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The use of an osteoperiosteal flap to close oroantral fistulas
CLOSURE OF TMJ MENISCOPLASTY
meeting the initial portion of the suture in the middle of the wound (Fig. 4). At this point, the suture is drawn snug and tied, burying the knot (Fig. 5). The suture presently being used is 4-OMersilene on an S-2 spatula needle.7 However, a 5-O Dacron suture on the same needle is now being developed. These sutures can be placed every 2 mm for a tight closure that will resist not only the immediate post-
operative testing of the incision but also normal mandibular function.
References 1. Farrar WB: Letter to the editor. J Am Dent Assoc 102:10, 1981 2. McCarty WL, Farrar WB: Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 42:191, 1979 3. Wilkes C: Personal communication 4. Dolwick MF: Personal communication
? Catalog No. 1779, ETHICON, INC., Somerville, N.J.
The Use of an Osteoperiosteal Flap to Close Oroan tral Fistulas ROBERTO
BRUSATI,
MD*
A method for closure of oroantral fistulas is presented that uses an osteoperiosteal flap with a posteriorly located pedicle that is rotated downward beneath the usual vestibular mucoperiosteal flap. With this method, reconstruction of the bone fistula is obtained, the degree of postoperative alveolar bone atrophy is reduced, and the success rate of the repair is further increased.
further decrease the possibility of failure of the operation, we employ an osteoperiosteal flap in association with the usual vestibular mucoperiosteal flap (Figs. 1 and 2).
The closure of oroantral fistulas does not usually present particular problems, and a high success rate (95%) is obtainable whenever a wide vestibular mucoperiosteal flap is used.‘,” However, especially when the bone perforation is particularly large, accentuated atrophy of the vestibular bony wall of the alveolus and healing of the bone perforation without osseous regeneration is often observed after the operation. This can be accompanied by serious deformation of the alveolar process, with a noticeable reduction of the depth of the fornix, which is particularly undesirable from the prosthetic point of view. To prevent such drawbacks, to obtain proper bone formation wherever bone should be present, and to
Technique After the customary incision has been performed and the vestibular mucoperiosteal flap has been raised to the level of the dental apices, the perios-
* Head. Received from the Department of Maxillofacial Surgery, University of Parma, Italy. Address correspondence and reprint requests to Dr. Brusati, Divisione di Chirurgia Maxillo-Facciale, Universitl Degli Studi di Parma, Parma, Italy.
FIGURE 1. LB, Preoperative view of orantral fistula. FIGURE 2. Right, Despite the appearance on intraoral e&u&nation, the radiograph reveals a large bony defect.
0278-2391/82/0400/0250 $00.40 @ American Association of Oral and Maxillofacial Surgeons
250
251
BRUSATI
FIGURE 3. Left, Mobilized osteoperiosteal flap. Notice size of tistula. FIGURE 4. Center, The posteriorly based osteoperiosteal flap is rotated downward and positioned to close the alveolar bony defect. FIGURE 5. Right, The mucoperiosteal flap is sutured over the area.
teum is cut horizontally to permit further elevation of the flap. The dissection proceeds superiorly to expose the lateral wall of the maxillary sinus, which remains covered by periosteum. Once the area has been localized in which the operculum is to be performed in order to permit access to the sinus, the periosteum is cut with a U-shaped incision, the U being placed horizontally with the arms directed posteriorly and diverging to widen the base of the flap. With a fine bur, the bony wall of the maxillary sinus is cut superiorly, anteriorly, and inferiorly. The bony flap is then levered with a periosteal elevator, and the remaining posterior one fourth of its circumference is fractured. Close attention being paid that the bony flap remains connected to its periosteal cover, the periosteal pedicle is gently elevated from the maxillary surface posteriorly (Fig. 3). In this way, mobilization of the osteoperiosteal flap is obtained so that the bony fragment can be transported to the level of the alveolar process to cover the bone fistula (Fig. 4). Once any necessary antral procedure has been performed and the fistula has been prepared, the reconstructive phase can begin. The bony flap is shaped with a small rongeur to the dimensions of the oroantral tistula. After the osteoperiosteal flap has been positioned, it can be held in place with a suture that exits through the palatal mucosa at a distance from its free margin. The vestibular mucoperiosteal flap is finally sutured according to the standard
The healed area is characterized by good FIGURE 6. alveolar structure and a deep vestibular sulcus. FIGURE 7. Right, Radiograph taken at six months shows ossification of the bony fistula.
