Trauma; PreprostheticSurgery

Mohd Noor Awang

Closure of oroantral fistula Department of Oral Surgery, Faculty of
Dentistry, University of Malaya

M.N. Awang: Closure o f oroantral fistula. Int. J. Oral Maxillofac. Surg. 1988; 17:
110-115.

Abstract. Oroantral fistula is an uncommon complication in oral surgery. Al-

though smaller fistulas of less than 5 mm in diameter may close spontaneously,
larger fistulas always require surgical closures. The literature review revealed
various procedures for the closure of oroantral fistulas. These procedures may
be subdivided into local flap, distant flap and grafting. Procedures involving
local flaps are usually adequate to close minor to moderate size defects. Those
procedures utilizing the buccal mucoperiosteal flap as the tissue closure include
straight-advancement, rotated, sliding and transversal flap procedures; while
those involving the palatal mucoperiosteum are straight advancement, rotational-
advancement, hinged and island flap procedures. The combinations of various
local flaps to strengthen the tissue closure are also being advocated. The advantages
and the limitations of these procedures are discussed. Distant flaps and bone
grafts are usually indicated in the closure of larger defects in view of their greater
tissue bulks. Tongue flaps have superseded extra-oral flaps from extremities and
forehead for aesthetic reasons and also in view of their similar tissue replace-
ment. Various tongue flap procedures are described. At present, various alloplastic
materials such as gold, tantalum and polymethylmethacrylate are infrequently
reported in the closure of oroantral fistulas. However, in the light of successful
Key words: fistula, oroantral; sinusitis; flaps,
reports over the use o f biological materials, collagen and fibrin, in the closure oral mucosal
of oroantral fistulas, there seems to be another simple alternative technique for
treating oroantral fistulas. Accepted for publication 20 April 1987)

Perforation of maxillary sinus and
leading to the formation of oroantral
fistula is a relatively uncommon con-
dition. It may occur as a complication
of trauma, surgery, irradiation, infec-
tion, cyst or neoplasm. A fistula of
more than 5 mm in diameter usually
fails to close spontaneously and re-
quires proper surgical closure 36,46.
The closure of oroantral fistulas is
one of the more challenging and diffi-
cult problems in the field of oral sur-
gery. The literature is full of various
techniques ranging from simple to
more complex surgical procedures.
The choice of each of these procedures
is however influenced not only by the
size and location of the defect but also
by the amount and condition of the
tissue available for repair. It was un-
animously agreed that, regardless of
the surgical technique, successful clo-
sure of the oroantral fistula must be
preceded by the complete elimination
of sinus pathology and the fistulous
tract.
The purpose of this article is to re-
view the various surgical procedures of
oroantral closure which have been
constantly reported in the literature.
The advantages, problems and limi- parallel incisions in the periosteum at
tations of these techniques are hi- the base of the flap. TANNER et al. 5 re-
glighted. ported 60% success, while KmLEY &
KAY34achieved 97.2% success using this
procedure. This technique is simple and
Surgical techniques
well tolerated by the patient. Denture
The techniques of oroantral closure may be worn immediately since the
may be divided into the following pro- palatal mucosa is intact. The donor site
cedures: closes exactly with no raw area left be-
A. Local flaps; hind for granulation. It has been argued
B. Distant flaps; that this method reduces the buccal ves-
C. Grafts. tibular sulcus 54,55. WOWERN55 found out
that 40% of the cases have suffered per-
manent vestibular reduction. Others 33,34
A. Local flap procedures pointed out that the buccal sulcus re-
I. Buccal flaps
shapes within 4 to ~8 weeks following
Closure of minor defects can usually the closure. JUSELIUS KATIOKALLIO33
be accomplished by local flaps. Such indicated this approach in cases where
procedures often give excellent func- Caldwell-Luc operations have to be per-
tional results with minimum morbidity. formed at the same time. They success-
Various buccal mucoperiosteal flaps fully closed fistula measuring up to
have been described: these include ro- 22 x 15 mm by this method.
tated flap 5, advancement flap 33'34'42'54'55, MOCZAIR39 described a buccal sliding
sliding flap 39,55and transversal flap 17,24,44. trapezoidal flap procedure for closure
Rehrmann's technique is the com- of alveolar fistulas (Fig. 2). This tech-
mon buccal flap procedure for closure nique was later reviewed by WOWERN55
of minor alveolar fistula42, (Fig. 1). and HAANAES& PEDERSEN24. WOWERN55
Having a broad base, it ensures ad- pointed out that the change in the ves-
equate blood supply to the flap. The tibular sulcus is negligible by shifting
flap mobility is improved by making the flap one tooth distally. The disad-
 Oroantral fistula 111

