas with purulent sinusitis. The lesions were repaired using an adipose flap of the Bichat bulla which was sandwiched between the mucous flap and the bony defect. The partial introduction of the adipose flap in to the maxillary sinus through the bony defect, enabled the osteomyelitis bony edges to revascularize and created a pathway and biological substratum for re-epithelialization of the maxillary sinus. Clinical and radiological follow-up 24 months after treatment revealed stable closure of the fistula and normal ventilation of the maxillary sinus. On the basis of these results and those reported in Literature, the Authors advise employment of this technique, particularly in extensive oro-antral fistulas which do recur with other techniques and which, furthermore are complicated by local infectious processes.

Staged repair of secondary cleft palate deformities

Despite improvements in cleft palate surgery, residual oronasal fistulas remain a frustrating problem for plastic and reconstructive surgeons because of a high incidence of failure when scarred and immobile neighboring palatal mucoperiosteum is used for secondary closure. Therefore, my colleagues and I have found it necessary to introduce additional tissue from regional sites to close persistent oronasal fistulas. Although each technique may have its successes, no one method can be consistently depended on to repair large palatal fistulas. Even with regional flaps, dehiscence from a scarred surgical site is quite frequent. However, these flaps may still provide satisfactory coverage with staged reconstruction because they will frequently close a significant percentage of the overall defects, which then may be reused to close the remaining defect.

Competent closure of chronic oroantral fistula with Zenoderm

Ten patients suffered from chronic oroantral fistula had been closed with Zenoderm (lyophilized porcine dermis) covering the bony defects by 1-2 mm. The Zenoderm was covered by buccal sliding and rotating pedicle palatal flaps after complete resolution of sinusitis and/or infection of the fistula. In nine patients, competent closure of the fistula had been achieved also Zenoderm supported the flaps against negative or positive pressure from the sinus and supported the bony contour. In only one case the Zenoderm was expelled from the tissues due to infection which prevented healing of the flaps; this patient was controlled diabetic. The current study showed that Zenoderm had promising results in closing the chronic oroantral fistula.

Closure of oroantral communications using a pedicled buccal fat pad graft

PURPOSE

This report evaluates the use of a pedicled buccal fat pad graft for closure of oroantral fistulae.

MATERIALS AND METHODS

Fourteen patients with oroantral communications, ranging from 8 to 20 mm in diameter, were treated by the use of a pedicled buccal fat pad graft.

RESULTS

The procedure was successful in 13 of 14 patients. Postoperatively, the orally exposed fat gradually was transformed into a granulation-like tissue and epithelization developed within 3 weeks.

CONCLUSION

It was concluded that the procedure has wide application and a high degree of success.

[The Bichat ball. The surgical value of oro-sinus communications]

Bichat's ball is a mass of adipose tissue used to fill communications between the buccal cavity and the sinus. The anatomy of the structure is presented. it has a body and 6 extensions. A surgical technique is proposed in comparison with previously described methods. At 6 weeks, there has been no recurrence of buccal-sinus communication in a series of approximately 300 cases operated over a period of 15 years.

[An analysis of the late treatment results in patients with odontogenic perforated maxillary sinusitis]

The authors analyze the results of sparing sinusotomy in 685 patients with chronic odontogenic perforative sinusitis. This effective method helped appreciably reduce the incidence of complications after surgical treatment of the said patient population.

Reconstructive options for maxillary defects

Reconstruction of the maxilla should aim to restore appearance, speech and occlusion. With modern reconstructive techniques and availability of an increasing variety of reliable tissue flaps, many of the traditional problems of treatment have been overcome. This paper reviews local and distant tissue flaps useful in rehabilitating an acquired maxillary defect of various dimensions. The local flaps discussed include flaps from the palate, cheek, tongue and the buccal fat pad. The distant flaps considered are the temporalis myofascial flap, pedicled cutaneous and myocutaneous flaps, and vascularized free flaps. Bony reconstruction of the maxilla with particular emphasis on restoring an anatomical alveolar ridge for occlusal rehabilitation by dental implants is presented.

