ORO-ANTRAL FISTULA

Presented By

Dr. Chandramohan. Chinta

III MDS Division of Oral and Maxillofacial Surgery

AETIOLOGY
An oro-antral fistula is an unnatural communication between the mouth and the maxillary sinus and it can result from several causes, for example, the extraction of teeth or through massive trauma to the face, surgery to the maxillary sinus, osteomyelitis of the maxilla, gumma involving the palate, infected upper implant dentures and as a result of such rare diseases as malignant granuloma. The most common cause of an oro-antral fistula is the inadvertent opening if the maxillary sinus during sinus during the extraction of an upper tooth, for the root apices of the upper canine, premolars and molars lie in immediate proximity of the floor of the air space. Indeed apices of adjacent teeth sometimes intrude into the antral cavity and are only separated from the lining membrane by the socket wall. Large maxillary sinus are especially at risk to a disruption of the antral floor, while the accident is less prone to occur in young persons whose antra have not yet reached adult size. The thickness, too, of the sinus floor appears to vary from individual to individual as a personal characteristic. Tooth removal may be difficult and be associated with an obvious fracture of the antral floor, a fragment of the floor of the maxillary sinus may be detached together with one or more of its associated teeth. The most common accident of this nature is a fracture of the tuberosity together with the upper third and/or second molar, but any of the maxillary teeth from the canine backwards may be involved. Rarely the entire floor of the maxillary sinus is detached together with its associated teeth, the resulting fistula being huge. Displacement of an upper tooth or root into the maxillary sinus also produces a fistula and in

this respect the upper third molar tooth and the palatal root of the upper first molar are especially liable to be involved. Forceps extraction of a solitary isolated premolar or molar in an edentulous part of the arch, the root or roots of which are enveloped by the antral air space, is also prone to cause disruption of the sinus floor. Rarely the extraction of an upper posterior tooth associated with periapical disease, e.g., acute periapical abscess, chronic granuloma or periapical sclerosis may be complicated by antral perforation. The surgical removal of impacted (e.g. canine, premolar, third molar supernumerary), submerged or geminated upper teeth certainly carries a risk of an inadvertent breach of the antrum , as does apicectomy on roots adjoining the sinus periphery. 'Blind' instrumentation, with out adequate surgical exposure, in the attempted retrieval of retained apices in the upper posterior quadrant is likewise a hazardous.

Facial Trauma
Oro-antral fistulae may occur following massive trauma to the middle third of the facial skeleton, especially if the face is struck by missiles or if a sharp object is driven through the mouth into the maxillary sinus. Penetrating injuries-gunshot wounds in particular-may create huge defects of the sinus walls.

Surgery
The fenestration operation, in effect a partial maxillectomy, which may be performed for the eradication of a malignant antral neoplasm, is responsible for a huge opening into the maxillary sinus, since one-half of the plate, alveolus and anterior and medial walls may be included in the

bony removal. The surgical treatment of large or abscessed maxillary cysts may also be complicated by inadvertent fistula formation. This necrotic cyst lining breaks down and involves the lining of the maxillary sinus with which it is in contact and the resultant tissue destruction may result in a massive fistula into the maxillary sinus.

Malignant Tumours
Malignant tumours of the maxillary sinus may penetrate the lateral bony wall or erode through the floor of the sinus into the mouth, producing symptoms referable to the oral cavity including an oroantral communication. Likewise, neoplasms arising in the upper jaw can, of course, extend into the sinus above them, leading to fistula formation.

Osteomyelitis
Osteomyelitis of the maxilla in the adult is rare unless there is an underlying systemic disease such as leukaemia, diabetes, uraemia, etc., or the maxillary region has been irradiated in the absence of adequate drainage for infection. A severe osteitis with bone loss could lead to the formation of an oro-antral fistula of one or both maxillary sinuses.

Syphilis
Gummata of the palate may result in a massive oro-antral fistula due to destruction of the intervening bone, and in hereditary or congenital syphilis any of the lesions normally associated with the secondary and tertiary forms of syphilis of the nose can also arise and extend into the mouth.

Implant Dentures
Destruction of the antral floor in a patient fitted with an upper implant denture.

