6/13/2014 A preliminary study of monocortical bone grafts for oroantral fistula closure

http://webcache.googleusercontent.com/search?q=cache:http://www.sgrottsaude.com.br/admin/arquivos/A%2520preliminary%2520study%2520of%2520mo 1/4
This is the html version of the file
http://www.sgrottsaude.com.br/admin/arquivos/A%20preliminary%20study%20of%20monocortical%20bone%20grafts%20for%20oroantral%20fistula%20closure.pdf.
Google automatically generates html versions of documents as we crawl the web.
Page 1
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 Mailath, DMD, PhD,a and Georg Watzek, MD, DMD, PhD,c
Vienna, Austria
UNIVERSITY OF VIENNA
Sinus floor elevat ion has become a st andard procedure in pat ient s affect ed by severe maxillary at rophy,
before implant placement , provided t hat t he maxillary sinus is int act and uninfect ed. In t he case of an oroant ral fist ula,
simple soft t issue closure may int erfere wit h t he process of elevat ing t he Schneiderian membrane. Tot al regenerat ion of
t he bony sinus floor is necessary t o prevent disrupt ion of t he sinus membrane.
In t his st udy, 5 pat ient s wit h oroant ral fist ulae of different causes were t reat ed wit h aut ogenous monocort ical
bone blocks harvest ed from t he chin. Press-fit closure for bony repair of t he basal maxilla was sufficient in 3 of t hem.
Two pat ient s needed addit ional int ernal graft fixat ion. In t he meant ime, t he 3 aforement ioned pat ient s underwent a
successful sinus lift procedure.
The use of a monocort ical bone block for t he closure of an oroant ral fist ula is recommended before int ernal
sinus augment at ion. (Oral Surg Oral Med Oral Pathol Oral Radi ol Endod 2003;96:263-6)
Communications between the 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 sinusitis
after 2 weeks of no treatment.4 Therefore, management
of communications between oral cavity and sinus after
tooth extraction are recommended to promote closure
within 24 hours.5
Numerous surgical techniques have been described
for the closure of oroantral fistulae. Most of them rely
on mobilizing the tissue and advancing the resultant
flap into the defect.6-9 A Rehrmann flap, which is
fashioned by mobilizing the vestibular mucosa,8 is the
most widely used technique. An alternative is the use of
the buccal fat pad.10 However, soft tissue coverage 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 continued need for implant reha-
bilitation and the necessity of preimplant surgical
procedures, such as sinus floor elevation, the routine
soft tissue closure of oroantral fistulae has become a
major problem. This method causes matting of the
mucosae and Schneiderian membrane and makes el-
evation of the sinus membrane without disruption
impossible.
This technical study was designed to show whether
chronic oroantral communications can successfully be
closed with intraoral bone grafts and whether these
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 to
fulfill 1 of the following criteria:
oroantral fistula and planned sinus floor elevation
oroantral fistula along a neighboring root surface
extending into the maxillary sinus and undesirable
tooth extraction
chronic oroantral fistula with multiple unsuccessful
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 solution
followed by an iodine-containing solution diluted with
physiological saline solution (1:1; betadine; Purdue,
Norwalk, Conn) to reduce infection.
Immediately before the surgical procedure, the pa-
tients received amoxicillin and clavulanic acid (Aug-
mentin; GlaxoSmithKline, 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
6/13/2014 A preliminary study of monocortical bone grafts for oroantral fistula closure
http://webcache.googleusercontent.com/search?q=cache:http://www.sgrottsaude.com.br/admin/arquivos/A%2520preliminary%2520study%2520of%2520mo 2/4
Page 2
Surgical procedure
Irregular bony defects of the sinus floor were stan-
dardized to the smallest possible rounded shape with a
trephine. A monocortical block graft was harvested at
the donor site (chin) by using a trephine with an inner
diameter matching the size of the round bony defect
(Fig 2); the graft was then press-fit into the defect (Fig
3). If the press fit was unstable, miniplates (Leibinger,
Freiburg, Germany) or screws were inserted for internal
fixation. Soft tissue closure was established by using a
Rehrmann flap.8 The sutures were drawn 1 week after
the surgical procedure. The miniplates were removed at
the time of the scheduled sinus lifting (ie, 3 months
after the bony closure of the oroantral fistula).
Sixto 12 months after the sinus-closure procedure,
the defect sites were evaluated on a computed tomo-
graph to ascertain whether the surgical procedure was
successful.
RESULTS
A total of 5 patients were treated with monocorti-
cal block grafts harvested at intraoral donor sites.
The mean age was 40.8 years (range, 32-50 years).
