Double-Layered Closure of Chronic Oroantral Fistulas Using a Palatal Rotational Flap and Suturing of the Sinus Membrane Perforation: Is It a Successful Technique?

Accepted Manuscript Double-layered closure of chronic oroantral fistulas using a palatal rotational flap and suturing of the sinus membrane perforation: Is it a successful technique? Aliaa Adel Sayed, B.D.S, M.Sc Ghada Amin Ahmed Khalifa, B.D.S, M.Sc., Ph.D. Susan Abd El-Hakim Hassan, B.D.S, M.Sc., Ph.D. Fatma Ibrahim Mohamed, B.D.S, M.Sc., Ph.D. PII:

S0278-2391(14)01615-2

DOI:

10.1016/j.joms.2014.10.016

Reference:

YJOMS 56534

To appear in:

Journal of Oral and Maxillofacial Surgery

Received Date: 30 May 2014 Revised Date:

8 October 2014

Accepted Date: 13 October 2014

Please cite this article as: Sayed AA, Ahmed Khalifa GA, El-Hakim Hassan SA, Mohamed FI, Doublelayered closure of chronic oroantral fistulas using a palatal rotational flap and suturing of the sinus membrane perforation: Is it a successful technique?, Journal of Oral and Maxillofacial Surgery (2014), doi: 10.1016/j.joms.2014.10.016. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Double-layered closure of chronic oroantral fistulas using a palatal rotational flap and

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suturing of the sinus membrane perforation: Is it a successful technique?

Aliaa Adel Sayeda

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Ghada Amin Ahmed Khalifab

Fatma Ibrahim Mohamedd a

Associate lecturer of Oral and Maxillofacial Surgery, Faculty of Oral and Dental

Medicine, Sinai University. Sinai. Egypt

Associate professor of Oral and Maxillofacial Surgery, Faculty of Dental

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b

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Susan Abd El-Hakim Hassanc

Medicine(Girls Branch), Al Azhar University. Cairo. Egypt c

Professor and Head of Oral and Maxillofacial Surgery, Faculty of Dental Medicine

Lecturer of Oral and Maxillofacial Surgery, Faculty of Dental Medicine (Girls Branch),

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d

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(Girls Branch), Al Azhar University. Cairo. Egypt

Al Azhar University. Cairo. Egypt

Corresponding author Fatma Ibrahim Mohamed

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Al Azhar University Faculty of Dental Medicine (girls branch)

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Yusuf Abbas St., Nasr City, Cairo, Egypt 00201155531928

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[email protected]

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Double-layered closure of chronic oroantral fistulas using a palatal rotational flap and suturing of the sinus membrane perforation: Is it a successful technique?

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Aliaa Adel Sayed, B.D.S, M.Sc., Ghada Amin Khalifa, B.D.S, M.Sc., Ph.D., Susan Abd El-HaKim Hassan, B.D.S, M.Sc., Ph.D., Fatma Ibrahim Mohamed, B.D.S, M.Sc., Ph.D.

Purpose: Chronic oroantral fistulas (OAFs) are a challenging problem in the field of oral

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and maxillofacial surgery, and the success rate of OAFs is as low as 67%. Thus, the double-layered closure has been described. The purpose of this study was to evaluate the

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simplicity and effectiveness of using a palatal rotational flap and suturing of the sinus membrane perforation as a new technique for double-layered closure.

Materials and Methods: A prospective case series study was performed on patients who had chronic OAFs and were treated at Al Zahraa Hospital from 2010 to 2013. The

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following demographic and clinical data were collected; age, gender, location of the defect, size, etiology, signs and symptoms, postoperative healing, and complications. Under local anesthesia, a fistulectomy and sinus irrigation were performed to control

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sinusitis. Under general anesthesia, the oral side of the fistulous tract was sutured with a

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purse suture. A palatal flap was reflected and sutured to the buccal tissue.

Results: Twelve patients were enrolled in this study, and their ages ranged from 19 to 51 years. All patients tolerated the surgical procedures; all surgical wounds healed uneventfully without recurrence.

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Conclusion: Double-layered closure of OAFs is a straightforward, convenient, and successful technique that provides stable, strong, and double-sealed closure of chronic

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OAFs.