Malignant Granuloma
Malignant granuloma is primarily localized to the nose, but may spread further to involve the palate, pharynx or orbit. When the invasive process spreads to the palate expansive perforation ulceration may occur leading to huge fistulae.

SYMPTOMS
The most common symptom is the regurgitation of liquids from the mouth into the nose. Patient washes the mouth after the extraction has been completed, passage of fluid from the mouth into the nostril on the side of the extraction is pathognomonic of an oro-antral fistula. Patients complained of an immediate escape of fluids from the nose when they rinsed out their mouths following an extraction. Unilateral epistaxis due to blood in the maxillary sinus escaping through the nasal ostium may also be an immediate result of fistula formation, escape of air from the mouth into the nose, an alteration in vocal resonance, an inability to blow out the cheeks and the passage of air into the mouth on sucking. Smokers will find that they are unable to draw on a cigarette. Oro-antral defect was completely occluded by blood clot and it is only when this plug disintegrates as result of infection that an oro-antral communication is firmly established. Patients may then present complaining of a unilateral malodorous nasal discharge (purulent or mucopurulent), especially when they bend down, or they may experience a foul, salty or sweetish fetid taste.

Once a fistula has been created, superimposed infection of the sinus ensues due to contamination by oral organisms. With a mild sinustitis, the clinical disturbance is often minimal, but a postnasal mucus drip will often lead to an unpleasant taste which may be accompanied by a nocturnal cough, hoarseness, earache or catarrhal deafness. This discomfort is frequently exacerbated on biting, bending, lifting, straining and by jarring movements, e.g. walking downstairs. They may be an associated frontal headache, malaise and anosmia. Swallowed pus gives rise to morning anorexia. The persistence of a fistula can lead to oblique problems, for instance, the inadvertent entry into the antrum of food particles, chewing gum, fluids, impression materials, dressings, packs etc. Any of these substances may provoke acute or subacute exacerbations of inflammatory disease.

PHYSICAL SIGNS
1. Those presenting immediately after the formation of the fistula. 2. Those relevant to an established oro-antral fistula.

1. The Recently Created Fistula

Most arise as a result of surgery in the immediate vicinity of the maxillary sinus and this is usually the extraction of maxillary molar or premolar teeth. When the roots of the tooth are examined a portion of the bony floor of the maxillary sinus is seen adhering to the tooth. Fractures of the maxillary tuberosity where the entire fragment is detached are especially liable to result in a fistula. Attempted extraction of an upper molar root

which suddenly disappears as soon as force is applied with an elevator also denotes its inadvertent displacement into the sinus and the presence of a coexistent fistula. A similar accident can occur in the attempted extraction of a partially erupted upper third molar.

Testing to establish the presence of an Oro-Antral Fistula

If the fistula is large it will be obvious on simple inspection, but if the patency of an oro-antral defect remains in doubt, the nose-blowing test may be confirmatory. Compression of the anterior nares followed by gently blowing down the nose (with the mouth open) causes a rise in intranasal pressure, exhibited by a whistling sound as air passes down the open passage. In addition, escaping air bubbles, blood, mucopus or pus may appear at the oral orifice. A wisp of cotton-wool held just below the alveolar opening will usually be deflected by the air stream. On no account should a suspected pinhole, antral defect at the site of a recent extraction be explore with an instrument, such as a silver probe, unless clinical manifestations of a patent communication are evident. A needless investigation could cause breakdown of a wound seal and establish a fistula.

2. Physical signs observed when a Fistula has been present for a considerable period of time
Sinusitis with repeated attacks of acute mucopurulent rhinitis, escape of air or fluid through the nostril or the development of a lump on the gum. The maxillary sinus is usually infected and on inspection of the suspected orifice of the fistula there is often an unmistakable discharge of foul-smelling pus. This can usually be demonstrated by occluding the patient's nose by pinching it with the thumb and forefinger and asking the patient to blow. If a free descent of pus into the mouth does not occur it

