A preliminary study of monocortical bone grafts for oroantral stula closure

Robert Haas, MD, DMD, PhD,a Georg Watzak, MD, DMD,b Monika Baron, MD, DMD,b Gabor Tepper, MD, DMD,b Georg Mailath, DMD, PhD,a and Georg Watzek, MD, DMD, PhD,c Vienna, Austria
UNIVERSITY OF VIENNA

Sinus oor elevation has become a standard procedure in patients affected by severe maxillary atrophy, before implant placement, provided that the maxillary sinus is intact and uninfected. In the case of an oroantral stula, simple soft tissue closure may interfere with the process of elevating the Schneiderian membrane. Total regeneration of the bony sinus oor is necessary to prevent disruption of the sinus membrane. In this study, 5 patients with oroantral stulae of different causes were treated with autogenous monocortical bone blocks harvested from the chin. Press-t closure for bony repair of the basal maxilla was sufcient in 3 of them. Two patients needed additional internal graft xation. In the meantime, the 3 aforementioned patients underwent a successful sinus lift procedure. The use of a monocortical bone block for the closure of an oroantral stula is recommended before internal sinus augmentation. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:263-6)

Communications between the oral cavity and the maxillary sinus commonly occur after extraction of the rst and second molars.1-3 If these problems go untreated, approximately 50% of patients will experience sinusitis 48 hours later and 90% of patients will have sinusitis after 2 weeks of no treatment.4 Therefore, management of communications between oral cavity and sinus after tooth extraction are recommended to promote closure within 24 hours.5 Numerous surgical techniques have been described for the closure of oroantral stulae. Most of them rely on mobilizing the tissue and advancing the resultant ap into the defect.6-9 A Rehrmann ap, which is fashioned by mobilizing the vestibular mucosa,8 is the most widely used technique. An alternative is the use of the buccal fat pad.10 However, soft tissue coverage may fail, especially in large bony defects. Therefore, a method that makes use of autogenous bone grafts harvested from the iliac crest for the closure of the defects has been used.11 Because of the continued need for implant rehabilitation and the necessity of preimplant surgical procedures, such as sinus oor elevation, the routine
a

soft tissue closure of oroantral stulae has become a major problem. This method causes matting of the mucosae and Schneiderian membrane and makes elevation of the sinus membrane without disruption impossible. This technical study was designed to show whether chronic oroantral communications can successfully be closed with intraoral bone grafts and whether these would provide the conditions required for subsequent subantral augmentation in terms of conventional sinus lifting before implant surgery. MATERIAL AND METHODS Patients enrolled in this preliminary study had to fulll 1 of the following criteria: oroantral stula and planned sinus oor elevation oroantral stula along a neighboring root surface extending into the maxillary sinus and undesirable tooth extraction chronic oroantral stula with multiple unsuccessful attempts at closure. Surgery was planned on the basis of a panoramic radiograph and an axial dental computed tomograph (Fig 1). Preoperatively, the affected sinus was irrigated through the stula with physiological saline solution followed by an iodine-containing solution diluted with physiological saline solution (1:1; betadine; Purdue, Norwalk, Conn) to reduce infection. Immediately before the surgical procedure, the patients received amoxicillin and clavulanic acid (Augmentin; GlaxoSmithKline, Uxbridge, England), 2 1 g/day for at least 5 days and a nasal decongestant. 263

Assistant Professor, Department of Oral Surgery, Dental School, University of Vienna, Austria. b Department of Oral Surgery, Dental School, University of Vienna, Austria c Professor and Head of Department of Oral Surgery, Dental School, University of Vienna, Austria. Received for publication Feb 13, 2003; returned for revision May 9, 2003; accepted for publication Jun 30, 2003. 2003, Mosby, Inc. All rights reserved. 1079-2104/2003/$30.00 0 doi:10.1016/S1079-2104(03)00375-5

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Fig 1. An axial computed tomograph shows a clearly dened oroantral stula in the region of the left second molar in the upper jaw. The small gure on the top of the left side shows the orthoradial reconstruction of the defect.

Fig 2. Above, Trephines with matching sizes; the smaller one was for defect creation, whereas the matching bigger one was for harvesting the block graft. Below, An intraoperative view shows the donor site of monocortical grafts in the chin region.

