Dental Tribune Middle East & Africa Edition

A Comparison between Submucosal Connective Tissue Palatal Flap and Conventional Pedicle Palatal Flap for the Closure of Oroantral Fistulae by Dr. Feras Yabroudi Abstract B ackground and Aim: Oroantral communication and subsequent formation of oroantral fistula is a common complication of dental ex- traction and/or other oro-facial surgeries. Many surgical procedures have been used for the treatment of oroantral fistula, and it is believed that long term successful clo- sure of oroantral fistula depends on the technique used, the size and the location of the defect. The aim of this study is to eval- uate the success of the submucosal connec- tive tissue palatal flap technique compared to the conventional pedicled palatal flap technique in the closure of oroantral fistula. Materials and Methods: Ten patients suf- fering from oroantral fistula were recruit- ed in the study, and they were divided into two groups. The first group was treat- ed with the conventional pedicled palatal flap technique, and the second group was treated with the submucosal connective tis- sue flap technique. Suitable post-operative care and observation in both groups were achieved. Results: It has been shown that all fistulae were closed successfully in both groups. There was no discomfort and no burning sensation in the second group. They all showed relatively fast healing. Interest- ingly, patients in the second group needed fewer amounts of post-operative analgesics than in the first group. Conclusion: Both types of flap techniques provided sufficient and successful closure of oroantral fistula. However, submuco- sal connective tissue palatal flap seems to be preferable for fistula closure because it overcomes the disadvantages of the full thickness palatal flap. Compared with the conventional palatal flap, submucosal con- nective tissue palatal flap technique may appear to be more difficult in terms of flap manipulation. The surgical experience plays an important role at this level. Key words: oroantral fistula, palatal flap, tooth extraction Introduction Oroantral fistula (OAF) is the communica- tion between the maxillary sinus cavity and the oral cavity through a perforation in the sinus wall. The term oroantral communication com- prises two pathological conditions; the acute oroantral perforation and the chronic communication ‘‘fistula’’1 . Oroantral communication and subsequent formation of OAF is a common complica- tion of dental extraction. Owing to its ana- tomical location and intimate relationship with the teeth, the maxillary sinus occupies an important place in oral surgery. From a small cavity at birth, the maxillary sinus starts to enlarge during the third month of fetal life and usually reaches maximum de- velopment around the eighteenth year. Its volume is approximately 20-25ml in a nor- mal adult. The removal of the first upper molar is the most common etiological fac- tor which may lead to OAF2 . Some pathological conditions that might also cause oroantral communication are: removal of tumors or cysts of the palate, cases of noma, syphilitic gumma, leprosy, and lishmaniasis3 . An OAF usually needs 7 days to epithelize and become a chronic fistulous tract4 . Long term successful closure of OAF de- pends on the technique used, the size and the location of the defect2 . Many surgical procedures have been used for the treatment of OAF3 such as: • Buccal flaps • Pedicle tongue flap • Combined buccal and reverse palatal flap • Pedicle buccal fat pad graft • Palatal pedicle flaps Several materials can also be used to en- hance a successful closure under the flap like bone or cartilaginous grafts, gold foil, and biodegradable ceramic5 . The optimal operative procedure to ac- complish closure of OAF ought to fulfill the following requirements: 1) Be applicable in most cases 2) Have minimal incidence of failure 3) Be relatively simple 4) Does not require removal of additional teeth or bone tissues The most common flaps used in the closure of OAF are the buccal flaps and the palatal flap with its modifications. Buccal flaps are successfully used in the clo- sure of OAF. Care must be taken to avoid injury to the parotid papilla or duct. Al- though the buccal flap is technically a sim- ple procedure, yet it has the following dis- advantages: 1) it is thin, 2) there is tenden- cy to obliterate the muco-buccal fold, and 3) it is unstable due to cheek movements5 . The palatal flap with its modifications re- sults in successful closure of the fistula. The palatal mucosa is much thicker and firmer than the buccal mucosa or cheek, and a flap can be designed that is well nourished by the blood vessels emerging from the ante- rior palatine foramen (greater palatine ar- tery)4 . Pedicled palatal flap closes the OAF with- out reduction in the depth of the buccal vestibule. However, rotation of the pala- tal mucoperiosteum flap leaves a raw area on the palate until secondary epithelization occurs and a bulge of soft tissue is creat- ed at the axis of rotation6. In trials to over- come these problems, submucosal connec- tive tissue palatal flap technique was used successfully and provided mucosal flap to cover the raw area7 . The aim of this study is to evaluate the suc- cess of the submucosal connective tissue palatal flap compared to the conventional pedicled palatal flap in the closure of OAF. Materials and Methods Ten patients suffering from OAF were re- cruited in the study. They were collected from the private clinic of Oral surgery and were divided into two groups; G1 and