may be due to the occlusion of the sinus orifice by polyp. If a silver probe is passed up the fistula into the antrum, the polypoidal mass is pushed to one side after which a free flow of pus can be expressed into the mouth on blowing the nose. Acute sinusitis and there is always tenderness to pressure over the maxilla, especially immediately below the eye. There may also be slight flushing of the cheek with oedema of the infra-orbital soft tissues. Rarely, a patient may complain of earache which could, of course, be referred from the antrum, but may be attributable to acute otitis media. Percussion of the upper premolars and molars on the same side as the infected sinus will frequently elicit pain. By careful examination of the nose using a nasal speculum and light source, e.g. headlight, nasal congestion (red, shiny and swollen mucous membrane) in the neighbourhood of the ostium can be confirmed. Another local sign is the presence of a trickle of pus of mucopus in the middle. Inspection of the oropharyx by depressing the posterior aspect of the tongue with a mouth mirror will often reveal a stream ('curtain') or trickle of pus or mcuopus tracking down the posterior wall of the pharynx. It is more common to encounter chronic antral infection in which the sense of smell may be impaired and foul-smelling mocopus is seen under the middle turbinate or in the postnasal space. Slight tenderness may be elicited over the infra-orbital nerve. For viewing the maxilla, the technique of choice has traditionally been waters view, however, periapical, occlusal and panaromic dental radiographs also projects the paradental structures, including the maxillary sinus. The periapical dental radiograph is the most simple,

satisfactory method for investigating defects in the floor of the maxillary sinus for both radiolucent and radioopaque defects. The occlusal view aid in locating radioopacity medial to the dental arch. The panoramic radiograph proved to the least useful for evaluating the maxillary sinus3. The advances in computed topography (CT) Scanning technologies since the early 1990s have made the imaging of the paranasal sinus precise. In clinical practice, computed tomography scan can visualized sinus pathologies more relevant then other imaging modalities. 14

MANAGEMENT OF ORO-ANTRAL FISTULA

An oro-antral fistula must be sealed in order to prevent the escape of fluids, the entry of other mouth contents into the antrum and to protect the sinus from oral bacteria.

The immediate treatment following the creation of an oroantral fistula

The ideal treatment following the creation of an oro-antral fistula is to perform an immediate surgical repair, so that primary closure can be combine with simultaneous antibiotic prophylaxis of sinus infection. Whether the fistula is complicated by the presence of a tooth or root in the maxillary sinus. A buccal flap is then advanced across the gap by incising the periosteum on its underside, after which it is sutured in position. The root or tooth may be in close proximity to the point of entrance and, therefore, can often be removed by the simple expedient of inserting the nozzle of a powerful sucker into the orifice and withdrawing it. Active

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supportive measures should be instituted. These will include antibiotics primarily combined with local decongestants and analgesics as required.

Antibiotic Medication
Phenoxymethylpenicillin (Penicillin V) should prove adequate on a dosage schedule of 250mg. 6-hourly. If the organism appear to be insensitive to penicillin, a swap would enable another antibiotic to be selected according to the sensitives, but in practice a broad-spectrum antimicrobial like ampicillin or oxytetracycline will usually be substituted on an identical regime to that ordered for the acid-resistant penicillin.

Local Decongestants
Vasoconstrictor nose drops (sprays) and inhalations to encourage the drainage of pus and secretions. The ideal decongestant will not interfere with ciliary action, but merely produce shrinkage of the antronasal mucous membrane and aeration of the sinus. Ephedrine Nasal Drops (0.5 per cent) instilled intranasally every 3 hours. When the nose is clear following the decongestant drops or spray, stem inhalation helps by encouraging drainage; it also tends to thin the mucus and have a soothing effect. Menthol and Benzoin Inhalation is an old favourite and the instructions are to add a teaspoonful to a pint of hot (not boiling) water and inhale the vapour for 10 minutes at least twice a day.

Analgesics
Aspirin soluble tablets (1-3 tablets up to four times daily), Aspirin, Phenacetin and Codeine Tablets (1-2 tablets up to four times daily) are usually sufficient to control the pain.

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Antral Lavage
Once pus accumulated in copious amounts in the antrum an integral part of remedial treatment is the establishment of surgical drainage. For dependent drainage is best achieved through the fistulous orifice in the antral floor which lies below the meatal level. Sometimes, however, the oral end of the communication may be partially or completely blocked by herniated antral mucosa, a polyp or mucosal cyst excised in order to permit free drainage. A slit like opening on the gum must be enlarged, preferably to conform with the existing diameter of the bony defect. A bacterial culture of the resultant discharge is most useful for sensitives if an antibiotic has not already been given. If necessary the sinus should be washed out with warm sterile normal saline at regular intervals (e.g. bi-weekly) until a clear return is obtained.