Table. Patient ages, histories, and the characteristics of the oroantral stulae
Patient no. 1 2 Age (y) 44 32 Duration of OAC (mo) 4 24 Cause of OAC Explantation Extraction Defect size (in mm) 10 mm 9 mm

Region of OAC Left side1PM, 2PM, 1M Right side, 2M

Indication Chronic OAF Chronic OAF; bony defect along root of 1M Chronic OAF Chronic OAF

Graft xation Miniplate Press-t

3 4

43 50

2 120

Explanation Explanation

Left side, 1M Left side2PM, 2M Left side, 2M

7 mm 6 mm (2PM) 8 mm (2M) 9 mm

Bone screw Press t

35

12

Explanation

Chronic OAF

Press t

OAF, Oroantral stula; PM, premolar; M, molar.

Surgical procedure Irregular bony defects of the sinus oor were standardized to the smallest possible rounded shape with a trephine. A monocortical block graft was harvested at the donor site (chin) by using a trephine with an inner diameter matching the size of the round bony defect (Fig 2); the graft was then press-t into the defect (Fig 3). If the press t was unstable, miniplates (Leibinger, Freiburg, Germany) or screws were inserted for internal xation. Soft tissue closure was established by using a Rehrmann ap.8 The sutures were drawn 1 week after the surgical procedure. The miniplates were removed at the time of the scheduled sinus lifting (ie, 3 months after the bony closure of the oroantral stula). Six to 12 months after the sinus-closure procedure, the defect sites were evaluated on a computed tomograph to ascertain whether the surgical procedure was successful.

RESULTS A total of 5 patients were treated with monocortical block grafts harvested at intraoral donor sites. The mean age was 40.8 years (range, 32-50 years). The causes of the oroantral stulae, the defect sizes, and other characteristics are listed in the Table. Each patient with extraction-related stulae (patients 2, 4, and 5) underwent 2 unsuccessful attempts of sinus closure with a buccal sliding ap. Three patients were candidates for 2-stage subantral sinus augmentation and implant placement after sinus closure. In 3 patients, a stable press-t of the grafts in the bony maxillary defect was achieved. The remaining 2 patients needed additional internal xation with miniplates or screws. The bony skeleton of the maxilla was completely restored throughout. In 1 patient, mucosal dehiscence developed 4 weeks after the surgical procedure. This necessitated super-

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Haas et al 265

Fig 3. An intraoperative view: Press-tted monocortical bone grafts in the region of the second left premolar and the second left molar.

brane and thus dictate that sinus lifting not be used. Solitary soft tissue closure of oroantral stulae before implant surgery carries a high risk of mucosal injury during augmentation because of the adhesion of the oral mucosa to the Schneiderian membrane. Sinus closure with bone grafts harvested from the iliac crest, as reported in 1969 by Proctor,11 is an attractive option, but its use should be reserved for large defects because of the known morbidity inherent with this procedure. A congruous t of the graft in the defect is the key to bony healing.12 This can be ensured with burs of matching sizes. In 3 of our 5 patients, the perfect press-t obviated additional internal graft xation. In the remaining 2 patients, press-t xation was inadequate, so a miniplate (patient 1) or a bone screw (patient 3) was necessary. In patient 2, closure of the communication along an adjacent root preserved the neighboring tooth. Bone graft harvesting at intraoral donor sites substantially reduced the demands made on the patients postoperatively.13-16 Nonetheless, 1 of the patients in this study developed wound dehiscence at the recipient site postoperatively. This complication rate is in keeping with those reported for other procedures17 and did not result in reopening of the sinus, but the wound healed by secondary intention. Therefore, this novel surgical technique is useful for closing chronic oroantral stulas in patients with known stulae between the maxillary sinus and the nasal cavity closing oroantral stulae to pave the way for subsequent conventional sinus lifting closing oroantral communications extending along exposed root surfaces.
REFERENCES
1. Killey HC, Kay LW. An analysis of 250 cases of oro-antral stula treated by the buccal ap operation. Oral Surg Oral Med Oral Pathol 1967;24:726-39. 2. von Wowern N. Oroantral communications and displacements of roots into the maxillary sinus: a follow-up of 231 cases. J Oral Surg 1971;29:622-7. 3. Ehrl PA. Oroantral communication. Epicritical study of 175 patients, with special concern to secondary operative closure. Int J Oral Surg 1980;9:351-8. 4. Wassmund M, Lidgas G, editors. Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer. Leipzig (Germany): Meusser; 1935. 5. Lindorf HH, editor. Chirurgie der odontogen erkrankten Kieferhohle. Munich (Germany): Hanser; 1983. 6. Pichler H, Trauner R. Mund- und Kieferchirurgie. Vienna: Urban and Schwarzenberg; 1948. 7. Axhausen G. Uber plastische Operationen in der Mundhohle und am Unterkiefer. Dtsch Zahnarztl Wschr 1930;33:338-42. 8. Rehrmann A. Eine Methode zur Schliessung von Kieferhohlen perforationen. Dtsch Zahnarztl Wschr 1936;39:1136-9. 9. Schuchart K. Zur Methodik des Verschlusses von Defekten im Alveolarfortsatz zahnloser Oberkiefer. Dtsch Zahn Mund Kieferheilkd 1953;17:366-70. 10. Egyedi P. Utilization of the buccal fat pad for closure of oroantral and/or oro-nasal communications. J Maxillofac Surg 1977; 5:241-4.

