Modification of the Vestibular Mucoperiosteal Flap Technique for Closure of Oroantral Fistula

A Novel Approach for the Treatment of Recurrent Oroantral Fistula Occurring at an Infected Sinus Augmentation Site

Closing a recurrent oroantral fistula (OAF) that occurs at an infected sinus augmentation site is a challenge for clinicians. The recurrent OAF has a detrimental impact on bone regeneration and subsequent implant placement. This case report includes three cases in which sinus graft infection and OAF occurred after maxillary sinus augmentation (MSA). In these cases, treatments to control sinus infection were performed using an otolaryngologist; then, intraoral interventions comprising mucosal flap procedures, bone grafts, and barrier membrane applications were performed 2-5 times by oral surgeons. Nevertheless, OAF recurred persistently. The failure to stop OAF recurrence may be due to the inability to effectively block air pressure at the OAF site. Following a comprehensive debridement of the infected tissue at the previous sinus augmentation site, a pouch was created through sinus mucosal elevation. The perforated sinus mucosa at the OAF site was covered with a non-resorbable membrane in one case and with resorbable collagen membranes in the other two cases, followed by bone grafting within the pouch. Lastly, this procedure was completed by blocking the entrance of the pouch with a cortical bone shell graft and a resorbable collagen membrane. The cortical bone shell graft, obstructing the air pressure from the nasal cavity, facilitated bone formation, and, ultimately, allowed for implant placement. Within the limitations of the present case report, the application of a guided bone regeneration technique involving a cortical bone shell graft and a barrier membrane enabled the closure of the recurrent OAF and subsequent implant placement.

The use of Titanium Meshes in Surgical Closure of the Oroantral Fistula. A Randomized Clinical Trial Study

The closure of oroantral communications (OACs) is challenging. The study aimed to assess the effect of titanium meshes in the outcome of OAC closure by local flaps. This is a prospective randomized, nonblinded clinical trial. Patients with a delay and large (≥7 mm 2 ) OAC were studied. Patients were randomly divided into 2 groups: in group 1, patients underwent OAC closure through a modified Rehrmann buccal advancement flap with a titanium mesh, and in group 2, the modified Rehrmann buccal advancement flap. The primary predictive factor was the use of titanium mesh. Dehiscence (the breakdown of the edge of flaps without the complete reopening of the defect) was a primary outcome. The defect's reopening was considered a secondary outcome. Nineteen patients in group 1 and 20 in group 2 were studied. In 2 months after treatments, the prevalence of dehiscence in group 1 was 3, and 10 patients in group 2 ( P =0.041). In group 1, patients did not show OAC exposure. However, OAC exposure was observed in 2 patients in group 2. This study demonstrates that using titanium mesh in combination with a modified Rehman flap decreases the prevalence of dehiscence compared with a flap alone.

Platelet-rich fibrin vs. buccal advancement flap for closure of oroantral communications: a prospective clinical study

OBJECTIVES

The primary aim was to evaluate the success of the defect closure (tight or open) of oroantral communications (OAC) after treatment with platelet-rich fibrin (PRF) clots or a buccal advancement flap (BAF). Secondary outcome measurements were the evaluation of the wound healing, the displacement of the mucogingival border (MGB), and the pain level.

MATERIAL AND METHODS

Fifty eligible patients with an OAC defect larger than 3 mm were randomly assigned to either PRF (test group, n = 25) or BAF (control group, n = 25) for defect closure. In a prospective follow-up program of 21 days, the defect closure healing process, the wound healing course using Landry's wound healing index (score: 0-5), the displacement of the MGB, and the postoperative pain score were evaluated.

RESULTS

Five patients in each group were lost to follow-up resulting in 40 patients (20 in each group) for continuous evaluation. On postoperative day 21 (study endpoint), no difference regarding success rate (defined as closure of OAC) was noticed between the test (90%; 18/20) and control group (90%; 18/20). A univariate analysis showed significant differences for age and defect size/height for the use of PRF between successful-tight and open-failed defect healing. At the final evaluation, a significantly (p = 0.005) better wound healing score, a lower displacement of the MGB as well as lower pain-score were seen for the use of PRF.

CONCLUSIONS

Based on the findings of the current study, the use of platelet-rich fibrin represents a reliable and successful method for closure of oroantral communications. The use of PRF clots for defect filling is associated with lowered pain levels and less displacement of the mucogingival border.

CLINICAL RELEVANCE

The defect size should be taken into account when choosing the number and size of PRF plugs.

Management of Oroantral Communications

Oroantral communication and fistula are commonly seen complications in the field of oral and maxillofacial surgery. Oral surgeons must be familiar with the diagnosis and proper management including multiple soft and hard tissue approaches to this surgical dilemma.

Surgical options in oroantral fistula management: a narrative review

An oroantral fistula (OAF) is a pathological abnormal communication between the oral cavity and the maxillary sinus which may arise as a result of failure of primary healing of an OAF, dental infections, osteomyelitis, radiation therapy, trauma, or iatrogenic complications. With the presence of a fistula, the maxillary sinus is permanently open. Microbial flora passes from the oral cavity into the maxillary sinus, and the inflammation of the sinus occurs with all potential consequences. In literature, various techniques have been proposed for closure of OAFs. Due to the heterogeneity of the data and techniques found, we opted for a narrative review to highlight the variety of techniques discussed in the literature. Techniques of particular interest include the bone sandwich with resorbable guided tissue regeneration (GTR) membrane and platelet-rich fibrin (PRF) used alone as both a clot and a membrane. The great advantage of these techniques is that no donor site surgery is necessary, making the outcome valuable in terms of time savings, cost and, more importantly, less discomfort to the patient. Additionally, both bony and soft tissue closure is performed for OAF, in contrast to flaps, which are typically used for procedures in the sinus area. The reconstructed bony tissue regenerated from these techniques will also be appropriate for endosseous dental implantation.