does not offer much greater mobility for

lateral coverage. Thus, it is suitable for
closure of minor palatal or alveolar de-
fect. Palatal rotational-advancement
flap (Fig. 4) provides adequate mobility
and tissue bulk to the flap. However, it
r)) requires the mobilization of large
amount of palatal tissue, and it often
kinks following the rotation of the flap
which may predispose to venous con-
gestion. KRUGER36suggested a V-shaped
excision of the lesser curvature of the
Fig. 3. Transversal flap, (A). Bipedicle flap, flap to minimise folding (Fig. 4). CHOU-
(B). KAS13 left adequate tissue bridge for the
Fig. 1. Rehrmann's buccal advancement flap.
placement of the flap underneath this
The periosteum at the base of the flap is
longitudinally incised to facilitate the ad- tissue bridge with minimum tension
vancement of the flap. a labial vestibular bipedicle flap to close (Fig. 4).
a fistula in the anterior region (Fig. 3). ITO & HARA29described a submucosal
This flap has an advantage in that it connective tissue pedicle flap in 13 cases
obtains bilateral blood supply. In ad- of oroantral fistula with success (Fig. 5).
vantages of this procedure are that it dition, the donor site can be closed exac- Besides having abundant blood supply,
necessitates greater amount of dento- tly by primary closure. This method ap- the connective tissue flap is extremely
gingival detachment in order to facili- pears favourable for closure of minor elastic, enabling it to be rotated without
tate the shift. This may result in variable anterior fistula in association with miss- tension. Another advantage of this flap
degree of periodontal diseases. Thus, , ing anterior teeth. However the pro- over the whole thickness flap is that
this procedure is suitable for the cedure reduces the labial sulcular
edentulous patient, In addition, the dis- height, and also results in the presence
tal shifting of the flap leaves a raw area of two pedicles on top of the alveolus.
on the mesial aspect which accounts for Buccal flap procedures are relatively
the increased scar formation. simple to perform. The blood supply to
Mucoperiosteum overlying an these flaps is good. However, these flaps
edentulous ridge in the vicinity of the require careful manipulation as they are
fistula has been utilized in the form of thin. Their application may be limited
transversal flap (Fig. 3). S c a u c ~ a ~4 in cases where previous operations have
described this procedure and found that caused considerable scarring in the re-
the buccal vestibular height was not af- gions where the flaps have to be raised.
fected following the closure of the fis- Such scarred tissues not only reduce the
tula. Unfortunately the design of this flap mobility but also result in poor
flap does not offer greater mobility, and healing.
it also results in a raw area over the Fig. 4. Straight advancement flap, (A). Pala-
donor site following the closure. A tal rotational advancement flap, (B). The kin-
II. Palatal flaps king of the flap may be minimised by excision
modification of Schuchardt's method at the lesser curvature of the flap (hatched
was described by EGYED117. He utilized Various palatal flap procedures based area) or tunnelling the flap underneath the
on the greater palatine vessels have been tissue bridge (area bounded by the broken
constantly described. These can be lines).
classified as straight-advancemenP 2,
veau or rotational-advance-
ment 4'13'27'36'46'54, hinged 28,43, and island
flap23,25,26,31,32.
Although palatal tissue is less elastic,
it is thicker than the buccal tissue. The
abundant blood supply in the palatal
tissue promotes satisfactory healing to
the flap. Procedures involving palatal
flaps do not affect the buccal vestibular
height. It is for these reasons that many
surgeons favour the palatal flap pro-
cedures for closure of small to moderate
size defects. HERBERT26pointed out that,
Fig. 2. Moczair buccal sliding trapezoidal when adequate local tissue is available, Fig. 5. Submucous connective tissue flap, (A).
flap. The periosteum at the base of the flap palatal mucoperiosteum is the tissue of The remaining tissue is returned to the donor
may be incised (broken lines) to facilitate the choice for repair. site. Island flap based on greater palatine
distal shift of the flap. Straight-advancement flap (Fig. 4) vessels, (B).
 112 Awang
the epithelial layer of the flap can be
returned to the donor site. This pro-
cedure gives the patient minimal dis-
comfort, and also provides early healing
of the wound as there is no raw area
left behind for granulation. However,
the dissection of the submucous layer is
often difficult and requires great care.
The use of a pedicle island flap for
surgery in various parts of the body has