[The maxillary challenge in oral implantology]

The implant recipient site may at times be inadequate or absent due to the presence of an oro-antral fistula, and procedures have to be implemented to remove the fistula, debride, and bone graft the implant site. This presentation and paper address several innovative procedures and their indications. Four sinus augmentation modalities and a "T.L.C. Window Approach" are described and illustrated. The first three modalities are classified as Sinus Augmentation No. 6. The debridement procedure is outlined in 4 steps: Deepithelialization of the soft tissue aspect of the oro-antral fistula; a circumferential incision; debridement and suture of the fistulous tract; and augmentation of the sinus. The extent of the osseous oro-antral fistulae involvement is classified as Types S, M, and L (small, medium, and large), and the measurements are indicated. The fourth modality is titled Sinus Augmentation No. 7, and it is concerned with the treatment of large sinus, further underlined by a severely lingualized "available bone" trajectory. To correct this type of case, the author suggests the Sinus Augmentation No. 7 modality, which, by definition, is the extemporaneous correction of the aforementioned deficiency, using a sinus augmentation (SA.4 modality) coupled to an autogenous inlay-onlay bone graft (endchondral or membranous), bearing root form implants and osteosynthesized to the palatal osseous wall of the S.4 type sinus. The "T.L.C. Window Approach" is used when a foreign body is present in the antral area and has to be removed to avoid the possibility of infection or impaired osteal drainage at the same time a sinus augmentation is performed.

Closure of oroantral communication using guided tissue regeneration and an absorbable gelatin membrane

Surgical intervention into the maxillary posterior area can lead to inadvertent communication with the maxillary sinus. Spontaneous healing of 1 to 2 mm openings can occur. However, in patients with larger oroantral communications and those with a history of sinus disease, surgical closure is often indicated. Acute and chronic oroantral fistula and sinusitis can occur as a result of inadequate treatment. The most common causes of complications include inadequate site preparation, flap closure, flap necrosis, infection, and patient non-compliance. A technique for the closure of oroantral communications using guided tissue regeneration is described. This technique utilizes an absorbable gelatin film (membrane), allogenic bone graft material (DFDBA), and non-resorbable expanded polytetrafluoroethylene (ePTFE) membrane. The gelatin membrane prevents displacement of graft material into the antrum and sinus epithelial cell migration, while the ePTFE membrane promotes selective cell population with subsequent regeneration of the osseous wall of the oroantral defect.

Sinus obliteration for chronic oro-antral fistula: a case report

This report describes a patient with chronic oro-antral fistula resulting from tooth extraction. Several local flap procedures failed to close the fistula, which was complicated by chronic sinusitis. Ultimately, cure was achieved via antral obliteration using vascularised temporoparietal fascia, sparing remaining maxillary alveolar bone. Total, trans-buccal maxillary sinus obliteration with fascia should be considered for the treatment of oro-antral communications refractory to treatment with intraoral tissues.

The buccal fat pad in the closure of oro-antral communications: a study of 56 cases

This article describes the surgical technique, indications and possible complications of the use of the buccal fat pad in the closure of oro-antral communications (OAC), following tooth extraction, in 56 cases. The technique was successful in all patients and did not interfere with the buccal sulcus depth. It is concluded that it can be safely applied in the closure of OAC.

[Diagnostic and treatment methods in patients with acute perforations and foreign bodies of the maxillary sinuses]

Sixty-nine patients with acute perforations of and foreign bodies in the maxillary sinuses were treated with the use of new methods for the diagnosis and treatment, suggested by the author. Good late results (in 3 months to 8 years) were achieved in 48 patients.

