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Modified double-layered flap technique for closure of an oroantral fistula: Surgical procedure and case report
ARTICLE IN PRESS
YBJOM-4921; No. of Pages 3
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Short communication
Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report Alberto Merlini a , Joseph Garibaldi a , Matteo Piazzai a , Luca Giorgis b,∗ , Paolo Balbi a a b
Department of Odontostomatology, Galliera Hospital, Genoa, Italy Private Practitioner, Chiavari, Genoa, Italy
Accepted 15 June 2016
Abstract Several techniques have been used to close oroantral communications, and they vary in their difficulty of execution and success. We present the “modified double-layered flap technique”, which is similar to the treatment of labiopalatoschisis, has a high rate of success that is dependent on the skill of the surgeon, and will involve a steep learning curve. © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: oroantral communication; oroantral fistula; double-layered flap; modified double-layered flap
Introduction
Operative technique
Oroantral communications are caused by odontogenic inflammatory processes, (which can cause progressive destruction of either the floor or side of the maxillary sinus), or by iatrogenic manoeuvres such as dental extractions, or even avascular necrosis (osteonecrosis) as a result of the use of bisphosphonates.1–3 We describe a variation of the double-layered flap that evolved from our clinical experience of about 25 patients over the past 10 years, and we have named this the “double-layered palatal or buccal flap”.
First we raise a full-thickness, trapezoidal flap from the buccal side of the oral mucosa and remove all muscular insertions to allow the flap to be repositioned on the palatal side to close the fistula. We then need to raise a half-thickness flap on the palatal side, which must be much larger than the fistula, allowing for a switch to a full-thickness flap close to it to permit full skeletonisation. This is done to allow better rotation of the flap, and reduces the risk of ischaemia. We anchor the palatal margin of the flap as deeply as possible with a “U” suture under the oral mucosa of the buccal fornix (Fig. 1). This is the first and inner part of the doublelayered flap, and the second part comes from the buccal flap, which is then sewn on to the exposed side of the palatal submucosa. The main advantage of this technique is the buccal flap, which completely covers the fistula and allows for initial healing (Fig. 2). The main change from the traditional technique is that the flap is made to be both longer and wider than the fistula, which makes suturing easier and reduces trauma
∗
Corresponding author. E-mail addresses: [email protected] (A. Merlini), [email protected] (J. Garibaldi), [email protected] (M. Piazzai), [email protected] (L. Giorgis), [email protected] (P. Balbi).
http://dx.doi.org/10.1016/j.bjoms.2016.06.011 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Merlini A, et al. Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.06.011
ARTICLE IN PRESS
YBJOM-4921; No. of Pages 3
2
A. Merlini et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Fig. 3. The resolved oroantral communication a month later. Fig. 1. The palatal margin of the flap anchored with a “U” suture.
Fig. 2. The final suture.
to both the buccal and palatal sides. In addition, both flaps have excellent vascularisation because of their anatomical origins, so the healing process is faster with a decreased risk of ischaemic complications and relapse. To make all of this possible, we must correctly raise the half-thickness palatal flap, identify the crestal bone in the vicinity of the fistula, (where the cut must be deep to allow its rotation), and mobilise the buccal flap sufficiently to cover the entire area of the palatal incision and provide adequate vascularisation.
We saw that it was producing pus and was easily seen on Valsalva manoeuvre, so we decided to treat the infection with aerosols of thiamphenicol glycinate acetylcysteinate before we operated. We raised a full-thickness trapezoidal flap on the buccal side which, after being released from muscular adherences, was revolved on to the palatal side. We made sure that the half-thickness palatal flap reached easily and slid it into the buccal side to cover the fistula, and then sutured it as deeply as possible to the buccal flap. The buccal flap was then anchored to the zone of free mucosa that had been left open in the palate. In this way the buccal flap was on the external side, the palatal flap was on the inner side, and vascularisation was maintained from the palate. We decided to remove some of the stitches after a week to soften the tension on the tissue to avoid ischaemic complications, and the rest after another week. At the first check up one month later the communication had completely resolved, which marked a full remission of the fistula (Fig. 3).
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission Ethical approval was not required. There are no pictures in which the patient is identifiable.
Case report
Acknowledgments
An 87-year-old man was referred to us after he had had a full-mouth extraction and had developed an alveolar sinus communication in the second quadrant.
We would like to give special thanks to Simona Cavani, Executive Biologist, Laboratory of Human Genetics, Galliera Hospital, for the Illustrations.
Please cite this article in press as: Merlini A, et al. Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.06.011
YBJOM-4921; No. of Pages 3
ARTICLE IN PRESS A. Merlini et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
References 1. Sandhya G, Reddy PB, Kumar KA, et al. Surgical management of oro-antral communications using resorbable GTR membrane and FDMB sandwich technique: a clinical study. J Maxillofac Oral Surg 2013;12:254–9.
3
2. Visscher SH, van Minnen B, Bos RR. Closure of oroantral communications using biodegradable polyurethane foam: a feasibility study. J Oral Maxillofac Surg 2010;68:281–6. 3. Mast G, Otto S, Mücke T, et al. Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw. J Craniomaxillofac Surg 2012;40:568–71.