INTRODUCTION:

The reported incidence of oroantral communication (OAC) is as high as 11%

(1)

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development

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The palatal root of the maxillary first molar is most commonly implicated in OAC (2)

. The presence of maxillary sinusitis, osteitis, or osteomyelitis at the

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communication’s margins or the presence of foreign bodies will prevent spontaneous healing and result in chronic fistula formation(3). Oroantral fistulas (OAFs) can be recognized as epithelialized communications that develops between the pseudo-stratified columnar ciliated epithelium of the maxillary sinus and the squamous epithelium of the

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oral cavity (4).

Different surgical and nonsurgical techniques have been described for closure of OAFs(5). Despite the various successful surgical techniques, OAF remains one of the

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most challenging and difficult problems in the field of oral surgery(3). It has been reported that the success rate of secondary repairs of chronic OAFs is as low as 67% (6). Providing

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epithelial coverage for the oral mucosa and the Schneiderian membrane are of prime importance for reducing contracture during wound healing and minimizing postoperative infection. These two factors result in increases in the incidence of wound breakdown and the recurrence of fistula

(4)

. The most common method used for the surgical repair of

OAF is a single-layered closure using buccal or palatal flaps (7- 9)

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Many authors have described methods of double-layered closure of chronic OAF, including the use of combinations of inversion and rotational advancement flaps, which provide sufficient tissue bulk (4,10,11). Candamourty et al. (12) and Batra et al. (13) noted that

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the use of combination technique for OAF closure provides more stability. These techniques are effective, but they require two donor sites, which increases the denuded

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surface area (7).

The purpose of the present study was to address the following question: Among

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patients suffering from chronic OAF, does the use of a double-layered closure, a palatal rotational flap, and suturing the sinus membrane perforation provide simple and successful surgical repair of chronic OAF? The study hypothesis was that the doublelayered closure of OAF using this technique is simple and can provide an adequate seal and a stronger closure to decrease the recurrence of this condition. The aim of this study

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was to prospectively evaluate the simplicity and effectiveness of double-layered closure of chronic OAFs using a palatal rotational flap and the suturing of the sinus membrane

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perforation.

PATIENTS AND METHODS:

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STUDY DESIGN AND SAMPLE

To address the purpose of the study, the investigators designed and achieved a

prospective case series study. The study sample was derived from the population of patients who attended to the Department of Oral and Maxillofacial Surgery at Al Zahraa University Hospital, Faculty of Dental Medicine for Girls, Al Azhar University for evaluation and management of chronic OAF between January 2010 and August 2013. All patients were informed about the study and provided written informed consent to

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participate in the research. The local ethics review committee of Al Azhar University Girls’ branch of medical sciences approved the study.

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INCLUSION AND EXCLUSION CRITERIA The patients included in this study were those suffering from chronic or recurrent OAF secondary to tooth extraction. The exclusion criteria included patients who had

DATA COLLECTION METHOD

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diseases, and OAFs that resulted from ablative surgery.

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systemic diseases that affected wound healing, such as uncontrolled diabetes and collagen

The following demographic and clinical data were abstracted from the patients’ charts: age, gender, signs and symptoms of sinusitis, nasal and/or fistulous discharge, previous surgical interventions, site and size of the OAF, duration, etiology, postoperative healing, and complications. The radiographic examinations included digital orthopantomogram (OPG) and computerized tomography (CT) to evaluate the maxillary

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sinus condition, exclude the presence of foreign bodies and remaining roots, and determine the size of the bony defect at the fistula site.

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VARIABLES

The primary predictor variables were operation time and the difficulties encountered during surgery. The primary clinical outcome variable was the success of the

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surgical closure of the fistula. The success variables were identified as uneventful wound healing and the disappearance of the signs and symptoms of OAF without recurrence. The variables were identified from the patients’ clinical records and radiographs (i.e., OPG and CT).

DATA ANALYSES The incidence of each success variable was determined and statistically analyzed. The descriptive statistics were analyzed with Pearson’s chi square tests, and the means

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and proportions were compared with independent sample t-test; p values below .05 were considered statistically significant.

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SURGICAL INTERVENTION Presurgical preparation:

Under local anesthesia, a fistulectomy was performed to remove the inflamed

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fistulous tract and sinus lining prolapse or sinus polyp, which might have obstructed sinus drainage. Antral infections were controlled with antibiotics, decongestant nasal drops,

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and frequent sinus irrigation through the fistula with an iodine-containing solution diluted with physiologic saline (1:1). This regimen was administered three times per day for 1015 days until there was no inflammatory exudate and no signs of gingival inflammation around the orifice of the OAF, which generally required 2-3 weeks.

