Dental Tribune Middle East & Africa Edition

cessful when primary healing had occurred at the time of suture removal19 . In our study ten cases of OAF were treated with two different types of palatal flaps, all fistulas had successfully closed without re- currence, primary healing had occurred at the time of suture removal. In all of the cas- es, neither nasal antrostomy, nor Caldwell- Luc procedure was used. Adequate sinus cleansing was performed by applying irrigation with antibiotics for at least five days, accompanied by vaso- constrictive nasal drops after complete ex- cision of the epithelial lining of the fistula track through the bone defect toward the maxillary sinus, and removal of all patho- logically-changed maxillary sinus mucosal tissues. Further support to our technique was giv- en by Car and Juretic (1998) who achieved successful closure in 38 cases of chron- ic OAF by treating them with antibiotics and without drainage of the maxillary si- nus into the nose20 . They also mentioned that Caldwell-Luc drainage into the nose prolonged the procedure and made it more difficult. Moreover, postoperative oedema and hematoma were more pronounced. Various palatal flap techniques based on the position of the greater palatine vessels have been advocated. These can be divid- ed into advancement flaps and rotation ad- vancement flaps. Straight advancement flaps do not offer great mobility for later- al coverage5, 16, 21-22 . Palatal rotation advancement flaps require mobilization of large amounts of palatal tissue because of the inelasticity of the tis- sue. This flap also has the disadvantage of tissue bunching at the base and causing a large area of palatal bone to be exposed23 . This was further proven by results of our study, since all the patients of G1, who were treated with the palatal rotation ad- vancement flap, had discomfort during swallowing and talking due to the presence of soft tissue bulge in the palate, and burn- ing sensation from the raw bone area un- til complete epithelization. However, all of the patients in this group showed success- ful closure. Herbert (1974) pointed out that for a large fistula, when local tissue is unavailable, palatal tissue-dependent flap is the meth- od of choice. The palatal technique results in successful closure of the fistula with the maintenance of an adequate blood supply without reduction in the depth of the buc- cal maxillary vestibule. Anavi et al. (2003) gave further support for the palatal rotation full thickness flap24 . They concluded that the palatal rotation advancement flap is recommended for the late repair of OAF owing to its good vascu- larization, excellent thickness and easy ac- cessibility. It also allows the maintenance of the vestibular depth, and is particular- ly indicated in cases of unsuccessful buc- cal flap closure. Gullane and Arena (1998) provided the main advantages of the palatal mucoperi- osteal flap including a local tissue with good blood supply, excellent mobility, lim- ited impairment of speech and a success rate of 96%25 . These advantages compen- sate for the relatively prolonged period re- quired for epithelialization of the donor site over the hard palate. This was supported by our clinical obser- vation among the patients of G2, since all of them showed excellent closure of the fis- tula without any palatal soft tissue bulge. The connective tissue flap was extreme- ly elastic, enabling it to be rotated without tension. Another advantage is that the epi- thelial layer of the flap was returned to its original place to cover the donor area. This technique offered the patients minimal dis- comfort and also provided early healing of the wound, as there was no raw area left behind for granulation. After healing, the palatal mucosa and the recipient site were smooth without a hole or bunching. All our cases were observed periodically and didn’t reveal sinusitis after the surgi- cal closure. Conclusion According to the results of our observation, the following points could be concluded: 1. Both types of palatal flaps (conven- tional pedicle palatal flap and submuco- sal connective tissue palatal flap) provided enough well-nourished tissue for sufficient and successful closure of OAF (chronic or acute, large or small). 2. Nasoanterostomy is unnecessary in the closure of oroantral communications. 3. Preoperative preparation with antibiot- ics and good sinus irrigation is mandatory. 4. Submucosal connective tissue palatal flap seems to be preferable for fistula clo- sure because it overcomes the disadvantag- es of the full thickness palatal flap (e.g. cre- ation of soft tissue bulge and production of raw surface on the hard palate). 5. Connective tissue palatal flap offered the patients minimal discomfort, provid- ed early healing of the wound, and did not create esthetic disturbance due to absence of the palatal raw area or any soft tissue bulge. Surgical splints or dressing were not necessary. 6. Due to the advantages of the connec- tive tissue palatal flap, we believe that it is the safest procedure for the closure of OAF. However, compared with the convention- al palatal flap, submucosal connective tis- sue palatal flap technique may appear to be more difficult in terms of flap manipu- lation. The surgical experience plays an im- portant role at this level. Reference is available upon request. Please contact deyanov@dental-tribune.com Dr. Feras Yabroudi, B.D.S, M. Sc, Ph.D., Oral and Maxillofacial Surgeon, Assis- tant Professor Department of Oral & Maxillofacial Surgery, Nicolas & Asp University College, Dubai Healthcare City, Dubai, UAE. e-mail: drferasyabroudi@gmail.com Contact Information 26 Dental acaDeMia triBUne Dental tribune Middle East & Africa Edition | March-April 2013