JOralMaxillofacSurg63:1288-1294,2005BonyPress-FitClosureofOro-AntralFi - PDF document

JOralMaxillofacSurg63:1288-1294,2005BonyPress-FitClosureofOro-AntralFistulas:ATechniqueforPre-SinusLiftRepairandSecondaryClosureGeorgWatzak,MD,DMD,*GaborTepper,MD,DMD,PhD,†WernerZechner,MD,DMD,PhD,‡GabrielMonov,MD,DMD,§DieterBusenlechner,MD,DMD,GeorgWatzek,MD,DMD,PhD¶Toevaluatetheuseofintra-oralbonegraftsforclosingchronicoro-antralÞstulas(OAFs),for ReceivedfromtheDepartmentofOralSurgery,DentalSchool,MedicalUniversityofVienna,Austria,andLudwigBoltzmannInsti-tuteofOralImplantology,Vienna,Austria.*SeniorResident. impossiblewithoutdisruptingit.AnotherproblemmaybethelocationofOAFsalongtherootsofneigh-boringteeth,whichareboundtobelostinthepro-Thisstudywasdesignedtoshowtheeffectivenessofintra-oralbonegraftsforclosingOAFs,forprovid-ingasoundbasisforsubsequentconventionalsinuslifting,andforpreservingtheteethadjacenttoOAFs.MaterialsandMethodsPatientsenrolledinthisstudyhadtofulÞll1ofthefollowingcriteria:OAFandplannedsinusßoorelevation;OAFalonganeighboringrootsurfaceextendingintothemaxillarysinusandundesirabletoothChronicOAFwithmultipleunsuccessfulat-temptsatclosure.SurgerywasplannedonthebasisofanOPG(Fig1andonaxialdentalcomputedtomography(CT)(Fig2Preoperatively,theaffectedsinuswasirrigatedthroughtheÞstulawithphysiologicsalinesolutionfollowedbyaniodine-containingsolutiondilutedwithphysiologicsaline(1:1;betadine;Purdue,Nor-walk,CT)tocontrolinfection.Thisregimenwasadministered3timesaweekuntilthelavageßuidnolongercontainedinßammatoryexudates.Peri-operatively,allpatientsreceivedamoxicillinandclavulanicacid(Augmentin;GlaxoSmithKline,Uxbridge,England),1gtwicedaily,orclindamycin(DalacinC;Pharmacia&Upjohn,Vienna),300mg3timesdailyforatleast5days,andanasaldeconges-tant(Otrivin0.05%;NovartisConsumerHealth-Gebro,SURGICALPROCEDURESurgerywasperformedinlocalanesthesia(UltracainDentalForte1:50,000epinephrine;AvantisPharma,Vi-Boneblockswereharvestedfromtheinterfo-raminalorretromolarregionsofthemandibleusingthetechniquesdescribedintheliterature.Thebasicprincipleofthesurgicalprocedureliesinpress-Þttingmonocorticalblockgraftsintothebonedefecttoensureprimarystability.Forthispurpose,ovoiddefects(Fig3)weretrimmedtoastandardshapewithatrephinetoobtainthesmallestpossiblecircularhole(Fig4).Usingatrephine(Fig5)withaninnerdiametermatchingthatofthecircularsinusßoordefect,amonocorticalblockgraftwasharvestedfromtheinterforaminalorretromolardonorsitesFig6)andpress-Þttedintothedefect(Fig7).Ifthepress-Þtwasunstable,miniplatesorbonescrews(Leibinger,Freiburg,Germany)wereusedforinternal FIGURE1.OPGshowingOAFinthemolarregionontheleftWatzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005. FIGURE2.SamepatientasinFigure1.OrthoradialreconstructionbasedontransverseCTscans.NotetheclearlydeÞnedOAFinthemolarregionontheleftside.Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005. FIGURE3.Intraoperativeviewofthebonedefectinthemolarregionontheleftside.Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005.WATZAKETAL Þxation.Carewastakennottoforcethegraftsintothesinusduringgraftplacement.Thisneverhap-penedinanyofthe21patientsreportedhere.Asimpletrickfacilitatingthesurgicalprocedureandmakingitsaferwasappliedin1case:twosmallholesweremadeinthecenteroftheblockgraftandathreadwaspulledthroughthesetomakesurethatthegraftdidnotfallintothesinus.Aftersuccessfulgraftplacement,thethreadwasremovedwithoutanyproblems.SofttissueclosurewasobtainedwithaRehrmanßap.Patientswereinstructedtoavoidstrenuousphysi-calactivitiesthatmightraisethepressurewithintheparanasalsinusesuntilthesuturesweredrawn1weekpostsurgery.Theminiplateswereremovedatthetimeofthescheduledsinuslift(ie,3monthsafterthebonyclosureoftheoro-antralÞstula).Sixto12monthsaftersinusclosure,thesiteswereevaluatedbyCTtoascertainwhethersurgeryhadbeensuccessful(Fig8Twenty-onepatientsweretreatedwithmonocorti-calblockgraftsharvestedatintra-oraldonorsites.Meanagewas49.8years(range,32to73years).ThecausesofOAFs,thedefectsizes,andothercharacter-isticsarelistedinTable1.ToothorimplantremovalintheregionoftheÞrstorsecondmolarswasthemostcommonunderlyingcause.Eachpatientwithextraction-relatedÞstulashadundergone2unsuccess-fulattemptsatsinusclosurewithabuccalslidingßap.Fivepatientswerecandidatesfor2-stagesubantralsinusaugmentationandimplantplacementaftersinusclosure.In17ofthe21patients,thebonegraftswereharvestedfromthechin.In4patientsthedonorsitewasretromolar.Thesizeofthedefectvariedindiam-eterbetween4and12mm(mean,7.35mm).Inthe FIGURE4.Bonedefectinthemolarregionontheleftsidetrimmedtostandardsizewithatrephine(intraoperativeview).Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005. FIGURE5.,Graphillustratingtrephinewithouterdiameterof8mmdiameterofbonedefecttrimmedtostandardsize.,Graphillustratingtrephinewithouterdiameterof9mminnerdiameterof8diameterofbonegraft(matchingsizeofstandardbonedefectshowninWatzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005. FIGURE6.)Intraoperativeviewofleftretromolardonorsite.)Trephinesofmatchingsizes.Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005.BONYPRESS-FITCLOSUREOFORO-ANTRALFISTULAS majorityofcases(17outof21)astablepress-Þtofthegraftsinthebonymaxillarydefectwasachieved.Theremaining4patientsneededadditionalinternalÞxa-tionwithminiplates(2patients)orbonescrews(2In3patients,mucosaldehiscencedeveloped2to4weekspostsurgery.ThisnecessitatedsuperÞcialde-corticationofthebonegraftwitharounddiamondburtothepointofbleeding.Inaddition,3%hydrogenperoxideandPeruvianbalm(resinextractedfromtheMyroxylonbalsamumtree)wereapplieddailytocom-batbacteria(bactericidalaction)andtopromotewoundhealing.Inallotherpatients,thepostopera-tivecoursewasuneventful.Radiologically,bonyunionwasveriÞed8monthsaftersurgery,onaverage,byCT.In3patientssched-uledforimplantrehabilitation,sinusliftingwasper-formedthroughalateralwindow3monthsafterbonysinusclosure.Atthetimeofsinuslifting,thesinusmembraneoverlyingtheoriginalbonedefectwasintact.Neithermembraneelevationnoraugmentationcausedanyproblems(Fig9).Healingaftersuccessfulsinusliftingwasuneventful.IfthesinusisuninfectedatthetimeOACsdeveloppostextractionandanormalbloodclotformswithinthesocket,spontaneousclosureislikely.ButaccordingtoSchuchardt,spontaneousclosureisjeopardizedbysofttissuedamageatthegingivalmargin,by4mmindiameterandasocketdepth5mm.ThisagreeswellwiththeÞndingsofthepresentstudy,whichshoweddiametersvaryingbe-tween4mm(smallestsize)and12mm.Ifthecom-municationfailstoclosespontaneously,itremainspatentandisepithelializedsothatanOAFdevelops.ToavoidproblemssecondarytoOACs(eg,infectionofthesinus),surgicalclosureisadvisablewithintheÞrst48hours.Forclosingsmallormoderatelysizeddefectsthebuccalßaptechniquehasbeenusedmostcommonly.Becauseoftheabsenceofabonybase,itsvariablesuccessrateisnobetterthan84%.Thesuccessrateofsecondaryclosurewasreportedtobenomorethan67%.AlongwithmodiÞcationsofexistingtechniquesforsofttissueclosure,autograftswererecommendedintheliteratureforclosingOAFs.Althoughusingpartofthebonefromtheextractionsocket,interseptalalveoplastyreportedbyMinoruetalisoflimitedusefulnessforcommunicationsbetweenteethbecauseofthelackofspace.Moreover,itrequiresaresidualalveolarpro-cessofadequateheightandanintactbuccalcorticallayer.SinusclosurewithbonegraftsharvestedfromtheiliaccrestasreportedbyProctorisanattractiveoption.Itshould,however,bereservedforlargede-fectsbecauseoftheknownmorbidityinherentinit.Thedemandsitmakesonthepatientscanbesubstan-tiallyreducedbyharvestinggraftsatintra-oraldonorTherefore,Haasetalproposedpress-Þttingmonocorticalblockgraftsharvestedintra-orallyforclosingOAFs.Intheirpreliminaryreport,5pa-tientsweresuccessfullytreatedwiththistechnique.Inthepresentstudyof21patients,secondaryclosurewasachievedwithcongruentlyÞttingblockgrafts.IfpressÞttingwasnotpossible,theboneblockswereÞxedwithminiplatesorbonescrews(4patients).PhillipsandRahnfoundgraftedmembranousbonetobemoreextensivelyrevascularizedifÞxed.Maxi-malrigidÞxationmaybe1reasonforthehighsuccessrateofthetechniqueinthepresentstudy.ÒThread-ingÓtheblockgraftsonasutureforgreatersafetyasdescribeddidnothaveanynegativeeffectsongraft FIGURE7.Intraoperativeviewshowingpress-Þtofmonocorticalbonegraftinthemolarregionontheleftside.Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005. FIGURE8.OrthoradialreconstructionbasedontransverseCTscansoftheleftmolarregionshowinggrafthealing8monthspost-Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005.WATZAKETAL healing.Although3patients(14.3%)developedwounddehiscencesattherecipientsite,whichisinkeepingwiththecomplicationratesreportedforotherprocedures,thesedidnotresultinre-openingofthesinus.Minoruetalclaimedthattheirtechniqueofferedtheaddedadvantageoffacilitatingspontaneouspostoperativehealingofthesofttissue,whichissupportedbythebonybase.Inthepresentstudy,wounddehiscencescausedmarginalproblems.Healingbysecondaryintentionandasuccessratecloseto100%forOAFclosurewere,nevertheless,attained.RecontouringofthemaxillarysinusisanaddedbeneÞt.Forinternalgraftingofthemaxilla,thesinusmembraneshouldbeintactwithoutanysignsofinßammation.ChronicOAFsusuallycauseseverechronicinßamma-torythickeningofthesinusmembraneandthusruleoutsinuslifting.SolitarysofttissueclosureofOAFsbeforeimplantsurgerycarriesahighriskofmucosalinjuryduringaugmentationbecauseoftheadhesionoftheoralmucosatotheSchneiderianmembrane.Inthepresentstudy,sinusclosurewithbonegraftshar-vestedfromintra-oraldonorsitespavedthewayforsubsequentconventionalsinuslifting,whichwassuc-cessfullycompletedin3patients.Inaddition,harvest