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Surgical closure of the OAF:

Under general anesthesia, the area of the OAF was infiltrated with adrenalin (1:1000) to provide homeostasis and increase tissue bulk. The bony boundary of the

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fistula was determined with a needle. A full thickness circular incision was performed

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around the fistula, which was then carefully reflected from the bony walls of the fistula. The oral side of the fistulous tract was sutured with the purse suture technique using 3-0 Vicryl sutures. Iodoform gauze was packed through the alveolar ridge to push the tissues upward (Figs.1A, B, C, and D). Next, a full-thickness mucoperiosteal palatal rotational flap was designed based on the greater palatine vessels. The width of the flap was determined according to the mesio-distal width of the fistula and the angle of rotation. Moreover, the anterior

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extension of the flap was determined according to the distance required for flap rotation. The medial border of the flap was placed 2-3 mm lateral to the median palatine raphe, and its lateral border was placed approximately 5 mm below palatal gingival margin to

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avoid periodontal damage, except at the area of the fistula; the flap included the palatal gingival margin to avoid the presence of any residual tissue after flap reflection. The alveolar bone was smoothed, and the palatal flap was reflected, rotated, advanced, and

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sutured to the buccal tissue with horizontal mattress and interrupted vicryl sutures (Fig. 2 A&B). A V-shaped or back-cut incision was made to avoid any wrinkles at the posterior

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end of the flap and to decrease venous congestion.

A palatal splint was placed and fixed with interdental wires and remained in place to 24 hours to avoid dropping of the palatal tissue due to the effects of hematoma and gravity. All of our patients received intraoperative and postoperative antibiotics

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(amoxicillin/clavulanate) for five days. Postoperatively, the patients applied nasal drops containing phenylephrine HCl and chlorhexidine gluconate 0.2% for two weeks and used saline mouth rinses. Non-steroidal anti-inflammatory drugs (NSAIDS) were also

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prescribed for pain control. Soft diet restrictions were advised, and the patients were

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warned against any maneuver that caused negative pressure in the paranasal sinuses, including sneezing, coughing, sucking, and smoking for one month. Moreover, the patients were asked to attend follow-up visits at one, three, and six months postoperatively. RESULTS:

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The study included 12 patients with a mean age of 35 ±10.829 years, and nine (75%) were males. The patients’ defect sizes ranged from 8 to 14mm, with a mean of 10.9 ± 1.88 mm. The interval from fistula development to repair ranged from two months

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to 15 years (mean 19.9 months). Tooth extractions were the cause of the OAF in all patients. The OAFs predominately occurred in the area of first molar (58.3%), followed by the second premolar (25%) and the second molar (16.7%). Four patients (33.3%) had

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undergone previous operations to close their fistulas using buccal advancement flaps. All patients appeared to be free of systemic diseases. The most common patient complaints

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were nasal regurgitation of fluids and unhealed sockets with extruded polyps. Additionally, various symptoms of chronic sinusitis were also reported by the patients and included postnasal discharge, nasal congestion, halitosis, referred pain to the upper teeth and anterior wall of the maxilla, and reductions in taste and smell sensations.

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Radiographically, all sinuses exhibited opacification in the CT scan. The preoperative demographic and clinical data of the patients were collected and are summarized in Table I.

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The closure of the sinus membrane perforation via suturing of the oral side of the

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fistulous tract was successful in 10 cases (83.3%) with a mean surgical time 90.3 ± 6.037 minutes. In the other two cases (16.7%), the fistulous tract became separated during suturing; thus, the Caldwell-Luc operation was performed to facilitate the direct suturing of the sinus membrane, and the collagen membrane was also used to cover the site of the perforation. These procedures required longer surgical times (mean 150± 14.14 minutes). The patients who underwent the Caldwell-Luc operation complained of postoperative

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infraorbital neuropathy, and symptoms spontaneously disappeared eight weeks after surgery (Table II).

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All patients tolerated the surgical procedures, and all surgical wounds healed uneventfully. The signs and symptoms of OAF disappeared immediately after surgery, and remained absent throughout the follow-up period. All patients exhibited high levels

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of satisfaction, especially those who had undergone previous operations. One patient (8.3%) developed immediate postoperative acute sinusitis, which was controlled with

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parenteral antibiotic therapy for five days. This patient exhibited fluid and air leakage beneath the medial side of the palatal flap, which stopped spontaneously within two months. The patients with previous histories of chronic sinusitis exhibited resolution of this condition with the closure of the OAFs.

