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A preliminary study of monocortical bone grafts for oroantral

fistula 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

Sinus floor 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 fistula,
simple soft tissue closure may interfere with the process of elevating the Schneiderian membrane. Total regeneration of
the bony sinus floor is necessary to prevent disruption of the sinus membrane.
In this study, 5 patients with oroantral fistulae of different causes were treated with autogenous monocortical
bone blocks harvested from the chin. Press-fit closure for bony repair of the basal maxilla was sufficient in 3 of them.
Two patients needed additional internal graft fixation. 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 fistula 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 max- soft tissue closure of oroantral fistulae has become a
illary sinus commonly occur after extraction of the first major problem. This method causes matting of the
and second molars.1-3 If these problems go untreated, mucosae and Schneiderian membrane and makes el-
approximately 50% of patients will experience sinusitis evation of the sinus membrane without disruption
48 hours later and 90% of patients will have sinusitis impossible.
after 2 weeks of no treatment.4 Therefore, management This technical study was designed to show whether
of communications between oral cavity and sinus after chronic oroantral communications can successfully be
tooth extraction are recommended to promote closure closed with intraoral bone grafts and whether these
within 24 hours.5 would provide the conditions required for subsequent
Numerous surgical techniques have been described subantral augmentation in terms of conventional sinus
for the closure of oroantral fistulae. Most of them rely lifting before implant surgery.
on mobilizing the tissue and advancing the resultant
flap into the defect.6-9 A Rehrmann flap, which is
fashioned by mobilizing the vestibular mucosa,8 is the MATERIAL AND METHODS
most widely used technique. An alternative is the use of Patients enrolled in this preliminary study had to
the buccal fat pad.10 However, soft tissue coverage may fulfill 1 of the following criteria:
fail, especially in large bony defects. Therefore, a ● oroantral fistula and planned sinus floor elevation
method that makes use of autogenous bone grafts har- ● oroantral fistula along a neighboring root surface
vested from the iliac crest for the closure of the defects extending into the maxillary sinus and undesirable
has been used.11 tooth extraction
Because of the continued need for implant reha- ● chronic oroantral fistula with multiple unsuccessful
bilitation and the necessity of preimplant surgical attempts at closure.
procedures, such as sinus floor elevation, the routine Surgery was planned on the basis of a panoramic
radiograph and an axial dental computed tomograph
Assistant Professor, Department of Oral Surgery, Dental School, (Fig 1). Preoperatively, the affected sinus was irrigated
University of Vienna, Austria. through the fistula with physiological saline solution
Department of Oral Surgery, Dental School, University of Vienna,
followed by an iodine-containing solution diluted with
Professor and Head of Department of Oral Surgery, Dental School, physiological saline solution (1:1; betadine; Purdue,
University of Vienna, Austria. Norwalk, Conn) to reduce infection.
Received for publication Feb 13, 2003; returned for revision May 9, Immediately before the surgical procedure, the pa-
2003; accepted for publication Jun 30, 2003.
© 2003, Mosby, Inc. All rights reserved.
tients received amoxicillin and clavulanic acid (Aug-
1079-2104/2003/$30.00 ⫹ 0 mentin; GlaxoSmithKline, Uxbridge, England), 2 ⫻ 1
doi:10.1016/S1079-2104(03)00375-5 g/day for at least 5 days and a nasal decongestant.

September 2003

Fig 1. An axial computed tomograph shows a clearly defined Fig 2. Above, Trephines with matching sizes; the smaller one
oroantral fistula in the region of the left second molar in the was for defect creation, whereas the matching bigger one was
upper jaw. The small figure on the top of the left side shows for harvesting the block graft. Below, An intraoperative view
the orthoradial reconstruction of the defect. shows the donor site of monocortical grafts in the chin region.

Table. Patient ages, histories, and the characteristics of the oroantral fistulae
Patient Age of OAC Cause of Defect size (in
no. (y) (mo) OAC Region of OAC Indication mm) Graft fixation
1 44 4 Explantation Left side—1PM, Chronic OAF 10 mm Miniplate
2PM, 1M
2 32 24 Extraction Right side, 2M Chronic OAF; bony 9 mm Press-fit
defect along root
of 1M
3 43 2 Explanation Left side, 1M Chronic OAF 7 mm Bone screw
4 50 120 Explanation Left side—2PM, Chronic OAF 6 mm (2PM) Press fit
8 mm (2M)
5 35 12 Explanation Left side, 2M Chronic OAF 9 mm Press fit

