A Preliminary Study of Monocortical Bone Grafts for Oroantral Fistula Closure

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A preliminary study of monocortical bone grafts for oroantral

fistula closure

Robert Haas, MD, DMD, PhD,a Georg Watzak, MD, DMD,b Monika Baron, MD, DMD,b

Gabor Tepper, MD, DMD,b Georg M ailath, DMD, PhD,a and Georg Watzek, MD, DMD, PhD,c

Vienna, Austria

UNIVERSITY OF VIENNA

Sinus floor elevation has become a standard procedure in patients affected by severe maxillary atrophy,

before implant placement , prov ided that the maxillary sinus is intact and uninfected. In t he case of an o roant ral 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 t he chin. P ress-fit closure for bony repair of t he basal maxilla was sufficient in 3 of them.

Two patients needed additional internal graft fixation. In the meant ime, 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. (Oral Surg O ral Med Oral Pathol O ral Radiol Endod 2003;96:263-6)

Communications between th e oral cavity and the max-

illary sinus commonly occur after extraction of the first

and second molars.1-3 If these problems go untreated,

approximately 50% of patients will experience sinusitis

48 hours later and 90% of patients will have sinus itis

after 2 weeks o f no t reatment.4 Therefore, management

of communications bet ween oral cavity and sinus after

tooth extraction are recommended to p romote closure

within 24 hours .5

Numerous s urgical techniques have been d escribed

for the closure of o roantral fistulae. Mos t of them rely

on mobilizing the tissue and advancing the resultant

flap into the d efect.6-9 A Rehrmann flap, which is

fashioned b y mobilizing the vest ibular mucosa,8 is the

most widely used technique. An alternative is the u se of

the buccal fat pad.10 However, soft tissue cov erage may

fail, especially in large bony defects. Therefore, a

method that makes use of autogenous bone grafts har-

vested from the iliac crest for the closure of the defects

has been used.11

Because of the co ntinued need for implant reha-

bilitation and the necessity o f preimplant s urgical

proced ures , such as s inus floor elevation, the routine

soft tiss ue closure of oroantral fistulae has become a

major problem. This method caus es matting o f the

mucosae and Schneiderian membrane and makes el-

evation of the s inus membrane without disruption

impossible.

This technical study was designed to s how whether

chronic oroantral communications can succes sfully be

closed with intraoral bone grafts and whether thes e

would provide the conditions required for subsequent

subantral augmentation in terms of conventional sinus

lifting before implant surgery.

MATERIAL AND METHODS

Patients enrolled in this preliminary study had t o

fulfill 1 of the following criteria:

oroantral fistula and planned s inus floor elevation

oroantral fistula along a neighboring root su rface

extending into the maxillary s inus and undes irable

tooth extraction

chronic oroantral fistula with multiple uns uccess ful

attempts at closure.

Surgery was planned on the basis of a panoramic

radiograph and an axial dental computed tomograph

(Fig 1). Preoperatively, the affected sinus was irrigated

through the fistula with physiological saline so lution

followed by an iodine-containing solution diluted with

physiolog ical saline solut ion (1:1; betadine; Purdue,

Norwalk, Conn) to reduce infect ion.Immediately before the surgical procedure, the pa-

tients received amoxicillin and clavulanic acid (Aug-

men tin ; GlaxoSmit hKline, Uxbridge, England), 2 1

g/day for at least 5 days and a nasal decongestant.

aAssistant Professor, Department of Oral Surgery, Dental School,

University of Vienna, Austria.

bDepartment of Oral Surgery, Dental School, University of Vienna,

Austria

cProfessor and Head of Department of Oral Surgery, Dental School,

University of Vienna, Austria.Received for publication Feb 13, 2003; returned for revision May 9,

2003; accepted for publication Jun 30, 2003.

2003, Mosby, Inc. All rights reserved.

1079-2104/2003/$30.00 0

doi:10.1016/S1079-2104(03)00375-5

263
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Surgical procedure

Irregular bony defects o f the sinus floor were stan -

dardized to the s mallest pos sible rounded shape with a

trephine. A monocortical block graft was harves ted at

the dono r site (chin) by us ing a trephine with an inner

diameter matching the size of the round bony defect

(Fig 2); the g raft was then press -fit into the defect (Fig

3). If the pres s fit was uns table, miniplates (Leibinger,

Freiburg, Germany) or screws were inserted for internal

fixation. Soft tiss ue closure was es tablished by u sing a

Rehrmann flap.8 The sutures were drawn 1 week afterthe s urgical procedure. The miniplates were removed at

the time of the scheduled s inus lifting (ie, 3 months

after the bony closure of the oroant ral fistula).

Six to 12 months after the sinus -closure procedure,

the defect sites were evaluated on a computed tomo-

graph to as certain whether the surgical procedure was

successful.

RESULTS

A to tal of 5 patients were treated with monocorti-

cal block grafts harves ted at intraoral donor sites.

The mean age was 40.8 years (range, 32-50 years).