Management of odontogenic sinusitis with persistent oro-antral fistula

Sixteen patients were treated for odontogenic sinusitis secondary to persistent oro-antral fistula. Males outnumbered females 12 to 4. Frequency of presentation increased directly with age. Chronic signs and symptoms included facial pain, swelling, tenderness and nasal and oral discharge. The clinical diagnosis of chronic sinusitis was confirmed in all cases by radiographic findings. An opacified maxillary sinus with or without ethmoid involvement was observed in all 16 patients. Surgical pathology revealed chronic mucosal thickening and/or antral polyps in 69% of the cases. Surgical treatment of the sinusitis consisted of antrostomy alone or in combination with Caldwell-Luc procedure. The oro-antral fistula was repaired with mucosal flaps from the buccal and/or palatal region. No postoperative recurrences have been noted during a follow-up period of six months to seven years. Bacterial cultures grew out pure aerobes (44%) or mixed aerobic-anaerobic bacteria (44%). None yielded pure anaerobes. The bacteriologic spectrum was notably lacking in S. pneumoniae and H. influenzae and differed from organisms commonly found in sinusitis of rhinogenous origin.

Herniation of the antral membrane through an extraction site. Report of a case

A case of herniation of the antral membrane through a recent extraction site is presented. The lesion was initially diagnosed as a tumor by the referring dentist. Oroantral fistulas are not an uncommon finding after dental extractions. It is rare, however, to see herniation of the antral membrane with large polyps extending through the fistula into the oral cavity. A search of the literature revealed only two other such cases. Surgical removal of the polyps and closure of the oroantral fistula by means of a buccal sliding flap technique is discussed.

A new approach for repair of oro-antral-nasal fistulae. The anteriorly based buccinator myomucosal island flap

Oral-antral-nasal fistula (OAN) is a commonly encountered clinical problem. The literature is filled with a plethora of methods described for closing a persistent OAN. Local flaps are available to close minor to moderate defects, however, large fistulae can be a very challenging reconstructive problem. Various areas of the oral cavity have been used for closure of OAN. We describe a technique to reconstruct the oral cavity, in this case an OAN. The anteriorly based buccinator myomuosal island pedicle flap (BMIP) provides an alternative method for reconstructing the oral cavity. An extensive review of the literature as well as the anatomy of the buccinator, its reconstructive capabilities, and two case reports are included.

[Central giant cell granuloma of the maxilla]

We report the experience of the clinical, histologic and radiologic features of a giant cell granuloma of the maxilla of severe growth. The removal of the lesion led to a large defect of the maxilla with oroantral fistula, which was immediately repaired by the use of the temporalis muscle flap. A four year follow-up period revealed no evidence of recurrence as well as excellent aesthetic and functional results. Further diagnostic and therapeutic problems are discussed in relation with recent literature.

[Alternate method for closure of oro-antral fistulas. Plastic covering of jaw opening with lyophilized Dura and alcoholic solution of Prolamin]

The operative closure of an oroantral fistula due to tooth extractions by the method of Rehrmann consists of various disadvantages, e.g. postoperative pain, swelling, flattening of the vestibulum and scar-tissue. Two alternative methods to close fresh oroantral fistulas without surgical intervention are described. By the use of prolamin occlusion gel or lyophilized dura these disadvantages can be avoided. Both techniques were successfully attempted on patients. The rate of failure is on both counts under 4%. Some indications limits must be strictly regarded. Both methods are really a good alternative to the usual operative procedure of Rehrmann and can easily be applied even on patients of great risk.

[Experimental study on the healing processes after the immediate reconstruction of maxillary bone defect--fresh autogenous iliac bone graft]