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At the area of the OAF, palatal flap appeared to be edematous during the first week. The alveolar ridge was covered with normal mucosa by the end of the third to fourth week. In nine (75%) patients, the reconstructed region exhibited excellent texture

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and matched the adjacent palate; in the remaining cases, the reconstructed region exhibited transposition of the rugae area over the ridge. Epithelialization of the denuded

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palatal bone at the donor site began during the second week and was completed by the end of the fourth week postoperatively with minimal discomfort. After healing, all patients exhibited a lack of alterations in the anatomy of the palate and only minimal color change in the palatal mucosa at the surgical site. Bulging of the posterior portion of the palatal flap was noted in one patient (8.3%) at the end of the follow-up period. In two (16.7%) patients, the lower molars impinged on the flap and necessitated spot grinding (Table III).

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DISCUSSION: The purpose of this study was to address the following question: Among patients

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suffering from chronic OAF, does the use of a double-layered closure with a palatal rotational flap and suturing of the sinus membrane perforation provide simple and successful surgical repair of chronic OAF? The study hypothesis was that the double-

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layered closure of the OAF with the technique is capable of providing an adequate seal and a stronger closure to decrease the risk of recurrence. The aim of this study was to

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prospectively evaluate the effectiveness of the double-layered closure of chronic OAF using a palatal rotational flap and suturing of the sinus membrane perforation. The key finding of this study is that the patients with chronic OAF who were treated with this technique exhibited a disappearance of all clinical signs and symptoms

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of OAF and no recurrence over the 6-month follow-up period. Additionally, this technique resulted in significant reductions in operating time, which supports the study hypothesis. The clinical significance of this finding is that the number of donor sites,

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surgical wounds, and operating time are reduced by turning over the oral side of the fistula after suturing and using it as one layer of the bi-layered closure. A practical

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outcome is that this technique is convenient for patients because it decreases the denuded surface area and postoperative pain and complications. From the surgical perspective this technique is easy, cost-effective, and less time-consuming. In the present study, a circular superiorly based oral mucosal flap around the OAF was elevated from the alveolus, sutured, and pushed upward through the bony defect into the sinus cavity. Our technical notes suggested that 3-4 mm of distance of the soft tissue

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from the bony boundaries of fistula was sufficient to restore the sinus membrane without tension, and this result agrees with those of a study by Lee

(14)

. We predict that this

technique will be able to restore the continuity of the residual sinus membrane in the area

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of the OAF, allow for superior primary healing of membrane, and prevent fusion between the oral and sinus mucosa. It has been reported that, in routine soft tissue closures of OAFs, the membrane is left denuded and heals secondarily through migrating sinus

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membrane cells, which results in matting of the oral mucosa with Schneiderian

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membrane (14, 15).

The dissection of the oral mucosa, which was continuous with the residual sinus membrane through the OAF, was performed successfully in 83.3% of cases. In the remaining patients, the tissues were friable and separated during the dissection or suturing due to the presence of residual inflammation with narrow bony defects; thus,

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these dissections and suturing were difficult and inaccessible. In these cases, closures of the sinus membrane perforation via the Caldwell-Luc approach were easier, but this procedure is considered to be more invasive procedure and associated with increased

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degrees of postoperative pain and edema and the presence of an additional another

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surgical wound. Moreover, these patients suffered from temporary infraorbital neuropathy, which might have been due to excessive stripping of the periosteum from the anterior wall of the antrum or traction on the infraorbital nerve during surgery. This supposition is in agreement with the findings of Anavi et al. (7). Our results also revealed resolutions of the clinical signs and symptoms of the sinusitis that developed following OAF development even among the cases with previous histories of chronic sinusitis prior to OAF development. Repair of sinus membrane

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seemed to return the sinus mucosa to normal over a short period and to improve sinus ventilation and drainage. It has been previously claimed that the introduction of oral squamous epithelium into the maxillary sinus increases the possibility of squamous

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metaplasia in the maxillary sinus(16). However, this is only theoretical possibility. Additionally, such squamous metaplasia occurs during the normal aging process and (17)

reported that sinus mucosa is capable

of regeneration and can return to its normal morphology.

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serves as a protective mechanism. Baĭdik et al.

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The palatal flap is an axial flap that has an abundant blood supply that depends on the greater palatine artery. The results of the current study revealed a 100% success rate for the closure of the oral side of the fistula with the palatal rotational flap, and this is consistent with the results of previous studies

(18,19)

. This flap is also accessible, mobile,

versatile, and elastic, so it can be rotated without tension. Furthermore, this flap preserves

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the maxillary vestibular sulcus depth. The epithelialization of the palate at the donor site was excellent, and no necrosis or folding of the palatal mucosa was observed. These results are in accordance with the results of Anavi et al.