Please cite this article in press as: Merlini A, et al. Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.06.011
YBJOM-4921; No. of Pages 3
Available online at www.sciencedirect.com
ScienceDirect British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Short communication
Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report Alberto Merlini a , Joseph Garibaldi a , Matteo Piazzai a , Luca Giorgis b,∗ , Paolo Balbi a a b
Department of Odontostomatology, Galliera Hospital, Genoa, Italy Private Practitioner, Chiavari, Genoa, Italy
Accepted 15 June 2016
Abstract Several techniques have been used to close oroantral communications, and they vary in their difficulty of execution and success. We present the “modified double-layered flap technique”, which is similar to the treatment of labiopalatoschisis, has a high rate of success that is dependent on the skill of the surgeon, and will involve a steep learning curve. © 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: oroantral communication; oroantral fistula; double-layered flap; modified double-layered flap
Introduction
Operative technique
Oroantral communications are caused by odontogenic inflammatory processes, (which can cause progressive destruction of either the floor or side of the maxillary sinus), or by iatrogenic manoeuvres such as dental extractions, or even avascular necrosis (osteonecrosis) as a result of the use of bisphosphonates.1–3 We describe a variation of the double-layered flap that evolved from our clinical experience of about 25 patients over the past 10 years, and we have named this the “double-layered palatal or buccal flap”.
First we raise a full-thickness, trapezoidal flap from the buccal side of the oral mucosa and remove all muscular insertions to allow the flap to be repositioned on the palatal side to close the fistula. We then need to raise a half-thickness flap on the palatal side, which must be much larger than the fistula, allowing for a switch to a full-thickness flap close to it to permit full skeletonisation. This is done to allow better rotation of the flap, and reduces the risk of ischaemia. We anchor the palatal margin of the flap as deeply as possible with a “U” suture under the oral mucosa of the buccal fornix (Fig. 1). This is the first and inner part of the doublelayered flap, and the second part comes from the buccal flap, which is then sewn on to the exposed side of the palatal submucosa. The main advantage of this technique is the buccal flap, which completely covers the fistula and allows for initial healing (Fig. 2). The main change from the traditional technique is that the flap is made to be both longer and wider than the fistula, which makes suturing easier and reduces trauma
∗
Corresponding author. E-mail addresses: [email protected] (A. Merlini), [email protected] (J. Garibaldi), [email protected] (M. Piazzai), [email protected] (L. Giorgis), [email protected] (P. Balbi).
http://dx.doi.org/10.1016/j.bjoms.2016.06.011 0266-4356/© 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Merlini A, et al. Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.06.011
ARTICLE IN PRESS
YBJOM-4921; No. of Pages 3
2
A. Merlini et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
Fig. 3. The resolved oroantral communication a month later. Fig. 1. The palatal margin of the flap anchored with a “U” suture.
Fig. 2. The final suture.
to both the buccal and palatal sides. In addition, both flaps have excellent vascularisation because of their anatomical origins, so the healing process is faster with a decreased risk of ischaemic complications and relapse. To make all of this possible, we must correctly raise the half-thickness palatal flap, identify the crestal bone in the vicinity of the fistula, (where the cut must be deep to allow its rotation), and mobilise the buccal flap sufficiently to cover the entire area of the palatal incision and provide adequate vascularisation.
We saw that it was producing pus and was easily seen on Valsalva manoeuvre, so we decided to treat the infection with aerosols of thiamphenicol glycinate acetylcysteinate before we operated. We raised a full-thickness trapezoidal flap on the buccal side which, after being released from muscular adherences, was revolved on to the palatal side. We made sure that the half-thickness palatal flap reached easily and slid it into the buccal side to cover the fistula, and then sutured it as deeply as possible to the buccal flap. The buccal flap was then anchored to the zone of free mucosa that had been left open in the palate. In this way the buccal flap was on the external side, the palatal flap was on the inner side, and vascularisation was maintained from the palate. We decided to remove some of the stitches after a week to soften the tension on the tissue to avoid ischaemic complications, and the rest after another week. At the first check up one month later the communication had completely resolved, which marked a full remission of the fistula (Fig. 3).
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient’s permission Ethical approval was not required. There are no pictures in which the patient is identifiable.
Case report
Acknowledgments
An 87-year-old man was referred to us after he had had a full-mouth extraction and had developed an alveolar sinus communication in the second quadrant.
We would like to give special thanks to Simona Cavani, Executive Biologist, Laboratory of Human Genetics, Galliera Hospital, for the Illustrations.
Please cite this article in press as: Merlini A, et al. Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.06.011
YBJOM-4921; No. of Pages 3
ARTICLE IN PRESS A. Merlini et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx
References 1. Sandhya G, Reddy PB, Kumar KA, et al. Surgical management of oro-antral communications using resorbable GTR membrane and FDMB sandwich technique: a clinical study. J Maxillofac Oral Surg 2013;12:254–9.
3
2. Visscher SH, van Minnen B, Bos RR. Closure of oroantral communications using biodegradable polyurethane foam: a feasibility study. J Oral Maxillofac Surg 2010;68:281–6. 3. Mast G, Otto S, Mücke T, et al. Incidence of maxillary sinusitis and oro-antral fistulae in bisphosphonate-related osteonecrosis of the jaw. J Craniomaxillofac Surg 2012;40:568–71.
Please cite this article in press as: Merlini A, et al. Modified double-layered flap technique for closure of an oro-antral fistula: Surgical procedure and case report. Br J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.06.011