The causes of the oroant ral fistu lae, the defect sizes,

and ot her characteristics are listed in theTable.

Each patient with extraction-related fistulae (patients

2, 4, and 5) underwent 2 unsucces sful attempts of sinus

closure with a b uccal sliding flap. Three pat ients were

candidates for 2-stage subantral sinus augmentation and

implant placement after sinus closure. In 3 patients , astab le press-fit of the grafts in t he bon y maxillary defect

was achieved. The remaining 2 patients needed add i-

tional internal fixation with miniplates or screws. The

bony skeleton of the maxilla was completely restored

throughout.

In 1 patient, mucosal dehiscence developed 4 weeks

after the surgical procedure. This necess itated superfi-

Fig 1. An axial computed tomograph shows a clearly defined

oroantral fistula in the region of the left second molar in the

upper jaw. The small figure on the top of the left side shows

the ort horadial reconstruction of the defect.

Fig 2.Abo ve, Trephines with matching sizes; the smaller one

was for defect creation, whereas the matching bigger one was

for harvesting the block graft. Below, An intraoperative view

shows the donor site of monocortical grafts in the chin region.

Table. Patient ages, histories, and th e characteristics of the oroantral fistu lae

Patient

no.

Age

(y)

Duration

of OAC

(mo)

Cause of

OAC Region of OAC Indication

Defect size (in

mm) Graft fixation

1 44 4 Explantation Left side1PM,

2PM, 1M

Chronic OAF 10 mm Miniplate

2 32 24 Extraction Right side, 2M Chronic OAF; bony

defect along root

of1M

9 mm Press-fit

3 43 2 Explanation Left side, 1M Chronic OAF 7 mm Bone screw

4 50 120 Explanation Left side2PM,

2M

Chronic OAF 6 mm (2PM) Press fit

8 mm (2M)

5 35 12 Explanation Left side, 2M Chronic OAF 9 mm Press fit

OAF, Oroantral f istula;PM, premolar;M, molar.

264Haas et a l ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGYSeptember 2003

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brane and thus d ictate that s inus lifting not be us ed.

Solitary so ft tissue closure of oroan tral fistulae before

Haas et a l 265ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGYVolume 96, Number 3
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cial decortication of the graft and daily disinfection

with 3% hydrogen and Peruvian balm application. The

soft tissue defect healed by secondary intention within

14 days . The sinus itself was unaffected. The postop -

erative course was uneventful in all other patients .

Radiologically, the bony union was verified 8

months after the surgical procedure, on average, by

computed tomographic evidence.

In 3 pat ients with planned implant rehabilitation, a

sinus lift procedure was performed th rough a lateralwindow 3 months after bony sinus closure. At the t ime

of the s inus lifting, the sinus membrane overlying the

original bony defect was found to be intact and neither

elevation nor augmentation caused any p roblems.

DISCUSSION

For internal grafting of the maxilla, the sinus mem-

brane s hou ld be intact witho ut any signs of inflamma-

tion. Chronic oroantral fistulae usually cause severe

chronic inflammatory thickening of the sinus mem-

implant s urgery carries a high risk of mucosal injuryduring augmentation because of the adhesion of the oral

mucosa to the Schneiderian membrane. Sinus closu re

with bone g rafts harvested from the iliac crest, as

reported in 1969 by Proctor,11 is an attractive option,

but its use should be reserved for large defects becaus e

of the known morbidity inherent with th is procedure.

A congruous fit of the graft in the defect is the key to

bony healing.12 This can be ens ured with burs o f matching

sizes. In 3 of our 5 patients, the perfect press-fit obviated

additional internal graft fixation. In the remaining 2 pa-

tients, p ress-fit fixation was inadequate, s o a miniplate

(patient 1) or a bone screw (patient 3) was neces sary. In

pat ient 2, closure of the communication along an adjacent

root preserved the neighboring tooth.

Bone graft harvesting at intraoral donor s ites sub -

stan tially reduced the demands made on the patients

pos toperatively.13-16Nonetheles s, 1 of the pat ients in

this study developed wound dehiscence at the recipient

site pos toperatively. This co mplication rate is in keep-

ing with thos e reported for other procedures17 and did

not result in reopening of the sinus, but the wound

healed by secondary intention.

Therefore, this novel surgical technique is useful for

closing chronic oroantral fistulas in patients with

known fistulae between th e maxillary s inus an d the

nasal cavity

closing oroantral fistulae to pave the way for subse-

quent conventional sinus lifting

closing oroan tral communications extending along

exposed root surfaces.

REFERENCES

1. Killey HC, Kay LW. An analysis of250 cases of oro-antral

fistula treated by the buccal flap operation. Oral Surg Oral Med

Oral Pathol 1967;24:726-39.

2. von Wowern N. Oroantral communications and displacements of

roots into the maxillary sinus: a follow-up of231 cases. J Oral

Surg 1971;29:622-7.