This study was designed to investigate the healing processes of fresh autogenous bone grafted from iliac to maxillary bone defect, which was an artificial oro-antro fistula and covered with submucosal flap made by ckeek mucosa. The experiments were carried out in vivo on adult mongrel dogs ranging 7,14,30,90,180 and 360 days postoperatively. Radiographic and histological investigations were made to evaluate details, further study has made by means of X-ray contact microradiography (CMR), tetracycline (TC) labeling and angiographic images. Results 1. Radiographic findings, the grafted bone remained unchanged until 14 days postoperatively. The bone bridge formation between host and grafted bone was completed after 30 days in all of the cases. Bone resorption can be observed at 90 days postoperatively, which were as much as one second or one third of grafted. But thereafter there were no changes on the grafting bone area, that is to say, bone resorption ceased and stabilised. 2. Histological findings, inflammatory changes can be mainly observed at the early postoperative stages. And osteoclasts and new bone formation can be observed along the host bone. On 14th postoperative day, all of the grafted bone cells turned to necrosis. Osteoclasts and the new bone formation were observed in that area. 30th postoperative day, new bone formation made connector between host and grafted bone area. And medullary cavity of the grafted bone was filled with fibrous connective tissue, new bone formation and bone resorption occurred at the same spot. On 90th day old grafted bone was scattered like an island among new bones. In 180 days, grafted area was nearly normal maxilla. 3. 7th postoperative day, inflammatory changes can be mainly observed on the mucosal bed of the grafted bone, those diminished in 14 days. It was completely changed to dense fibrous connective tissue. 4. Angiographic images, vascularization to medullary cavity of the grafted bone started on 7 days. In 14 days, vascularization filled about half of the grafted bone. Vascularization was also observed a little in cortical bone. It was completed throughout the entire grafted bone in 30 days and it connected with the host bone. In 180 days, the grafting bone was nearly normal angiographic image. 5. Contact microradiogram, the new bone formation was partially observed in the host bone in 7 days. In 14 days, the bone bridges formation started. It was almost completed in 30 days after transplantation. In 180 days, it was entirely completed. 6. Tetracycline labeling, the host bone was labelled weakly in the early postoperative stages.(ABSTRACT TRUNCATED AT 400 WORDS)

Grafting of the buccal fat pad into palatal defects

Grafting of the buccal fat pad was performed in combination with lyophilized porcine dermis in six cases of palatal defects. The use of lyophilized porcine dermis not only simplified the surgical procedure but also permitted a proper prosthetic rehabilitation. This technique proved to have more advantages for palatal defects.

[The closure of oroantral fistulae by Celestnick's technic. Its applications and the authors' modifications]

Occasionally an oroantral communication persists after rigorous standard therapy. This case report demonstrates the successful use of a personal method for the closing of persistent oroantral fistulas.

[Odontogenic sinusitis. An evaluation and the radiologic checkup protocol after a Caldwell-Luc intervention]

A homogeneous group of 30 patients who were operated over a 5-year period for odontogenic sinusitis using a buccosinusal communication following Caldwell-Luc's technique were studied. A marked discrepancy between the conventional X-ray picture and the clinical picture emerged from these 30 case studies. So as to find an explanation for this discrepancy, all patients underwent CAT tests. On the basis of a critical evaluation of the results obtained it is suggested that patients be followed using a postoperative instrumental control protocol.

Oronasal fistulae in repaired cleft palates

The study reviews oronasal fistulae occurring after palatoplasty. Subjects were fifty-two patients who had received palatoplasty in our clinic from 1981 to 1987. In twenty-one cases (40%) oronasal fistulae persisted. Two-thirds of these fistulae were slits or pinholes. The ratio of fistula occurrence was relatively high compared to other reports. Most of them were observed at the junction of the premaxilla and maxilla. There was no significant difference between fistula formation and the distance of the push back, and also there was no correlation with the width of the cleft.

Orthodontic treatment in adults with cleft lip and palate

A conventional orthodontic treatment method for typical malocclusions of adult patients will be described. Over 100 patients have undergone this treatment during the last decade in our cleft centre. The method involves four stages: I) orthodontics, expansion of the upper dental arch with modified quad-helix and edge-wise appliances and alignment of the teeth; II) bone grafting and closure of the oronasal fistula; III) prosthodontics, bridgework in the upper dental arch; IV) soft tissue correction of the lip and nose. The method is easy, cheap, safe and rapid enough if the forces of the quad-helix appliance are modified individually. The orthodontic, surgical and prosthodontic treatment result in a permanently balanced dental occlusion.

The tongue and forehead flap in the closure of residual oronasal fistulae

Some defects related to untreated palatal or residual clefts represent major deformities. A review of 177 cases, untreated or operated on according to Schwekkendiek's (1958) chronology, was carried out. The advantage of simultaneous operative techniques is discussed, specifically pharyngoplasties, vestibular flap rotation, and osteoplastic closure. When all other surgical possibilities have failed, some flaps have been used to restore mucosal continuity. A multidisciplinary evaluation of each individual case is emphasized.