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.

[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.