The causes of the oroantral fistulae, the defect sizes,
and other characteristics are listed in the Table.
Each patient with extraction-related fistulae (patients
2, 4, and 5) underwent 2 unsuccessful attempts of sinus
closure with a buccal sliding flap. Three patients were
candidates for 2-stage subantral sinus augmentation and
implant placement after sinus closure. In 3 patients, a
stable press-fit of the grafts in the bony maxillary defect
was achieved. The remaining 2 patients needed addi-
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 necessitated superfi-
Fig 1. An axial comput ed t omograph shows a clearly defined
oroant ral fist ula in t he region of t he left second molar in t he
upper jaw. The small figure on t he t op of t he left side shows
t he ort horadial reconst ruct ion of t he defect .
Fig 2. Above, Trephines wit h mat ching sizes; t he smaller one
was for defect creat ion, whereas t he mat ching bigger one was
for harvest ing t he block graft . Below, An int raoperat ive view
shows t he donor sit e of monocort ical graft s in t he chin region.
Table. Patient ages, histories, and the characteristics of the oroantral fistulae
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
of 1M
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 fistula; PM, premolar; M, molar.
264 Haas et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2003
Page 3
brane and thus dictate that sinus lifting not be used.
Solitary soft tissue closure of oroantral fistulae before
Haas et al 265
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 96, Number 3
6/13/2014 A preliminary study of monocortical bone grafts for oroantral fistula closure
http://webcache.googleusercontent.com/search?q=cache:http://www.sgrottsaude.com.br/admin/arquivos/A%2520preliminary%2520study%2520of%2520mo 3/4
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 patients with planned implant rehabilitation, a
sinus lift procedure was performed through a lateral
window 3 months after bony sinus closure. At the time
of the sinus lifting, the sinus membrane overlying the
original bony defect was found to be intact and neither
elevation nor augmentation caused any problems.
DISCUSSION
For internal grafting of the maxilla, the sinus mem-
brane should be intact without any signs of inflamma-
tion. Chronic oroantral fistulae usually cause severe
chronic inflammatory thickening of the sinus mem-
implant surgery carries a high risk of mucosal injury
during augmentation because of the adhesion of the oral
mucosa to the Schneiderian membrane. Sinus closure
with bone grafts 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 because
of the known morbidity inherent with this procedure.
A congruous fit of the graft in the defect is the key to
bony healing.12 This can be ensured with burs of matching
sizes. In 3 of our 5 patients, the perfect press-fit obviated
additional internal graft fixation. In the remaining 2 pa-
tients, press-fit fixation was inadequate, so a miniplate
(patient 1) or a bone screw (patient 3) was necessary. In
patient 2, closure of the communication along an adjacent
root preserved the neighboring tooth.
Bone graft harvesting at intraoral donor sites sub-
stantially reduced the demands made on the patients
postoperatively.13-16 Nonetheless, 1 of the patients in
this study developed wound dehiscence at the recipient
site postoperatively. This complication rate is in keep-
ing with those 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 the maxillary sinus and the
nasal cavity
closing oroantral fistulae to pave the way for subse-
quent conventional sinus lifting
closing oroantral communications extending along
exposed root surfaces.
REFERENCES
1. Killey HC, Kay LW. An analysis of 250 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 of 231 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. Wassmund M, Lidgas G, editors. Lehrbuch der praktischen
Chirurgie des Mundes und der Kiefer. Leipzig (Germany):
Meusser; 1935.
5. Lindorf HH, 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. Uber 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 of oro-
antral and/or oro-nasal communications. J Maxillofac Surg 1977;
5:241-4.
Fig 3. An int raoperat ive view: Press-fit t ed monocort ical bone
graft s in t he region of t he second left premolar and t he second
left molar.
Page 4
11. Proctor 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. Chin 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, Timmenga 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. Schmelzeisen R, Hessling KH, Barsekow F, Girod S. Complica-
tions in the plastic closure of oro-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
robert.haas@univie.ac.at
266 Erratum ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
September 2003
6/13/2014 A preliminary study of monocortical bone grafts for oroantral fistula closure
http://webcache.googleusercontent.com/search?q=cache:http://www.sgrottsaude.com.br/admin/arquivos/A%2520preliminary%2520study%2520of%2520mo 4/4
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 version of Table VI from Mag-
netic resonance evaluation of the disk before and after
arthroscopic surgery for temporomandibular joint dis-
orders (Ohnuki T, Fukuda M, Iino M, Takahashi T,
2003;96:141-8).
Table VI Preoperative versus postoperative disk mor-
phology according to 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 ranktest P .01.
P
.01 (Mann-Whitney U test).