Discussion The possibility of making an osteoperiosteal flap at the level of the maxillary sinus has been described by Abello, Akuamoa-Boateng,4 and Mela. These authors, after having performed the classic sinus operation, have repositioned the osteoperiosteal flap in the original place to avoid the drawbacks caused by the wide opening of the lateral wall of the antrum. By modification of the site of the base of the periosteal flap, the possibility of transporting the bone flap to a considerable distance from its original place, and of using such a flap to better repair an oroantral fistula, seemed feasible. This has encouraged us to experiment with the technique described. The advantages of such a procedure, biologically sound insofar as it reconstructs bone with bone and mucosa with mucosa, are a reduction of the failure rate of repair, because of the use of two biologic and vital layers for tissue closure, the reduction in postoperative alveolar vestibular bone atrophy, and the osseous closure of the bone tistula. The procedure does not entail any obstacles, and it prolongs the operation for only a few minutes.
References 1. Rehrmann A: Eine Methode zur Schhessung von Kieferhohlen Perforationen. Msch Zahnaerzth Wochenschr 48: 1136, 1936 2. Killey H, Kay L: An analysis of 250 cases of oro-antral fistula treated by the buccal flap operation. Oral Surg 24:726, 1967 3. Abe110 P: La trepanation en opercule du sinus maxillaire. Rev Laryngol79:747, 1958 4. Akuamoa-Boateng E: Reconstruction of the facial fenestration with a whole thickness mucosa-muscle-periostealbone flap. Abstracts of the European Association of Maxillofacial Surgeons Fourth Congress, Venice, 1978. p 120 5. Mela F: Conservazione deha parete anteriore mediante Ia tecnica della “botola” negli interventi sul seno mascellare. In Monduzzi (ed): Chirurgia Maxiho-Facciale, Atti de1 Congresso Italiano di Chirurgia Maxillo-Facciale, Saint Vincent 1979. Bologna, 1980, p 281
meeting the initial portion of the suture in the middle of the wound (Fig. 4). At this point, the suture is drawn snug and tied, burying the knot (Fig. 5). The suture presently being used is 4-OMersilene on an S-2 spatula needle.7 However, a 5-O Dacron suture on the same needle is now being developed. These sutures can be placed every 2 mm for a tight closure that will resist not only the immediate post-
operative testing of the incision but also normal mandibular function.
References 1. Farrar WB: Letter to the editor. J Am Dent Assoc 102:10, 1981 2. McCarty WL, Farrar WB: Surgery for internal derangements of the temporomandibular joint. J Prosthet Dent 42:191, 1979 3. Wilkes C: Personal communication 4. Dolwick MF: Personal communication
? Catalog No. 1779, ETHICON, INC., Somerville, N.J.
The Use of an Osteoperiosteal Flap to Close Oroan tral Fistulas ROBERTO
BRUSATI,
MD*
A method for closure of oroantral fistulas is presented that uses an osteoperiosteal flap with a posteriorly located pedicle that is rotated downward beneath the usual vestibular mucoperiosteal flap. With this method, reconstruction of the bone fistula is obtained, the degree of postoperative alveolar bone atrophy is reduced, and the success rate of the repair is further increased.
further decrease the possibility of failure of the operation, we employ an osteoperiosteal flap in association with the usual vestibular mucoperiosteal flap (Figs. 1 and 2).
The closure of oroantral fistulas does not usually present particular problems, and a high success rate (95%) is obtainable whenever a wide vestibular mucoperiosteal flap is used.‘,” However, especially when the bone perforation is particularly large, accentuated atrophy of the vestibular bony wall of the alveolus and healing of the bone perforation without osseous regeneration is often observed after the operation. This can be accompanied by serious deformation of the alveolar process, with a noticeable reduction of the depth of the fornix, which is particularly undesirable from the prosthetic point of view. To prevent such drawbacks, to obtain proper bone formation wherever bone should be present, and to
Technique After the customary incision has been performed and the vestibular mucoperiosteal flap has been raised to the level of the dental apices, the perios-
* Head. Received from the Department of Maxillofacial Surgery, University of Parma, Italy. Address correspondence and reprint requests to Dr. Brusati, Divisione di Chirurgia Maxillo-Facciale, Universitl Degli Studi di Parma, Parma, Italy.