Temporary Therapeutic Measures before Surgical Closure

Pack
The ribbon gauze pack is positioned at the entrance to the socket, overlying both the orifice and brim and held securely by a simple structure framework.

Denture Plate
The construction of a well-fitting upper base plate with a flange extension to cover the artificial opening is another sensible precautionary measure if surgical repair of the fistula is to be deferred. The appliance should not penetrate the fistula but merely provide a barrier to the inadvertent entry of food particles. Before taking the impression the hole should be occluded with a piece of tulle gras or Cellophane, so that there is no danger of forcing impression material into the sinus space.

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Treatment of Delayed Cases

1. Treatment of an Oro-antral Fistula seen within 24 hours of the Accident.
If an oro-antral fistula is referred within 24 hours of its occurrence, the edges of the wound are fresh and surgically clean and it should be closed immediately, after which the usual postoperative treatment of nasal drops, inhalations and antibiotics is instituted. A defect uncomplicated by concurrent deflexion of tooth or root into the antrum can usually be closed by a buccal flap and sutured under local analgesia.

2. Treatment of Cases seen more than 24 hours after the Injury.

After a period of 24 hours has elapsed the soft-tissue margins of the fistula are often infected and successful primary closure is less likely. If early surgery is impracticable, it is preferable to defer the operation until the gingival edges of the fistula have healed soundly, i.e. in approximately three weeks. Prophylactic treatment consisting primarily of antibiotics along with local decongestants and analgesics should, however, be prescribed immediately. Treatment of an Oro-Antral Fistula which has been present for more than a month: On examination pus can be seen discharging from a fistula into the mouth. The flow of pus is increased when the patient blows his nose or when the clinician holds the nose and instructs the patient to blow. Some persons complain of a unilateral nasal discharge whenever they bend down, and the fistulous track may be continually bathed of offensive pus. If the free flow of pus is impeded by a narrow orifice at the oral end of

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the fistula, the patient will experience acute antral pain infra-orbitally and in the alveolus on the affected side. Drainage of the maxillary sinus should be re-established through the fistula by enlarging it surgically, and the sinus should be gently irrigated daily with normal saline until the washings are clear.

SURGICAL PROCEDURES
The technique of oro-antral closure may be divided into the flowing procedures. A. Local Flaps B. Distant Flaps C. Grafts

Local Flap procedures

1. Buccal Flaps - These include

Rotated Flap Advancement Flap Sliding Flap Transverse Flap

Buccal Flap Operation

Buccal flap operation, originally described by von Rehrmann in 1936. The upper buccal sulcus at the reflection is richly vascularized and before commencing the operation about 1 ml. Of local analgesic solution should be injected into the muco-alveolar fold to reduce local capillary bleeding by vasoconstriction. This measure minimizes bleeding at the time of operation, reduces the risk of a postoperative haematoma which could possibly imperil the suture line and helps to define tissue planes.

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Incision is made around the fistulous track 3-4 mm. marginal to the orifice. A No. 11 scalpel blade is used and the entire epithelized tract together with any associated antral polyps is dissected out and discarded. The edge of the gum bordering the defect is freshened. If, to improve flexibility, the free end of the proposed flap needs to be longer than the width of the delineated defect, then crest-or-ridge or gingival margin extensions are placed on each side. Next, two divergent incision are made with a No. 15 blade from each side of the oro-antral orifice up into the buccal sulcus for a distance of 2.5 cm. or more. These incisions are made down to bone and carried well above the reflection. This implements the principle that the base of the flap should be broader than the tip so that an adequate blood supply reaches the free margin. Some limitation of the width of the flap base must inevitably occur when there are teeth present on each side of the fistula, but it must never be so narrow that vascularization of the apex is impaired, leading to sloughing. It is of incidental importance that when extending the oblique incision into the cheek, care must be taken to avoid injury to the parotid papilla or duct. In its unaltered state the buccal mucoperiosteal flap cannot be stretched because of the inelastic nature of the limiting membrane-the periosteal component. However, if the flap is raised and turned over reveal its undersurface, a horizontal relasing incision made as high as possible through the taut periosteum will allow advancement of the buccal tissues. Before suturing the flap across the bony opening, the maxillary sinus should be carefully inspected for evidence of infection, If the maxillary sinus is empty and the mucosa healthy-looking, the wound can be closed. However, if it contains polypoid masses or other diseased tissues, these should be removed with Luc's forceps before repairing the