3. Ehrl PA. Oroantral communication. Epicritical study of 175

patients, with special concern to secondary operative closure. Int

J Oral Surg 1980;9:351-8.

4. W assmund M, Lidgas G, editors. Lehrbuch der praktischen

Chirurgie des Mundes und der Kiefer. Leipzig (Germany):

Meusser; 1935.

5. LindorfHH, editor. Chirurgie der odontogen erkrankten Kiefer-hhle. Munich (Germany): Hanser; 1983.

6. Pichler H, Trauner R. Mund- und Kieferchirurgie. Vienna: Urban

and Schwarzenberg; 1948.

7. Axhausen G. U ber plastische Operationen in der Mundhhle und

am Unterkiefer. Dtsch Zahnrztl Wschr 1930;33:338-42.

8. Rehrmann A. Eine Methode zur Schliessung von Kieferhhlen-

perforationen. Dtsch Zahnrztl Wschr 1936;39:1136-9.

9. Schuchart K. Zur Methodik des Verschlusses von Defekten im

Alveolarfortsatz zahnloser Oberkiefer. Dtsch Zahn Mund Kief-

erheilkd 1953;17:366-70.

10. Egyedi P . Utilization of the buccal fat pad for closure oforo-

antral and/or oro-nasal communications. J Maxillofac Surg 1977;

5:241-4.

Fig 3. An intraoperative view: Press-fitted monocortical bonegrafts in the region of the second left premolar and the second

left molar.

Page 4

11. P roctor B. Bone graft closure of large or persistent oromaxillary

fistula. Laryngoscope 1969; 79:822-6.

12. Drtbudak O, Haas R, Bernhart T, Mailath-Pokorny G. Inlay

autograft of intra-membranous bone for lateral alveolar ridge aug-

mentation: a new surgical technique. J Oral Rehabil 2002;29:835-41.

13. Nkenke E, Schultze-Mosgau S, Radespiel-Troger M, Kloss F,

Neukam FW . Morbidity of harvesting of chin grafts: a prospec-

tive study. Clin Oral Implants Res 2001;12:495-502.

14. Dario LJ, English R Jr. C hin bone harvesting for autogenous

grafting in the maxillary sinus: a clinical report. Prac Periodon-tics Aesthet Dent 1994;6:87-91.

15. Raghoebar GM, Batenburg RH, Timm enga NM, Vissink A,

Reintsema H. Morbidity and complications of bone grafting of

the sinus floor of the maxillary sinus for the placement of

endosseous implants. Mund Kiefer Gesichtschir 1999;3:65-9.

16. Lundgren S, Nystrom E, Nilson H, Gunne J, Lindhagen O. Bone

grafting to the maxillary sinuses, nasal floor and anterior maxilla

in the atrophic edentulous maxilla. A two-stage technique. Int

J Oral Maxillofac Surg 1997;26:428-34.

17. S chmelzeisen R, Hessling KH, Barsekow F, Girod S. Complica-

tions in the plastic closure oforo-antral communications. Dtsch

Zahnrztl Z 1988;43:1335-7.

Reprint requests:

Robert Haas, MD, DMD Department of Oral Surgery Dental

School University of Vienna, Austria Waehringerstrasse 25A

A-1090 Vienna Austria, European Union

[email protected]

266Erratum ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGYSeptember 2003


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Erratum

Magnetic resonance evaluation of the disk before and after

arthroscopic surgery for temporomandibular joint

disorders (Ohnuki T, Fukuda M, Iino M, Takahashi T,

2003;96:141-8)

Following is a revised v ersion of Table VI from Mag-

netic resonance evaluation of the disk before and after

arthroscopic s urgery for temporomandibular joint d is-

orders (Ohnuki T, Fukuda M, Iino M, Takahashi T,

2003;96:141-8).

Table VI Preoperative versus postoperative disk mor-

pho logy according t o group

Successful group*

Preoperative disk

morphology

Postoperative disk morphology

total no.

of TMJs

Enlargement

of posterior

band

Even

thickness Biconvex

Enlargement of

posterior band

1 0 9 10 (31.3%)

Even thickness 0 1 0 1 (3.1%)

Biconvex 0 0 21 21 (100%)

Total 1(3.1%) 1(3.1%) 30(93.8%) 32(100%)

Unsuccessful group*

Preoperative

disk

morphology

Postoperative disk morphology

total no.

of TMJs

Enlargement

of posterior

band

Even

thickness Biconvex

Enlargement of

posterior band

1 1 8 10 (90.9%)

Even thickness 0 0 0 0 (0.0%)

Biconvex 0 0 1 1 (9.1%)

Total 1 (9.1%) 1 (9.1%) 9 (81.7%) 11 (100%)

On preoperative MRI, the diskmorphology of the successful group showed

more progressive deformity than that of the unsuccessful group.

*Wilcoxon single ranktestP .01.

P .01 (Mann-Whitney U test).
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A Preliminary Study of Monocortical Bone Grafts for Oroantral Fistula Closure

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