328 Indian Journal of Multidisciplinary Dentistry, Vol.

1, Issue 6, September-October 2011

*Senior lecturer
**Senior lecturer

Professor

Professor and Head

$
Reader
Dept. of Oral and Maxillofacial Surgery
Sree Balaji Dental College and Hospital, Chennai
Address for correspondence
Dr Prakash dhanavelu
Senior Lecturer
Dept. Oral and Maxillofacial Surgery
Sree Balaji Dental College and Hospital,Chennai
E-mail:prakash.oralsurgeon@gmail.com
ABSTRACT
A novel method for closure of large Oro antral stula is presented that uses an autogenous corticocancellous bone graft
harvested from mandibular symphysis region. Te advantages of using mandibular bone grafts are reduced operating time
and minimal postoperative complaints. Furthermore it helps in reconstructing the sinus oor as well as alveolar bone defect
and also shows less resorption when compared with iliac bone graft.
Key words: Oro antral stula, corticocancellous bone graft, autogenous
Management of Oroantral Fistula with Autogenous
Corticocancelous Symphysial Bone Graft
Prakash Dhanavelu*, B Sreevidya**, R Balakrishnan

, Vijay Ebenezer

, Abudakir
$
O
ro antral stula is an epithelialized
communication between the oral cavity and
the maxillary sinus.
1
It is a relatively common
complication with the incidence between 0.31-4.7%
after extraction of maxillary posterior teeth.
1-5
Other
causes are dento alveolar infection, cysts, tumours,
osteonecrosis, trauma and dental implant failure in the
atrophic posterior maxilla.
2,6
Numerous surgical techniques such as palatal pedicle
ap, Rehrmann buccal advancement and buccal fat
pad techniques have been described for the closure of
OAF. Most of them rely on mobilizing the tissue and
advancing the resultant ap into defect.
2,7
However,
especially when the bone perforation is particularly large,
accentuated atrophy of the vestibular bony wall of the
alveolus and healing of the perforation without osseous
regeneration has been observed after the operation.
Tis 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.
8
To prevent such drawbacks, to obtain proper bone
formation and to further decrease the possibility
of failure of operation, we employed autogenous
corticocancellous bone graft harvested from mandibular
symphysis region for OAF closure.
Case History
A 70-year-old female patient presented to the
department of oral and maxillofacial surgery, Balaji
Dental College with the chief complaint of nasal
regurgitation while taking liquid diet since 2 years
following extraction of upper right posterior teeth.
Patients past medical history reveals diabetes and on
medication (insulin). She also had myocardial infarction
2 years back and underwent bypass surgery for the
same. Presently she is taking anticoagulants (aspirin).
Physical examination revealed 2 x 5 mm opening in the
region of 16 (Fig. 1). Valsalvin test was performed and
was positive. Radiographic examination (oclussal view;
Figure 1.
CASE REPORT
329 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 6, September-October 2011
CASE REPORT
Fig. 2, IOPA) revealed destruction of bone without
any evidence of chronic sinusitis and foreign bodies.
Surgical Technique
After obtaining physician consent, procedure was
performed under local anesthesia (2% lignocaine
with 1: 80,000 parts of adrenaline). Anticoagulant
was stopped ve days prior to the surgery. Antibiotic
prophylaxis (amoxicillin) given preoperatively.
Recipient Site
Incision was placed from 13 to 18 regions of alveolar
crest and around the stula (Fig 3). Mucoperiosteal
ap was elevated (Fig. 4).Epithelial lining of the stula
Figure 2. Occlusal view revealing OAF.
Figure 3. Incision placed.
Figure 4. Site exposed.
Figure 5. Epithelialized tissue removed. Figure 6. Donor site exposed.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 6, September-October 2011 330
CASE REPORT
Figure 7. Horizontal and vertical osteotomy cuts.
Figure 8. Graft harvested.
Figure 9. Graft placed in the recipient site.
Figure 10. Graft is secured with screw.
Figure 11. Recipient site closure.
Figure 12. Donor site closure.
331 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 6, September-October 2011
CASE REPORT
tract removed(Fig. 5). Bony defect was exposed and,
measured with stainless steel scale. Te actual bony