been documented. However, its use for
closure of oroantral defect was only
mentioned by HEND~RSEN25in 1974 (Fig.
5). The versatility, simplicity and mo-
bility of the palatal island flap were rea-
sons given by many surgeons for its ap-
plication in the closure of oroantral fis-
tula 23'z6'31'32. GULLANE ~ ARENA23 have
pointed out that approximately 75% of
the palate may be pedicled and rotated
180 into position to provide 8-10 sq.
cm of tissue coverage. HERBERT 26 con-
cluded that the size of the defect is not
as important as the amount and lo-
cation of the palatal tissue available for
repair. He achieved closure of 3 x 2.3
cm fistula by island flap.
Palatal island flap offers several ad-
vantages in closure of large fistula. It is
a one-stage local procedure that pro-
vides a flap with an excellent bulk,
blood supply and mobility. This tech-
nique uses only the tissue required to
close the defect. Necrosis of the palatal
bone of the donor site is not a problem
with this procedure, as there is ample
blood supply from the nasal mucosa.
This procedure is suitable for closure
of posterior fistula as the island flap is
pedicled on the greater palatine vessels.
These vessels will be stretched if the flap
is advanced too far anteriorly, and thus
its application is limited in closure of
anterior defect. GULLAN & ARENA23 de-
scribed a modification of island flap to
obtain approximately 1 cm extra length
of the flap by freeing the vessels at the
greater palatine foramen. This provides
an additional mobility for anterior ad-
vancement of the flap.
Island flap requires great care during
manipulation in order to avoid injury
to the vessels. JAMES31 suggested that the
sectioning of the island should be done
last, so that if such injury occurs the
flap can still be used as a rotational-
advancement flap or returned to its
original site and closure done at a sub-
sequent time.
The mucoperiosteum surrounding
the palatal defects has also been utilized
for closure of small to moderate size
fistulas. Such tissue was designed to
Fig. 6. Hinged flap. The palatal hinged flap
is deepithelized.
form a hinged or inversion flap 28,43(Fig.
6). The procedure is simple to perform
with minimum morbidity. Both island
and hinged flaps leave a small raw area
for granulation compared to that of ro-
tational-advancement whole thickness
flap, since the former use only the tissue
required to close the fistula.
III. Combined local flaps
An attempt to close larger defects by
local flaps often leads to failure. Various
double-layer closures utilizing local tis-
sues have been described, providing suf-
ficient tissue bulk. These include the
combination of inversion and rotation-
al-advancement flaps ~8,2~,4~, doubled
overlapping hinged flaps 43, doubled is-
land flaps 26 and superimposition of re-
verse palatal and buccal flaps 56 (Fig.
6-9). All these procedures except that
described by ZmMBA56 preserve the buc-
cal vestibular height. It was also argued
Fig. 7. Combined local flaps. Hinged and
palatal rotational advancement flap (A & B).
that the buried epithelium in Ziemba's
technique may predispose to subsequent
pathology4~. In view of the two donor
sites involved, many of these procedures
would result in a greater amount of de-
nuded areas and increased time of the
surgical procedure. BJOKLUND et al. 7 in
1976 reinforced the flap with surgicel
and fascia lata. These materials were
interposed between the two layers of
tissue closure. The authors suggested
that the incorporation of these materials
could promote fibrosis and subsequent
bone formation.
B. Distant flap procedures
Tongue flaps
Larger fistulas are technically difficult
to close by local flaps in view of the
limited tissue bulk. Distant flaps from
extremities or forehead have earlier
been described for repair of larger de-
fects 6,16,45.However, poor aesthetic effect
has led to the withdrawal of these pro-
cedures.
Tongue flaps have been formerly de-
scribed for the reconstruction of lip,
cheek and pharyngeal wall. Their appli-
cation in the closure of palatal fistula
were highlighted by GUERRERO-SAN-
TOS ALTAMIRANO22 in 1966. This flap
provides sufficient tissue bulk, and it is
extremely pliable which allows suturing
of the flap without tension. The donor
site can be closed by primary closure. Its
versatility and safety have been further
emphasized by many authors 19,3,35,47. In
view of the tongue being a mobile struc-
ture, many authors favour its immobili-
zation to prevent flap dehiscence.
GUERRERO-SANTOS ~ ALTAMIRANO 22
fixed the tongue to the upper dental
Fig. 8. Combined local flaps. Inversion flap
(A) and palatal rotational advancement flap
(B). The hatched area is excised to facilitate
the rotation of the palatal flap.
 Oroantral fistula 113