cial decortication of the graft and daily disinfection with 3% hydrogen and Peruvian balm application. The soft tissue defect healed by secondary intention within 14 days. The sinus itself was unaffected. The postoperative course was uneventful in all other patients. Radiologically, the bony union was veried 8 months after the surgical procedure, on average, by computed tomographic evidence. In 3 patients with planned implant rehabilitation, a sinus lift procedure was performed through a lateral window 3 months after bony sinus closure. At the time of the sinus lifting, the sinus membrane overlying the original bony defect was found to be intact and neither elevation nor augmentation caused any problems. DISCUSSION For internal grafting of the maxilla, the sinus membrane should be intact without any signs of inammation. Chronic oroantral stulae usually cause severe chronic inammatory thickening of the sinus mem-

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16. Lundgren S, Nystrom E, Nilson H, Gunne J, Lindhagen O. Bone grafting to the maxillary sinuses, nasal oor and anterior maxilla in the atrophic edentulous maxilla. A two-stage technique. Int J Oral Maxillofac Surg 1997;26:428-34. 17. Schmelzeisen R, Hessling KH, Barsekow F, Girod S. Complications in the plastic closure of oro-antral communications. Dtsch Zahnarztl Z 1988;43:1335-7. Reprint requests: Robert Haas, MD, DMD Department of Oral Surgery Dental School University of Vienna, Austria Waehringerstrasse 25A A-1090 Vienna Austria, European Union robert.haas@univie.ac.at

11. Proctor B. Bone graft closure of large or persistent oromaxillary stula. Laryngoscope 1969;79:822-6. 12. Dortbudak O, Haas R, Bernhart T, Mailath-Pokorny G. Inlay autograft of intra-membranous bone for lateral alveolar ridge augmentation: a new surgical technique. J Oral Rehabil 2002;29:835-41. 13. Nkenke E, Schultze-Mosgau S, Radespiel-Troger M, Kloss F, Neukam FW. Morbidity of harvesting of chin grafts: a prospective study. Clin Oral Implants Res 2001;12:495-502. 14. Dario LJ, English R Jr. Chin bone harvesting for autogenous grafting in the maxillary sinus: a clinical report. Prac Periodontics Aesthet Dent 1994;6:87-91. 15. Raghoebar GM, Batenburg RH, Timmenga NM, Vissink A, Reintsema H. Morbidity and complications of bone grafting of the sinus oor of the maxillary sinus for the placement of endosseous implants. Mund Kiefer Gesichtschir 1999;3:65-9.

Erratum Magnetic resonance evaluation of the disk before and after arthroscopic surgery for temporomandibular joint disorders (Ohnuki T, Fukuda M, Iino M, Takahashi T, 2003;96:141-8)

Following is a revised version of Table VI from Magnetic resonance evaluation of the disk before and after arthroscopic surgery for temporomandibular joint disorders (Ohnuki T, Fukuda M, Iino M, Takahashi T, 2003;96:141-8).

Table VI Preoperative versus postoperative disk morphology according to group

Successful group* Postoperative disk morphology Preoperative disk morphology Enlargement of posterior band Even thickness Biconvex Total Enlargement of posterior Even band thickness 1 0 0 1 (3.1%) 0 total no. of TMJs 10 (31.3%)

Biconvex 9

1 0 1 (3.1%) 0 21 21 (100%) 1 (3.1%) 30 (93.8%) 32 (100%)

Unsuccessful group* Postoperative disk morphology Preoperative disk morphology Enlargement of posterior band Even thickness Biconvex Total Enlargement of posterior Even band thickness 1 0 0 1 (9.1%) 1 total no. of TMJs 10 (90.9%)

Biconvex 8

0 0 0 (0.0%) 0 1 1 (9.1%) 1 (9.1%) 9 (81.7%) 11 (100%)

On preoperative MRI, the disk morphology of the successful group showed more progressive deformity than that of the unsuccessful group. *Wilcoxon single rank test P .01. P .01 (Mann-Whitney U test).