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fistula. The remainder of the lining membrane in such cases should not be sacrificed unless irreversibly damaged, for this tissue is capable of repair and regeneration. If the orifice of the fistula is not sufficiently wide to enable polyps and pathological tissue to be removed, then it can be enlarged by using Jansen-Middleton bone nibblers. If it is considered undersirable to enlarge the original bony defect, then a routine CaldwellLuc approach should be made into the sinus for this purpose. The antrum should then be gently irrigated with warm sterile normal saline and the mucoperiosteal flap sutured into position across the opening of the fistula with interrupted black silk sutures. If necessary, the wound edges can be trimmed to improve adaptation and ensure accurate coaption. Postoperatively the patient should have antibiotic cover with phenoxymethylpenicillin or a suitable alternative for 5 days and use nasal drops and inhalations five times a day for a week. The patient should be restricted to a soft diet to avoid the implantation of irritant food particles along the suture line. Instructions should be given to the patient to avoid sneezing, exploring the wound with the tongue or deliberately sucking air or fluid through it. Nose-blowing is also prohibited since, in the early stages, not only does it create back-pressure on the suture line before consolidation is complete, but it also invites the risk of surgical emphysema for air may be forced through the periosteal gap which is then a freeway to the soft tissues of the cheek. If the patient wears a denture care must be taken tot avoid injury to the swollen cheek tissues. Sutures should not be removed earlier than 10-14 days post-operatively. MOCZAIR4 described a buccal sliding trapezoidal flap procedure for closure of alveolar fistulas. The disadvantages of this procedure are that it necessitates greater amount of dentogingival detachment in order to facilitate the shift. This may result in variable degree of periodontal

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disease. Thus, this procedure is suitable for the edentulous patient. In addition, the distal shifting of the flap leaves a raw area on the mesial aspect which accounts of the increased scar formation. Mucoperiosteum overlying an edentulous ridge in the vicinity of the fistula has been utilized in the form of transversal flap. SCHUCHARDT5 described this procedure and found that the buccal vestibular height was not affected following the closure of the fistula. Unfortunately the design of this flap does not offer greater mobility and it also results in a raw area over the donor site following the closure. A modification of SCHUCHARDTS method was described by EGYEDI
6 .

He utilized a labial vestibular bipedicle flap to close a fistula in

the anterior region. This flap has an advantage in that it obtains bilateral blood supply. In addition the donor site can be closed exactly by primary closure. This method appears favourable for closure of minor anterior fistula in association with missing anterior teeth. However the procedure reduces the labial sulcular height and also results in the presence of two pedicles on top of the alveolus. Buccal flap procedures are relatively simple to perform. The blood supply to these flaps is good. However, these flaps require careful manipulation as they are thin. Their application may be limited in case where previous operations have caused considerable scarring in the regions where the flaps have to be raised. Such scarred tissues not only reduce the flap mobility but also result in poor healing. Buccal fat pad Buccal fat pad (BFP) was mentioned for the first time by Heister in 1732 and better described by Bichat in 1802. However, it was described

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only as an anatomic element. Egyedi15 was the first to report use of the BFP in oral reconstruction for the closure of oro-antral and oro-nasal communications. BFP lies in the masticatory space between the buccinator muscle and masseter muscle, and it is wrapped within a thin fascial envelope. Anatomically, BFP consists of three independent lobes: anterior, intermediate and posterior. Some authors describe it as a central body with four process: buccal, pterygoid, superficial and deep temporal. Each lobe is encapsulated by an independent membrane and a natural space between them. The blood supply to the BFP derives from buccal and deep temporal branches of the maxillary artery, from the transverse facial branch of the superficial temporal artery and from some small branches of the facial artery. BFP mean volume is approximately 10ml and weights 9.3gms15. it is capable of covering defects of about 4cm in diameter15. BFP flap is epithelialised in 4 6 weeks. Before epithelialisation, an initial phase of granulation is observed, probably because fat tissue is replaced with granulation tissue and it is covered by stratified parakerototic stratified squamous epithelium migrating from the margin of the flap15. BFP has many possible functions16. filling and allowing slippage of fascial spaces between mimetic muscles; enhancement of intermusclar motion, separating muscles of mastication from one another; to counteract negative pressure during suction in the newborn; protection and cushion of neurovascular bundles from injuries.