AN & BROWN5~in 1983 suggested a back-
cut incision at the base of the flap to
improve the mobility of the flap. This
flap can be expanded to provide a large
area of coverage by making a serirs of
longitudinal incisions (Fig. 11).
tissue coverage. This method is suitable
for closure of fistula situated in the buc-
cal or alveolar area, where the bone
which is pedicled on the periosteum can
readily be advanced into the required
position (Fig. 12).

C. Grail procedures II. All plastic materials

Fig. 9. Combined local flaps. Reverse palatal
(A) and buccat advancement flap, (B). The
palatal and buccal periosteum of the donor
sites are intact.
arch and lip. GOLDEN et al. 19 used sup-
portive 'basket', while KRtJCI~INSK~q35
sutured lateral border of the tongue to
the maxillary premolars. STEINI-IAUSER49
advocated maxillomandibular fixation
in his cases.
The anteriorly based partial thickness
dorsal tongue flap 47 (Fig. 10) has a dis-
advantage in that it requires restrictive
tethering o f the mobile tongue during
healing. However, this is not a problem
with the posteriorly based full thickness
lateral tongue flap, since the base of this
latter flap is situated in the less mobile
posterior 1/3rd of the tongue (Fig. 11).
Mouth function and appearance is
much improved with the posteriorly
based full thickness lateral tongue
flap 12,5~. The reported complication in-
volving necrosis of the flap following
the use of this flap is minimal. VAUGrI-
I. Bone
Various alloplastic materials have been
The use of an autogenous cancellous used in the past for the closure of oroan-
bone in the closure of palatal defect is tral fistula (Fig. 13). These include gold
a well known procedure. COCKERHAM foiF,37, gold plate 2,15,48,tantalum plate H,
et al. 14 in 1976 suggested that, when a soft polymethylmethacrylate3 and ly-
conservative method fails or when the ophilized collagen 38. Gold is seldom
size of the defect is too large, bone graft available and expensive. The insertion
should be indicated in the closure (Fig. of the alloplastic materials is a simple
12). WmTNEY et al? 3 advocated bone procedure and does not require raising
grafts in cases where there is need to of a large amount of local tissue. The
recontour the alveolar ridge. Soft tissue procedure does not affect the buccal
coverage may be accomplished by pala- vestibular height. There is no raw area
tal flaps ~,3,buccal ftaps 8,9,14,4,53or tongue left behind for granulation following the
flaps 3. Closure of the defect by bone closure. The use of collagen has an ad-
not only ensures strength to the flap vantage over the other materials in that
but also replaces the defect with similar it does not require removal prior to
tissue. This technique has been reported complete healing as it probably be-
as greatly successful. The disadvantage comes incorporated in the granulation
of this method is that it requires an tissue 38.
additional surgical procedure to obtain A simple non-surgical technique by
a bone graft. This increases the length of application of lyophilized fibrin seal
the procedure and morbidity. A single- (human) - Tissucol to the defect de-
stage and simpler surgical procedure of scribed by ZTmcIc et al. 57 in 1985. This
obtaining a bony closure was described material forms clot after reacting with
by BRUSATI1 in 1982. He took the bone a solution ofthrombin, calcium chloride
from the lateral wall of the antrum, and and aprotinin. The resultant whitish
had it pedicled on the periosteum to elastic gel clot of increasing strength ad-
close the alveolar defect. The disadvan- heres firmly to the defect wall. The au-
tage of his procedure is that the buccal thors achieved complete closure of the
vestibular height was reduced as a result defects within 1 month by single appli-
of the use of the buccal flap as a soft cation of Tissucol . This method does
not require raising the flap. Thus, it is