G2. Each group contained five patients. The first group was treated with the conven- tional pedicled palatal flap technique, and the second group was treated with the sub- mucosal connective tissue flap technique. A comprehensive history was collected from the patients considering the cause and onset of OAF, and about the duration of the condition. The clinical examination of the patients in- cluded the observation of remarkable fea- tures such as: regurgitation of liquids from the mouth into the nose, which is the most common complaint, unilateral epistaxis, al- teration in the resonance of the voice, in- ability to blow-out the cheek, difficulty in smoking, and/or foul or salty unpleasant taste. X-ray examinations revealed the presence of a fistulous tract connecting the oral cavi- ty with the maxillary sinus. After suitable anesthesia, in both groups of patients, the OAF was prepared by excising the epithelium from its margins and by un- dermining the mucoperiosteum on its buc- cal aspect, followed by removal of diseased bone if present, so that the flap would rest on healthy bone tissue and thus enhance successful closure. The first group (G1) was treated by conven- tional pedicled palatal flap (also known as palatal rotation advancement flap). Briefly, the flap was extending anterior and large enough with the base of the pedicle over the greater palatine foramen. The flap start- ed approximately in the middle between the gingival margin and the median pala- tine raphe. This flap is rotated across the fistula so that its anterior suture line rests on sound bone on the buccal side of the fis- tula (Figures 1 and 2). The second group (G2) was treated by pal- atal submucosal flap. This technique is con- sidered as a modification of the previous procedure and was achieved by separating the full thickness palatal flap into a muco- sal layer and an underlying connective tis- sue layer. The submucosal connective tissue flap was used to close the fistula, and the mucosal part of this flap is then returned to its orig- inal position and sutured in place to obtain primary closure (Figures 3 and 4). The patients were post-operatively in- structed to avoid any actions which may cause negative or positive pressure inside the sinus (e.g. drinking tubes, blowing the nose, sneezing with opened mouth, etc…). Antibiotics were also prescribed to avoid infection for 5-7 days, and analgesics to re- lieve pain. Decongestant nasal drops and inhalants to shrink the nasal mucosa and promote healing were advised, as well as normal saline mouth washes after 24 hour post-operatively. Sutures were removed af- ter 10-12 days post-operatively. Immediate evaluation of the surgical pro- cedure and consequences was done at the day of the operation after complete recov- ery and then one day after the operation through clinical objective findings includ- ing: 1) Bleeding (ranging from no bleeding to active bleeding), and 2) Pain; could be evaluated by the amount of analgesics con- sumed per day. Late post-operative evaluation was con- ducted in the follow-up once a week up to 4 weeks. The evaluation included: healing, the color of the flap, texture of the tissue, integrity of the suture line, signs of flap ep- ithelialization, infection, pain, headache, numbness of the operated area, fistulae re- currence (if recurrence occurred, it would appear at the time of suture removal and not later), posterior nasal discharge and/or maxillary sinusitis, chewing and swallow- ing difficulties, and speech problems. Results Clinical results in G1 During the immediate post operative peri- od, all patients were complaining of pain and burning sensation with discomfort during chewing and swallowing. The ear- ly postoperative period started directly af- ter the end of the operation till the end of the first week. All patients showed slight bleeding in the early post operative few hours. The late observation period extended for three months. By the end of the second month the flap was healed and the raw area was covered and there was no complaint from the patient. Clinical results in G2 During the immediate post operative peri- od there was no bleeding at all, no discom- fort during eating, which might be present- ed due to the absence of bulky palatal soft tissue mass, no raw area, and no burning sensation. The late observation period showed that the fistula was completely closed in all the patients at the time of suture removal. The edges of the flap were healed, and the gran- ulation tissue changed into a firmer granu- lation tissue during the second week and it became completely epithelialized, with slight contraction and shrinkage. By the end of the third week the submucosal lay- er became completely healed and its color Fig. 1: Preoperative photograph of fistula with 1 month duration. Fig. 2: Rotation of the palatal flap to cover the defect. Fig. 3: Preoperative photograph of fistu- la with 2 year-duration Fig. 1: Preoperative photograph of fistula with 1 month duration Fig. 2: Rotation of the palatal flap to cover the defect Fig. 3: Preoperative photograph of fistula with 2 year-duration Fig. 1: Preoperative photograph of fistula with 1 month duration Fig. 2: Rotation of the palatal flap to cover the defect Fig. 3: Preoperative photograph of fistula with 2 year-durationFig. 1: Preoperative photograph of fistula with 1 month duration Fig. 2: Rotation of the palatal flap to cover the defect Fig. 3: Preoperative photograph of fistula with 2 year-duration 24 Dental acaDeMia triBUne Dental tribune Middle East & Africa Edition | March-April 2013