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*Senior lecturer**Senior lecturerProfessorProfessor and Head$ReaderDept. of Oral and Maxillofacial SurgerySree Balaji Dental College and Hospital, Chennai

Address for correspondenceDr Prakash dhanaveluSenior LecturerDept. Oral and Maxillofacial SurgerySree Balaji Dental College and Hospital,ChennaiE-mail:prakash.oralsurgeon@gmail.com

ABSTRACT

A novel method for closure of large Oro antral fistula is presented that uses an autogenous corticocancellous bone graftharvested from mandibular symphysis region. Te advantages of using mandibular bone grafts are reduced operating timeand minimal postoperative complaints. Furthermore it helps in reconstructing the sinus floor as well as alveolar bone defectand also shows less resorption when compared with iliac bone graft.

Key words: Oro antral fistula, corticocancellous bone graft, autogenous

Management of Oroantral Fistula with AutogenousCorticocancelous Symphysial Bone GraftPrakash Dhanavelu*, B Sreevidya**, R Balakrishnan, Vijay Ebenezer, Abudakir$

Oro antral fistula is an epithelializedcommunication between the oral cavity andthe maxillary sinus.1It is a relatively common

complication with the incidence between 0.31-4.7%after extraction of maxillary posterior teeth.1-5 Othercauses are dento alveolar infection, cysts, tumours,osteonecrosis, trauma and dental implant failure in theatrophic posterior maxilla.2,6

Numerous surgical techniques such as palatal pedicleflap, Rehrmann buccal advancement and buccal fat

pad techniques have been described for the closure ofOAF. Most of them rely on mobilizing the tissue andadvancing the resultant flap into defect.2,7 However,especially when the bone perforation is particularly large,accentuated atrophy of the vestibular bony wall of thealveolus and healing of the perforation without osseousregeneration has been observed after the operation.Tis can be accompanied by serious deformation ofthe alveolar process with a noticeable reduction of thedepth of the fornix, which is particularly undesirablefrom the prosthetic point of view.8

o prevent such drawbacks, to obtain proper boneformation and to further decrease the possibilityof failure of operation, we employed autogenouscorticocancellous bone graft harvested from mandibularsymphysis region for OAF closure.

Case History

A 70-year-old female patient presented to thedepartment of oral and maxillofacial surgery, BalajiDental College with the chief complaint of nasal

regurgitation while taking liquid diet since 2 yearsfollowing extraction of upper right posterior teeth.Patients past medical history reveals diabetes and onmedication (insulin). She also had myocardial infarction2 years back and underwent bypass surgery for thesame. Presently she is taking anticoagulants (aspirin).Physical examination revealed 2 x 5 mm opening in theregion of 16 (Fig. 1). Valsalvin test was performed andwas positive. Radiographic examination (oclussal view;

Figure 1.

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Fig. 2, IOPA) revealed destruction of bone withoutany evidence of chronic sinusitis and foreign bodies.

Surgical Technique

After obtaining physician consent, procedure wasperformed under local anesthesia (2% lignocainewith 1: 80,000 parts of adrenaline). Anticoagulantwas stopped five days prior to the surgery. Antibioticprophylaxis (amoxicillin) given preoperatively.

Recipient Site

Incision was placed from 13 to 18 regions of alveolarcrest and around the fistula (Fig 3). Mucoperiostealflap was elevated (Fig. 4).Epithelial lining of the fistula

Figure 2. Occlusal view revealing OAF.

Figure 3. Incision placed.

Figure 4. Site exposed.

Figure 5. Epithelialized tissue removed. Figure 6. Donor site exposed.

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Figure 7. Horizontal and vertical osteotomy cuts.

Figure 8. Graft harvested.

Figure 9. Graft placed in the recipient site.

Figure 10. Graft is secured with screw.

Figure 11. Recipient site closure.

Figure 12. Donor site closure.

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tract removed(Fig. 5). Bony defect was exposed and,measured with stainless steel scale. Te actual bonydefect was longer than the soft tissue defect. Te sizeof the defect was 3 x 8 mm in diameter.

Donor Site

Vestibular incision placed from 32 to 42 regions.Mucoperiosteal flap was reflected and donor site exposed(Fig. 6). wo horizontal osteotomy cuts were performedwith bur, with a length of 1.2 cm. First horizontalosteotomy cut was placed 5 mm below the crest of thealveolar ridge. Second horizontal osteotomy cut wasplaced 5 mm below the first horizontal osteotomy cut.Tese two horizontal osteotomy cuts were connectedwith vertical osteotomy cuts (Fig. 7). A thin, broad

osteotome was used for freeing the corticocancellousblock, leaving the lingual cortex intact (Fig. 8).

Te harvested bone was modified with bur accordingto the defect shape and fixed with 2 x 6 mm stainlesssteel screw (Figs. 9, 10). wound closure was achievedwith 30 silk (Figs. 11, 12). Routine postoperativeinstructions, including medications (antibiotics andanalgesics) and to avoid sternous physical activities(nose blowing, sneezing, vigorous rinsing) that mightraise the pressure within the para nasal sinuses are givenfor one week. Postoperative period was uneventful.

Sutures were removed after ten days.

Discussion

OAF usually occurs after the third decade of age and iscommon in elderly individuals. It is considered that theloss of teeth in association with advancing age increasesthe likelihood of fistula formation.5,6,9 Te frequencyof OAF is nearly the same in both sexes. However,according to lin et al, females exhibit larger sinusesthan males and should therefore be at greater risk ofOAF. Most frequent cause of OAF is tooth extraction.

Some studies showed that, highest incidence of OAFis found after extraction of a second premolar followedby the first molar.6Whereas other studies showed thatit is common after extraction of upper first molarfollowed by the second molar.9

Numerous surgical techniques have been described forthe closure of OAF. Long term successful closure ofthe OAF depends on the acuteness of the problem,absence of sinus disease, size and location of the defectand the amount and condition of the adjacent tissue.

Te literature has shown that openings >5 mm indiameter have a substantially decrease the chance ofspontaneous primary closure.10,11 reatment includesthe use of local/distant tissue flaps and interpositional

autogenous grafts/alloplastic implants. Because ofthe high recurrence of OAF with soft tissue coveragetechniques especially in large bone defects, closure ofOAF with autogenous (or) allogenous bone graft isrecommended.10

Proctor first reported the bony closure of large OAFby grafting a piece of corticocancellous block from theanterior iliac spine. Complications associated with thistechnique are donor site morbidity and hospitalization.Hass et al introduced another OAF bony closuretechnique using a monocortical press fit graft from the

chin area.2,12

In our case, autogenous corticocancellous mandibularsymphysis graft is used for closure of OAF. Teadvantages of using mandibular bone grafts are relatedto using the same operation field easier accessibilityreduced operating time, minimal post operativecomplaints and absence of visible scar. Furthermoreoperating exclusively inraorally is considered to beless extensive surgery by patients compared with usingiliac crest as donor site.2,13 Mandibular symphysialcorticocancellous graft considered to be an ideal graft

because it provides a cortical portion for reconstructinga solid sinus floor as well as alveolar defect at theOAF site and its cancellous portion contains viablemultipotent mesenchymal stem cells for osteogenesis.Several authors suggested that chin bone grafts requireshorter healing time compared with iliac crest bonegrafts. Tey have reported that membranous bone(symphysial bone graft) undergoes less resorption thanbone of endochondral origin (iliac crest bone graft)owing to earlier revascularization of membranousbone grafts.2,14,15

o conclude, this technique may be useful to treat OAFand to provide a solid alveolar bone site for subsequentprosthesis placement.

References

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