(7)

. However, some technical

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difficulties with palatal rotational flaps were observed, including kinking of the flap or

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the creation of a “dog ear”at its axis of rotation and painfully exposed bone at the anterior donor site. These complications were also reported by Lazow

(6)

. Moreover, one of the

drawbacks of the palatal rotational flap is the transposition of the rugae area of the palate over the ridge, particularly in cases of OAF at premolar areas that necessitate more anterior extension of the flap (Fig.3). One patient in the current study suffered from air and fluid leakage at the medial aspect of palatal flap that spontaneously stopped within two months. This leakage caused

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some short-term inconvenience to the patient and might have caused the acute sinusitis that developed but did not affect the success of the OAF repair. We assume that this drawback occurred due to the possibility of liquid passage beneath the palatal rotational

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flap, which could not be compressed against the bone. Other postoperative complications, such as the encroachment of the lower teeth on the flap and the bulging of the flap

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seemed to be unavoidable. Similar notions were also suggested by Avani et al. (7).

The limitations of the present study were the limited number of patients in the

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study group and the tearing of the fistulous tract during dissection and suturing due to narrow bony defects. The level of experience and dexterity of the surgeon is very important because great care is required during flap manipulation. However, our results revealed that the study’s technique of OAF closure is simple, convenient, and reliable for many reasons. First, this technique decreases the number of donor sites, surgical wounds,

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and operating time. Second, this technique provides stable and strong double-layered flap closure. Third, this technique exhibited a 100% success rate without recurrence. However, the level of experience and dexterity of the surgeon is very important because a

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great care is required during flap manipulation.

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In conclusion, the key finding of this study was that patients with chronic OAF

who were treated with this technique exhibited a disappearance of all clinical signs and symptoms of OAF with no recurrence over a six-month follow-up period. This technique resulted in a significant reduction in operating time. The clinical significance of this technique involves reductions in the number of donor sites, surgical wounds, and operating time. A practical outcome is that this technique is convenient for patients because it decreases the denuded surface area and postoperative pain and complications.

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From the surgical perspective, the technique is easy, cost-effective, and less time consuming. Hence, we recommend this technique as an alternative to bi-layered traditional flaps for the closure of chronic OAF. However, much controversy remains in

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the literature regarding to the introduction of oral mucosa into the sinus, and the

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performance of well-designed studies to resolve this issue is highly recommended.

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REFERENCES:

1. Rothamel D, Wahl G, d'Hoedt B, Nentwig GH, Schwarz F, Becker J: Incidence and predictive factors for perforation of the maxillary antrum in operations to remove upper wisdom teeth: prospective multicentre study. Br J Oral MaxillofacSurg45:387, 2007.

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2. Ogle OE1, Weinstock RJ, Friedman E: Surgical anatomy of the nasal cavity and paranasal sinuses. Oral MaxillofacSurgClin North Am 24:155, 2012. 3. Yalçın S, Oncü B, Emes Y, Atalay B, Aktaş I: Surgical treatment of oroantral

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fistulas: a clinical study of 23 cases. J Oral MaxillofacSurg 69:333, 2011. 4. Hassan O, Shoukry T, AbdelRaouf A, Wahba H: Combined palatal and buccal

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flaps in oroantral fistula repair. EJENTAS13: 77, 2012.

5. Weinstock RJ, Nikoyan L, Dym H: Composite three-layered closure of oroantral communication

with

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months

follow-up

a

case

study.

J

Oral

MaxillofacSurg72:266.e1, 2014. 6. Lazow SK:Surgical management of the oroantral fistula: flap procedures. Oper Tech Otolaryngol-Head Neck Surg 10:148, 1999.

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7. Anavi Y, Gal G, Silfen R, Calderon S: Palatal rotation-advancement flap for delayed repair of oroantral fistula: a retrospective evaluation of 63 cases. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 96:527, 2003.

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8. Isler SC, Demircan S, Cansiz E: Closure of oroantral fistula using auricular cartilage: a new method to repair an oroantral fistula. Br J Oral MaxillofacSurg 49:e86, 2011.

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9. Lee BK: One-stage operation of large oroantral fistula closure, sinus lifting, and autogenous bone grafting for dental implant placement. Oral Surg Oral Med Oral

10.