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Advantages It is a simple and easy flap to use It has a rich blood supply. Its epithelialisation is complete within 6 weeks. Morbidity and failure rate is very low. It is well accepted by the patient, and it can be associated with other pedicle flaps. Disadvantages Can only be used once Limitation of oral opening due to scar retraction and by the loss of separation of the muscles of mastication from each other. Mouth exercises are used post operatively to improve mouth opening. Surgical approach Incision through the superior vestibular sulcus. The incision cuts mucosa and buccinator fibres, exposing the maxillary periosteum and the BFP. Its fascia is severed, and the fat pad is placed into the mouth by pulling it and by pushing the check skin under the zygomatic arch. The flap is pulled with tissue forceps and rotated or transferred onto the defect and sutured with no tension. Physical therapy was recommended for 4 to 6 weeks after the surgery.

II. Palatal flaps

Various palatal flap procedures based on the greater palatine vessels have been constantly described. These can be classified as

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Striaght-advancement7 Hinged8 and Island flap.

Although palatal tissue is less elastic, it is thicker than the buccal

Rotational advancement

tissue.

The abundant blood supply in the palatal tissue promotes It is for these reasons that many

satisfactory healing to the flap. Procedures involving palatal flaps do not affect the buccal vestibular height. moderate size defects. Straight-advancement flap does not offer much greater mobility for lateral coverage. Thus, it is suitable for closure of minor palatal or alveolar defect. Palatal rotational-advancement flap provides adequate mobility and tissue bulk to the flap. However, it requires the mobilization of large amount of palatal tissue, and it often kinks following the rotation of the flap which may predispose to venous congestion. CHOUKAS left adequate tissue bridge for the placement of the flap underneath this tissue bridge with minimum tension. ITO & HARA described a submucosal connective tissue pedicle flap. Besides have abundant blood supply, the connective tissue flap is extremely elastic, enabling it to be rotated without tension. Another advantage of this flap over the whole thickness flap is that epithelial layer of the flap can be attached to the donor site. This procedure gives the patient minimal discomfort and also provides early healing of the wound as there is no raw area left behind for granulation. However, the surgeons favour the palatal flap procedures for closure of small to

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dissection of the submucous layer is often difficult and requires great care. Palatal island flap offers several advantages in closure of large fistula. It provides a flap with an excellent bulk, blood supply and mobility. This technique 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 & ARENA described a This modification of island flap to obtain approximately 1 cm extra length of the flap by freeing the vessels at the greater palatine foramen. provides an additional mobility for anterior advancement of the flap. The mucoperiosteum surrounding the palatal defects has also been utilized for closure of small to moderate size fistulas. Such tissue was designed to form hinged or inversion flap. 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 advancement whole thickness flap. rotational-

III Combined local flaps

An attempt to close larger defects by local flaps often leads to failure. Various double-layer closure utilizing local tissues have been described, providing sufficient tissue bulk. These include the combination of inversion and rotational-advancement flaps9, doubled overlapping

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hinged flaps8, doubled island flaps and superimposition of reverse palatal and buccal flaps.

B. Distant flap procedures Tongue flaps

Larger fistulas are technically difficult to close by local flaps in veiw of the limited tissue bulk. Distant flaps from extremities or forehead have early been described for repair of larger defects. However, poor aesthetic effect has led to the withdrawal of these procedures. Tongue flaps have been formerly described for the reconsturction of a cheek and pharyngeal wall. Their application in the closure of palatal fistula were highlighted by GUERRERO SANTOS & ALTAMIRANO
10

in

1966. This provides sufficient tissue bulk, and extremely pliable which allows suturing of the flap without tension. The donor site can be closed by primary closure. The anteriorly based partial thickness dorsal tongue flap has a disadvantage in that it requires restrictive tethering of 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 anterior 1/3 rd of the tongue. Mouth function and appearance is much improved with the posteriorly based full thickness lateral tongue flap.

