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Evaluation of Vestibular depth with

Inverted Periosteal Flap vs. Buccal Advancement Flap
for Closure of Oroantral Communication

Dr. Sajeel Ahmad
BDS, FCPS II Resident (Oral and Maxillofacial Surgery)

Supervised by:
Prof. Dr. Muhammad Usman Akhtar
BSc, BDS (Hons), MCPS, MDS
DeMontmorency Institute of Dental Sciences/
Punjab Dental Hospital, Lahore, Pakistan
The Director,
Research and Training Monitoring Cell,
College of Physicians and Surgeons, Pakistan,
7th Central Street Phase II,
DHA, Karachi- 75500

SUBJECT: Submission of Synopsis for Dissertation

Dear Sir/Madam,
Enclosed herewith please find research study titled

Evaluation of Vestibular depth with

Inverted Periosteal Flap vs. Buccal Advancement Flap for Closure of Oroantral Communication

Prepared by: Dr. Sajeel Ahmad

Name of specialty: Oral and Maxillofacial Surgery

RTMC Reg. no: DSG-2016-077-1827
CPSP ID: 2016-1739

Trainees signature: _________________________________

Name of supervisor: Prof. Dr. Muhammad Usman Akhtar

Qualification: BSc, BDS (Hons), MCPS, MDS

Designation: Professor
Department: Oral and Maxillofacial Surgery
Name of training institution: DeMontmorency College of Dentistry/ Punjab Dental Hospital,

Signature of Supervisor: ______________________________

The Director,
Research and Training Monitoring Cell,
College of Physicians and Surgeons, Pakistan,
7th Central Street, Phase II,
DHA, Karachi- 75500

This is to certify that the FCPS II synopsis topic Evaluation of Vestibular depth with

Inverted Periosteal Flap vs. Buccal Advancement Flap for Closure of Oroantral Communication

of my candidate has not been conducted in the Department of Oral & Maxillofacial Surgery at

deMontmorency College of Dentistry/ Punjab Dental Hospital. Furthermore this study is not

currently being duplicated in this institute.

It is further explained that ethical issues regarding the topic have been discussed and found

to have no objection regarding study by the ethical committee.

Signature of Supervisor: _____________________________

Prof. Dr. Muhammad Usman Akhtar

Department of Oral and Maxillofacial Surgery
Punjab Dental Hospital/ DeMontmorency College of Dentistry

An oroantral communication (OAC) is an open connection between the oral cavity and
the maxillary sinus.1 Extraction of maxillary posterior teeth is the most common cause of an
oroantral communication as the thickness of the sinus floor in that region ranges from 1 to 7
mm, resulting in an anatomically close relationship between the root apices of the premolar
and molar teeth and the maxillary antrum. 1, 2 Other less common causes includes maxillary
cysts, benign or malignant tumors and trauma.3 The most common sequelae of such a
communication are postoperative maxillary sinusitis and the formation of a chronic oroantral

The management of an oroantral communication depends on a number of factors

including size of the communication, site, time since creation of communication etc. Despite
the existence of numerous alternative techniques, surgical closure still remains the treatment
of choice. Surgical options include the buccal advancement flap, the Moczair flap, the buccal
fat pad, palatal flaps, tongue flaps, autogenous bone graft as well as allogenic, xenografts and
synthetic graft materials.

The Buccal advancement flap described by Rehrmann is the most commonly used
method for closure of oroantral communications. While the procedure carries a high success
rate of up to 93%, the Buccal sulcus depth is almost invariably compromised. The advancement
of the Buccal flap crestally and medially causes a significant reduction in the vestibular depth,
leading to a level of discomfort that is described by patients as a sensation that their Buccal
mucosa has been sutured to their alveolar mucosa. (Reference master article) The compromised
sulcus depth also leads to limitation in the future restorative options of patients planned for
removable prosthesis requiring adequate vestibular depth. (reference batra)

Intro of inverted periosteal flap.


The rationale of this study is to suggest the inverted periosteal flap as a beneficial alternative
treatment for closure of oroantral communications, in terms of better conservation of vestibular
depth as compared to other surgical options.


To evaluate the change in vestibular depth using two different methods of surgical closure of
oroantral communications.

1. Oroantral communication is an open connection between the oral cavity and the
maxillary sinus.

2. Vestibular depth The distance from the crest of the residual alveolar ridge to the fornix
of the buccal vestibule. The fornix is the highest part of the vestibule next to the maxilla.
The maxillary buccal vestibule is the area bounded by the alveolar gingiva, the buccal
mucosa, the buccal frenum, and the hamular notch.

3. Periodontal probe It is a long, thin, blunted instrument which is used to measure the
depth of the maxillary vestibule. It has 0.5mm ball at the tip and millimeter markings are
present at 3.5mm, 5.5mm, 8.5mm and 11.5mm interval and colour coding at 3.5mm to


Study design: Descriptive case series

Setting: Outdoor Patient Department, Oral and Maxillofacial Surgery, Punjab Dental Hospital/
deMontmorency College of Dentistry, Lahore.

Duration of study: Six months after approval of synopsis.