Fig. 12. Bone graft shown in cross section.

Fig. 10. Anteriorly based partial thickness
dorsal tongue flap. The donor site is closed
by primary closure. After 2-3 weeks, the ped-
icle is divided and the proximal portion is
returned to the donor site.
Fig. 11. Posteriorly based full thickness lat-
eral tongue flap. The broken lines show the
back cut incision to improve the flap mo-
bility. Longitudinal incisions into the muscle
layer to expand the flap.
The excess bone is trimmed to the level of
the defect. The palatal rotational advance-
ment flap is used as its tissue coverage, (A),
The alloplastic material is being inserted
under the surrounding mucoperiosteum, (B).
114 Awang
), /
Fig. 13. Buccal osteoperiosteal flap. The bone
from the lateral wall of the sinus is pedicled
on the periosteum and rotated to cover the
defect. The soft tissue coverage is ac-
complished by the buccal advancement flap.
advantageous in cases where there are
limited available local tissues for repair
as a result o f considerable scarring of
these tissues. The use of h u m a n fibrin
seal may predispose to the transmission
of viral hepatitis. A l t h o u g h it is care-
fully controlled by the manufacturer,
such a complication could not be ruled
out entirely.
Summary
Closure of oroantral fistula may often
be a difficult problem presenting a chal-
lenge to the oral surgeon. The review
of the literature revealed many surgical
techniques that have been advocated to
close varying degrees of oroantral de-
fects. Assessment o f local and general
factors of the patient have to be care-
fully made prior to the selection of the
technique. It is further emphasized that
complete elimination of sinus infections,
excision of the fistulous epithelial tract
and proper postoperative care are
equally important, leading to the suc-
cess of the closure.
Local mucoperiosteal flaps are often
indicated in closure of small to moder-
ate size defects because they are simple
to perform and well tolerated by all pa-
tients. The reduction o f buccal vestibu-
lar height following the closure by buc-
cal flap procedures has received m u c h
criticism. Local flaps are utilized in both
single- and double-layer closures. A
double-layer closure not only improves
the strength o f the flaps but also mini-
mises contraction and risk o f infection.
The strength o f the double-layer clo-
sures has been further improved by the
incorporation of surgical and fascia
lata.
Distant flaps and bone grafts are sig-
nificant in closure o f large defects or in
cases where local flap procedures have
failed. The posteriorly based full thick-
ness lateral tongue flap has been shown
to be superior to the anteriorly based
partial thickness dorsal tongue flap.
Alloplastic materials may not be eas-
ily available, and are costly compared
to the use of flap procedures. Works
on the use o f collagen and fibrin have
received particular attention. This is be-
cause these materials are biologically
competent and they are easy to use.
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Address:
Mohd Noor Awang
Department o f Oral Surgery
Faculty of Dentistry
University o f Malaya
59100 Kuala Lumpur
Malaysia