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Pathol Oral RadiolEndod 105:707, 2008.

Quayle AA: A double flap technique for the closure of oronasal and oroantral fistulae. Br J Oral Surg 19:132, 1981.

11.

Toshihiro Y, Nariai Y, Takamura Y, Yoshimura H, Tobita T, Yoshino A, Tatsumi

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H, Tsunematsu K, Ohba S, Kondo S, Yanai C, Ishibashi H, Sekine J: Applicability of buccal fat pad grafting for oral reconstruction. Int J Oral MaxillofacSurg 42:604, 2013.

Candamourty R, Jain MK, Sankar K, Babu MR: Double-layered closure of

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oroantral fistula using buccal fat pad and buccal advancement flap. J Nat SciBiol

13.

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Med 3:203, 2012.

Batra H, Jindal G, Kaur S: Evaluation of different treatment modalities for closure of oroantral communications and formulation of a rational approach. J Oral MaxillofacSurg 9:13, 2010.

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14.

Lee BK: One-stage operation of large oroantral fistula closure, sinus lifting, and autogenous bone grafting for dental implant placement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod105:707, 2008. Ahmed MS, Askar NA: Combined bony closure of oroantral fistula and sinus lift

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15.

with mandibular bone grafts for subsequent dental implant placement. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 111:e8, 2011.

Chackoa JP, Josepha C, Jamesb H: Technical note Turn over flap for longstanding

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16.

oroantral fistula closure. J Oral MaxillofacSurg Med Patholo 25:24, 2013. Baĭdik OD, LogvinovSV, Zubarev SG, Sysoliatin PG, Gurin AA: Structure of

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17.

maxillary sinus mucous membrane under normal conditions and in odontogenic perforative sinusitis. Morfologiia 139:49, 2011. [Article in Russian] 18.

Dergin G, Gurler G, Gursoy B: Modified connective tissue flap: a new approach

19.

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to closure of an oroantral fistula. Br J Oral MaxillofacSurg 45:251, 2007. Abuabara A, Cortez AL, Passeri LA, de Moraes M, Moreira RW: Evaluation of different treatments for oroantral/oronasal communications: experience of 112

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cases. Int J Oral MaxillofacSurg 35:155, 2006.

Fig. (1) Intraoperative photographs showing A) the use of a needle to determine the bone boundaries of the fistula, B) the circular incision around the fistula and its reflection from the bony walls, C) the purse suturing of the fistulous tract, and D) the upward pushing of the sutured tissues.

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Fig. (2) Intraoperative photographs showing A) the mucoperiosteal palatal rotational flap was designed and reflected and B) the flap was rotated and sutured to the buccal tissues.

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Fig. (3) Postoperative photograph demonstrating soft tissue healing of the flap and the presence of rugae area on the crest of the ridge.

Table I: Summary of study variables for the entire sample Descriptive statistics

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Study variable Sample size

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Sex: male

9 (75%)

35±10.829

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Age Size

10.9±1.88 19.9±50.536

Duration Anatomical location 2nd premolar 1st molar 2nd molar

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Sinus disease Clinical Radiographic

3(25%) 7(58.3%) 2(16.7%)

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Associate signs and symptoms Unhealed socket with: Polyp emerged from socket Nasal regurgitation of fluid Pus in socket Remaining root in sinus Pain related to side

Previous attempts for closure by another surgeon

100% Infected 100% Opacification

12 (100%) 5 (41.7%) 3(25%) 2(16.7%) 1(8.3%) 1(8.3%) 4 (33.3%)

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Variable Gender: Male Female

2 (100%) 0

7 (70%) 3 (80%)

1(50%) 1(50%) 0

2 (20%) 6 (60%) 2(20%)

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Anatomical location 2nd premolar 1st molar 2nd molar Age Surgical time (minutes)

34.5±0.707

35.1±11.96

150±14.14

90.3 ±6.037

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*Tearing of fistulous tract during suturing. †Sig: significant.

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Complication* (no) n=10

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Complication* (yes) n=2

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Table II: Summary of predictor variables for the entire sample

p- value 0.371 no sig.†

0.598 no sig.

0.947 no sig. 0.001 highly sig.

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Table III: Summary of the postoperative complication variables

1 (8.3%) 2(16.7%) 1 (8.3%)

Late Bulging of the flap Infraorbital neuropathy

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1(8.3%) 2(16.7)

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Descriptive statistics

Variable Immediate Air and fluid escape Teeth encroachment on the flap Acute sinusitis

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