defect was longer than the soft tissue defect. Te size
of the defect was 3 x 8 mm in diameter.
Donor Site
Vestibular incision placed from 32 to 42 regions.
Mucoperiosteal ap was reected and donor site exposed
(Fig. 6). Two horizontal osteotomy cuts were performed
with bur, with a length of 1.2 cm. First horizontal
osteotomy cut was placed 5 mm below the crest of the
alveolar ridge. Second horizontal osteotomy cut was
placed 5 mm below the rst horizontal osteotomy cut.
Tese two horizontal osteotomy cuts were connected
with vertical osteotomy cuts (Fig. 7). A thin, broad
osteotome was used for freeing the corticocancellous
block, leaving the lingual cortex intact (Fig. 8).
Te harvested bone was modied with bur according
to the defect shape and xed with 2 x 6 mm stainless
steel screw (Figs. 9, 10). wound closure was achieved
with 30 silk (Figs. 11, 12). Routine postoperative
instructions, including medications (antibiotics and
analgesics) and to avoid sternous physical activities
(nose blowing, sneezing, vigorous rinsing) that might
raise the pressure within the para nasal sinuses are given
for one week. Postoperative period was uneventful.
Sutures were removed after ten days.
Discussion
OAF usually occurs after the third decade of age and is
common in elderly individuals. It is considered that the
loss of teeth in association with advancing age increases
the likelihood of stula formation.
5,6,9
Te frequency
of OAF is nearly the same in both sexes. However,
according to lin et al, females exhibit larger sinuses
than males and should therefore be at greater risk of
OAF. Most frequent cause of OAF is tooth extraction.
Some studies showed that, highest incidence of OAF
is found after extraction of a second premolar followed
by the rst molar.
6
Whereas other studies showed that
it is common after extraction of upper rst molar
followed by the second molar.
9
Numerous surgical techniques have been described for
the closure of OAF. Long term successful closure of
the OAF depends on the acuteness of the problem,
absence of sinus disease, size and location of the defect
and the amount and condition of the adjacent tissue.
Te literature has shown that openings >5 mm in
diameter have a substantially decrease the chance of
spontaneous primary closure.
10,11
Treatment includes
the use of local/distant tissue aps and interpositional
autogenous grafts/alloplastic implants. Because of
the high recurrence of OAF with soft tissue coverage
techniques especially in large bone defects, closure of
OAF with autogenous (or) allogenous bone graft is
recommended.
10
Proctor rst reported the bony closure of large OAF
by grafting a piece of corticocancellous block from the
anterior iliac spine. Complications associated with this
technique are donor site morbidity and hospitalization.
Hass et al introduced another OAF bony closure
technique using a monocortical press t graft from the
chin area.
2,12
In our case, autogenous corticocancellous mandibular
symphysis graft is used for closure of OAF. Te
advantages of using mandibular bone grafts are related
to using the same operation eld easier accessibility
reduced operating time, minimal post operative
complaints and absence of visible scar. Furthermore
operating exclusively inraorally is considered to be
less extensive surgery by patients compared with using
iliac crest as donor site.
2,13
Mandibular symphysial
corticocancellous graft considered to be an ideal graft
because it provides a cortical portion for reconstructing
a solid sinus oor as well as alveolar defect at the
OAF site and its cancellous portion contains viable
multipotent mesenchymal stem cells for osteogenesis.
Several authors suggested that chin bone grafts require
shorter healing time compared with iliac crest bone
grafts. Tey have reported that membranous bone
(symphysial bone graft) undergoes less resorption than
bone of endochondral origin (iliac crest bone graft)
owing to earlier revascularization of membranous
bone grafts.
2,14,15
To conclude, this technique may be useful to treat OAF
and to provide a solid alveolar bone site for subsequent
prosthesis placement.
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Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 6, September-October 2011 332
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