FIGURE 1. LB, Preoperative view of orantral fistula. FIGURE 2. Right, Despite the appearance on intraoral e&u&nation, the radiograph reveals a large bony defect.
0278-2391/82/0400/0250 $00.40 @ American Association of Oral and Maxillofacial Surgeons
250
251
BRUSATI
FIGURE 3. Left, Mobilized osteoperiosteal flap. Notice size of tistula. FIGURE 4. Center, The posteriorly based osteoperiosteal flap is rotated downward and positioned to close the alveolar bony defect. FIGURE 5. Right, The mucoperiosteal flap is sutured over the area.
teum is cut horizontally to permit further elevation of the flap. The dissection proceeds superiorly to expose the lateral wall of the maxillary sinus, which remains covered by periosteum. Once the area has been localized in which the operculum is to be performed in order to permit access to the sinus, the periosteum is cut with a U-shaped incision, the U being placed horizontally with the arms directed posteriorly and diverging to widen the base of the flap. With a fine bur, the bony wall of the maxillary sinus is cut superiorly, anteriorly, and inferiorly. The bony flap is then levered with a periosteal elevator, and the remaining posterior one fourth of its circumference is fractured. Close attention being paid that the bony flap remains connected to its periosteal cover, the periosteal pedicle is gently elevated from the maxillary surface posteriorly (Fig. 3). In this way, mobilization of the osteoperiosteal flap is obtained so that the bony fragment can be transported to the level of the alveolar process to cover the bone fistula (Fig. 4). Once any necessary antral procedure has been performed and the fistula has been prepared, the reconstructive phase can begin. The bony flap is shaped with a small rongeur to the dimensions of the oroantral tistula. After the osteoperiosteal flap has been positioned, it can be held in place with a suture that exits through the palatal mucosa at a distance from its free margin. The vestibular mucoperiosteal flap is finally sutured according to the standard
The healed area is characterized by good FIGURE 6. alveolar structure and a deep vestibular sulcus. FIGURE 7. Right, Radiograph taken at six months shows ossification of the bony fistula.
Discussion The possibility of making an osteoperiosteal flap at the level of the maxillary sinus has been described by Abello, Akuamoa-Boateng,4 and Mela. These authors, after having performed the classic sinus operation, have repositioned the osteoperiosteal flap in the original place to avoid the drawbacks caused by the wide opening of the lateral wall of the antrum. By modification of the site of the base of the periosteal flap, the possibility of transporting the bone flap to a considerable distance from its original place, and of using such a flap to better repair an oroantral fistula, seemed feasible. This has encouraged us to experiment with the technique described. The advantages of such a procedure, biologically sound insofar as it reconstructs bone with bone and mucosa with mucosa, are a reduction of the failure rate of repair, because of the use of two biologic and vital layers for tissue closure, the reduction in postoperative alveolar vestibular bone atrophy, and the osseous closure of the bone tistula. The procedure does not entail any obstacles, and it prolongs the operation for only a few minutes.
References 1. Rehrmann A: Eine Methode zur Schhessung von Kieferhohlen Perforationen. Msch Zahnaerzth Wochenschr 48: 1136, 1936 2. Killey H, Kay L: An analysis of 250 cases of oro-antral fistula treated by the buccal flap operation. Oral Surg 24:726, 1967 3. Abe110 P: La trepanation en opercule du sinus maxillaire. Rev Laryngol79:747, 1958 4. Akuamoa-Boateng E: Reconstruction of the facial fenestration with a whole thickness mucosa-muscle-periostealbone flap. Abstracts of the European Association of Maxillofacial Surgeons Fourth Congress, Venice, 1978. p 120 5. Mela F: Conservazione deha parete anteriore mediante Ia tecnica della “botola” negli interventi sul seno mascellare. In Monduzzi (ed): Chirurgia Maxiho-Facciale, Atti de1 Congresso Italiano di Chirurgia Maxillo-Facciale, Saint Vincent 1979. Bologna, 1980, p 281