-ingthegraftsatintra-oraldonorsitesratherthanfromtheiliaccrestreducedthedemandsmadeontheThelocationofOAFsalongtherootsofneighboringteethmaybeaproblemaftersolitarysofttissueclosure.Whilemucoperiostealßapsmayreattachtoexposedcervices,relapsesarequitecommon.Salvageoftheteethadjacenttothecommunicationbyrestoringthebonysheatharoundtheexposedrootsurfacesisyetanotheradvantageofthepress-Þttechnique.Thankstothisadvantage,theÞrstrightmolarofpatientno.5wassaved.Becausetherewasonly1patientwiththiskindofOAFinthepresentstudy,furtherresearchisneededtoshedlightonthisspecialaspect.Onelimitingfactorofthetechniquemaybetheamountofboneavailableintra-orally.Therefore,itisimportanttoidentifythelargestdiameterofthebonedefectonpreoperativeCTscansandtodecide(clin-Table1.OVERVIEWOFCLINICALDATAOFPATIENTSINCLUDEDINTHISSTUDY ofOAFCauseofOAFSiteofOAFIndicationDefectSize(inmm)1481ExtractionLeftside-1MChron.OAFChin5mmPress-Þt2461ExtractionLeftside-1MChron.OAFRamus4mmPress-Þt3602ExtractionRightside-1PMChron.OAFChin4mmPress-Þt4444ExplantationRightside-1PM,2PM,1MChron.OAFSinusliftChin10mmMiniplate5323ExtractionRightside-2M,3MChron.OAFalongroot16Chin9mmPress-Þt6432ExplantationLeftside-1MChron.OAFSinusliftChin7mmBonescrew7483ExtractionRightside-1PMChron.OAFChin8mm(1PM)MiniplateLeftside-1PM,1M5mm(1PM)5mm(1M)8474ExtractionLeftside-1MChron.OAFSinusliftRamus8mmPress-Þt9463ExtractionLeftside-2MChron.OAFRamus6mmPress-Þt103512ExtractionLeftside-2MChron.OAFChin9mmPress-Þt11450ExplantationRightside-2PM,2MBonedefectduringexpl.Chin8mm(2PM)MiniplateLeftside-1PM6mm(2M)6mm(1PM)1249120ExtractionLeftside-canine,2MChron.OAFChin8mm(canine)Press-Þt12mm(2M)136126ExtractionLeftside-1MChron.OAFChin10mmPress-Þt1456132ExtractionLeftside-2MChron.OAFChin9mmPress-Þt1547120ExtractionRightside-1MChron.OAFChin8mmPress-Þt165818ExtractionLeftside-1MChron.OAFChin10mmPress-Þt17702ExtractionLeftside-2PMChron.OAFRamus4mmPress-Þt18734ExtractionRightside-2MChron.OAFChin7mmPress-Þt19412ExtractionLeftside-1MChron.OAFChin9mmPress-Þt20429ExtractionRightside-1MChron.OAFChin6mmPress-Þt21546ExplantationRightside-1MChron.OAFChin8mmBonescrewAbbreviations:OAF,oro-antralÞstula;PM,premolar;M,molar;Extraction,toothremoval;Explantation,implantremoval.Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005.BONYPRESS-FITCLOSUREOFORO-ANTRALFISTULAS icallyand/orradiologically)whetherthechinortheretromolarregionsareadequatedonorsites.Some-timesitisimpossibletogetablockgraftofsuitablesizebecauseoftheproximitytosensitiveanatomicstructures(rootapices,mentalnerve,mandibularmargin)orbecauseofaninsufÞcientretromolarInthesecasesitisinevitabletoconsiderextra-oraldonorsites(eg,theiliaccrest)forgraft FIGURE9.,CTscansshowingclearlydeÞnedOAF(,OPGaftersurgicalclosureofOAFwithmonocorticalbonegraft.NotebonescrewforinternalgraftÞxation.,OPGaftersinusliftingandlateralgraftingwithboneautograftfromiliaccrest.,CTscansaftersinusliftingandlateralgraftingwithboneautograftfromiliaccrest.Noteclearsterilesinus.,OPGafterplacementof8implantsintheposteriormaxillabilaterally.Watzaketal.BonyPress-FitClosureofOro-AntralFistulas.JOralMaxillofacSurg2005.WATZAKETAL 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