Sample size: The calculated sample size is ??????????????

Sampling technique: Non-probability purposive sample


Inclusion Criteria
1. Patients ages 18-65 years of both genders.
2. Presence of post extraction oroantral communication as revealed by history
3. Size of oroantral communication between 2-10 mm on clinical examination
Exclusion Criteria
1. Medically compromised patients like Diabetes mellitus (DM) assessed on history.
2. Patients who are regular smokers.
3. Patients who are unable to attend follow up visits and unwilling to give informed consent.


All the patients fulfilling the inclusion criteria will be selected from the outpatient
department of oral and maxillofacial surgery, Punjab Dental Hospital on the basis of history,
clinical and radiographic examination. Study protocol use of data for research and risk benefit
ratio will be explained to the patients and a written informed consent will be taken. The ethical
committee of de Montmorency College of Dentistry shall review ethical aspect of synopsis. A
structured proforma will be used to record the patients demographic details like name, age,
gender. A preoperative recording of the maxillary buccal vestibular depth at three points
(anterior, middle and posterior) adjacent to the oroantral communication will be made using a
periodontal probe.
The surgical procedure will be performed under local anesthesia. After the injection of
sufficient local anesthetic (lignocaine 2% with 1:100,000 adrenaline), a crestal incision will be
made with a no.15 blade, with anterior and posterior releasing incisions and a full thickness
mucoperiosteal flap will be raised. To retract the flap, two sutures will be passed through each
of the two corners of the full thickness flap at its crestal aspect. One suture each will then
passed through both apical corners of the flap through the periosteal layer only, using a separate
needle for each corner, and clipped with a small hemostat. A sharp scissor or blade will then
be used to dissect the periosteum in a split-thickness manner from the underlying submucosal
tissue in an apical to crestal direction, while applying traction on the hemostats. To avoid
unintentional separation of the periosteal layer, the dissection will be stopped at least 3mm
short of the crestal edge of the flap. The periosteal free edge will then be approximated to the
palatal or lingual tissues using the two sutures already passed at the apical edges, and any
additional sutures will be placed if required. The wound will be then irrigated with saline and
the buccal flap approximated and closed with resorbable sutures. Postoperative recording of
the maxillary buccal vestibular depth at the three locations will be taken with a periodontal
probe. Oral antibiotics Amoxicillin 500 mg and NSAIDS three times daily for 5 days will be
prescribed to all patients. All patients will be instructed to avoid blowing their nose, drinking
with a straw, playing any wind instruments etc. All patients will be invited to return for follow
up after 3 weeks. The procedure described will be carried out by the researcher himself.


Data will be entered and analyzed by using Statistical Package for Social Sciences (SPSS)
version 17.0. Mean and standard deviation will be calculated for quantitative variables like age
and duration. Qualitative variables like gender and sensation will be calculated as frequency
and percentage. Effect modifiers like age and gender will be controlled through stratification.
Post stratification Chi square test will be applied by taking P=0.05 as a significant.

1. Visscher S, van Minnen B, Bos R. Closure of Oroantral Communications: A Review of the

Literature. Journal of Oral and Maxillofacial Surgery. 2010;68(6):1384-1391.

2. Abuabara A, Cortez A, Passeri L, de Moraes M, Moreira R. Evaluation of different treatments

for oroantral/oronasal communications: experience of 112 cases. International Journal of Oral
and Maxillofacial Surgery. 2006;35(2):155-158.

3. Hernando J, Gallego L, Junquera L, Villarreal P. Oroantral communications. A retrospective

analysis. Medicina Oral Patologa Oral y Cirugia Bucal. 2010;:e499-e503.

4. Visscher S, van Roon M, Sluiter W, van Minnen B, Bos R. Retrospective Study on the Treatment
Outcome of Surgical Closure of Oroantral Communications. Journal of Oral and Maxillofacial
Surgery. 2011;69(12):2956-2961.

5. Rosenfeld E. Inverted Periosteal Flap: An Alternative to the Buccal Advancement Flap for
Tension-Free, Watertight Closure. Journal of Oral and Maxillofacial Surgery. 2014;72(7):1244-


Evaluation of Vestibular depth with Inverted Periosteal Flap vs.

Buccal Advancement Flap for Closure of Oroantral Communication

Name _______________________________ Age ______________ Gender: Male Female

Address: ____________________________ Contact No.: _________________________________

Clinical Data - (Pre Op and Immediate Post Op)

Site of OAC: ________________________________________________________________________

Duration of OAC: ___________________________________________________________________

Removal method: Simple Extraction Surgical Extraction

Treatment Strategy: Inverted Periosteal Flap Buccal Advancement Flap

Vestibular depth (in mm) Pre-Op Post-Op

Reading 1
Reading 2
Reading 3

Follow Up

Closure of communication: Yes No

Presence of Maxillary Sinusitis at follow up: Yes No
Satisfactory wound healing: Yes No

Vestibular depth (in mm) Follow Up (3 weeks)

Reading 1
Reading 2
Reading 3

Decrease in Vestibular Depth: Yes No

Informed Consent: _____________________________________________________

Doctors Signature: _____________________________________________________