C. Graft procedures 1. Bone

The use of an autogenous cancellous bone in the closure of palatal defect is a well known procedure. COCKERILAM et al. in 1976 suggested that, when a conservative method fails or when the size of the defect is too large, bone graft should be indicated in the closure.

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WHITNEY et al7 advocated bone grafts in cases where there is need to recontour the alveolar ridge. Soft tissue coverage may be accomplished by palatal flaps, buccal flaps or tongue flaps. Closure of the defect by bone not only ensures strength to the flap but also replaces the defect with similar tissue. successful. This technique has been reported as greatly The disadvantage of this method is that it requires an A single stage and simpler

additional surgical procedure to obtain a bone graft. This increases the length of the procedure and morbidity. surgical procedure of obtaining a bony closure was described by BRUSATI in 1982. He took the bone from the lateral wall of the antrum and had it pedicled on the periosteum to close the alveolar defect. The disadvantage of his procedure is that the buccal vestibular height was reduced as a result of the use of the buccal flap as a soft tissue coverage. This method is suitable for closure of fistula situated in the buccal or alveolar area, where the bone which is pedicled on the periosteum can readily be advanced into the required position.

II. Alloplastic materials

Various alloplastic materials have been used in the past for the closure of oroantral fistula. These include gold foil, gold plate, tantalum plate, soft polymethylmethacrylate and lyophilized collagen. Gold is seldom available and expensive. The insertion of the alloplastic materials is a simple procedure and does not require raising of a large amount of local tissue. The procedure does not affect the buccal vestibular height. There is no raw area left behind for granulation following the closure. The use of collagen has an advantage over the other materials in that it does not require removal prior to complete healing as it probably becomes incorporated in the granulation tissue.

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References
1. H.C. KILLEY and L.W. KAY. implications. 2. AXHAUSEN. Methodik des verschlusses van Defekten in alveolar for Satzoberkiefer. Deutsche manatschrift for zahnekam. 48: 193-196. 1930. 3. WOWERN. N.V. Treatment of oroantral fistula.. Arch otolaryngal. 96; 99-104, 1972. 4. 1930. 5. SCHUCMARDI.K. METHODIK DES VERSCHILUSSES VON DEFEKTEE Alvealor forsate zahnlose oberkiefer, Dtsch. zahn mund kieferheick 17: 366-369-1953. 6. EGYEDI. P. The bucket-handle flap for closure of fistulas around the premaxilla. J. Maxillofac. Surg. 4: 212-210-1976. 7. WNITNEY.J.H.S HAMNER et al, The use of cancellous bone for closure of oroantral fistula and oronasal defect. J. oral Surg. 681, 1980. 8. RINTALA. A couble overlapping hinged flap to close palatal fistula. Scand. J. Plast. Reconstr. Surg. 5, 91-98-1971. 9. QUAYLE.A. Double flap technique for closure of oronasal and oroantral fistula. BJOMFS, 19-132-137.1981 38-679MOCZAIR, L NUOVO. methodo operatiopela chirsura dele fistole del seno mascellase di origina oentale. Stomatol (Roma). 28. 1087-1088, The maxillary sinus and its dental

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10.

GUERERO-SANTOS, et al, The use of Lingual flaps in repaire of fistula of hard plate. Plast. Recrost. Surg 38, 123-128, 1966.

11.

AL SIBAHI, A. & Al- BADR. Closure of oroantral fistula. J. oral maxillofac. Surg 40, 165-166,1982.

12.

MOHD NOOR AWANG, Closure of oroantral fistula, Int. JOMFS, 17, 110-115. 1988.

13.

CARLOS A. PEREZ, et al, Diagnostic radiology of maxillary sinus defects. J. oral surg oral med oral pathol. 66,507-512-1988.

14.

RAHUL K.SHAH et al, Paransal sinus development A radiographic study. Laryngoscope 113,205-209, 2003.

15.

EGYEDI P. Utilization of the buccal fat pad for closure of oroantral/nasal communications. J. Maxillofac surg, 5: 241-244, 1977.

16.

GIUSEPPE COLELLA, The buccal fat pad in oral reconstruction. British Journal of plastic surgery, 57: 326-329, 2004.