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

Surgical procedure RESULTS

Irregular bony defects of the sinus floor were stan- A total of 5 patients were treated with monocorti-
dardized to the smallest possible rounded shape with a cal block grafts harvested at intraoral donor sites.
trephine. A monocortical block graft was harvested at The mean age was 40.8 years (range, 32-50 years).
the donor site (chin) by using a trephine with an inner The causes of the oroantral fistulae, the defect sizes,
diameter matching the size of the round bony defect and other characteristics are listed in the Table.
(Fig 2); the graft was then press-fit into the defect (Fig Each patient with extraction-related fistulae (patients
3). If the press fit was unstable, miniplates (Leibinger, 2, 4, and 5) underwent 2 unsuccessful attempts of sinus
Freiburg, Germany) or screws were inserted for internal closure with a buccal sliding flap. Three patients were
fixation. Soft tissue closure was established by using a candidates for 2-stage subantral sinus augmentation and
Rehrmann flap.8 The sutures were drawn 1 week after implant placement after sinus closure. In 3 patients, a
the surgical procedure. The miniplates were removed at stable press-fit of the grafts in the bony maxillary defect
the time of the scheduled sinus lifting (ie, 3 months was achieved. The remaining 2 patients needed addi-
after the bony closure of the oroantral fistula). tional internal fixation with miniplates or screws. The
Six to 12 months after the sinus-closure procedure, bony skeleton of the maxilla was completely restored
the defect sites were evaluated on a computed tomo- throughout.
graph to ascertain whether the surgical procedure was In 1 patient, mucosal dehiscence developed 4 weeks
successful. after the surgical procedure. This necessitated superfi-
Volume 96, Number 3

brane and thus dictate that sinus lifting not be used.

Solitary soft tissue closure of oroantral fistulae 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 fit 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-fit obviated
additional internal graft fixation. In the remaining 2 pa-
tients, press-fit fixation 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 sub-
stantially 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 keep-
ing 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 fistulas in patients with
known fistulae between the maxillary sinus and the
nasal cavity
Fig 3. An intraoperative view: Press-fitted monocortical bone
● closing oroantral fistulae to pave the way for subse-
grafts in the region of the second left premolar and the second
left molar. quent conventional sinus lifting
● closing oroantral communications extending along
exposed root surfaces.

cial decortication of the graft and daily disinfection 1. Killey HC, Kay LW. An analysis of 250 cases of oro-antral
with 3% hydrogen and Peruvian balm application. The fistula treated by the buccal flap operation. Oral Surg Oral Med
soft tissue defect healed by secondary intention within Oral Pathol 1967;24:726-39.
2. von Wowern N. Oroantral communications and displacements of
14 days. The sinus itself was unaffected. The postop- roots into the maxillary sinus: a follow-up of 231 cases. J Oral
erative course was uneventful in all other patients. Surg 1971;29:622-7.
Radiologically, the bony union was verified 8 3. Ehrl PA. Oroantral communication. Epicritical study of 175
patients, with special concern to secondary operative closure. Int
months after the surgical procedure, on average, by J Oral Surg 1980;9:351-8.
computed tomographic evidence. 4. Wassmund M, Lidgas G, editors. Lehrbuch der praktischen
In 3 patients with planned implant rehabilitation, a Chirurgie des Mundes und der Kiefer. Leipzig (Germany):
Meusser; 1935.
sinus lift procedure was performed through a lateral 5. Lindorf HH, editor. Chirurgie der odontogen erkrankten Kiefer-
window 3 months after bony sinus closure. At the time höhle. Munich (Germany): Hanser; 1983.
of the sinus lifting, the sinus membrane overlying the 6. Pichler H, Trauner R. Mund- und Kieferchirurgie. Vienna: Urban
and Schwarzenberg; 1948.
original bony defect was found to be intact and neither 7. Axhausen G. Über plastische Operationen in der Mundhöhle und
elevation nor augmentation caused any problems. am Unterkiefer. Dtsch Zahnärztl Wschr 1930;33:338-42.
8. Rehrmann A. Eine Methode zur Schliessung von Kieferhöhlen-
perforationen. Dtsch Zahnärztl Wschr 1936;39:1136-9.
DISCUSSION 9. Schuchart K. Zur Methodik des Verschlusses von Defekten im
For internal grafting of the maxilla, the sinus mem- Alveolarfortsatz zahnloser Oberkiefer. Dtsch Zahn Mund Kief-
brane should be intact without any signs of inflamma- erheilkd 1953;17:366-70.
10. Egyedi P. Utilization of the buccal fat pad for closure of oro-
tion. Chronic oroantral fistulae usually cause severe antral and/or oro-nasal communications. J Maxillofac Surg 1977;
chronic inflammatory thickening of the sinus mem- 5:241-4.
September 2003

11. Proctor B. Bone graft closure of large or persistent oromaxillary 16. Lundgren S, Nystrom E, Nilson H, Gunne J, Lindhagen O. Bone
fistula. Laryngoscope 1969;79:822-6. grafting to the maxillary sinuses, nasal floor and anterior maxilla
12. Dörtbudak O, Haas R, Bernhart T, Mailath-Pokorny G. Inlay in the atrophic edentulous maxilla. A two-stage technique. Int
autograft of intra-membranous bone for lateral alveolar ridge aug- J Oral Maxillofac Surg 1997;26:428-34.
mentation: a new surgical technique. J Oral Rehabil 2002;29:835-41. 17. Schmelzeisen R, Hessling KH, Barsekow F, Girod S. Complica-
13. Nkenke E, Schultze-Mosgau S, Radespiel-Troger M, Kloss F, tions in the plastic closure of oro-antral communications. Dtsch
Neukam FW. Morbidity of harvesting of chin grafts: a prospec- Zahnärztl Z 1988;43:1335-7.
tive 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 Periodon- Reprint requests:
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Robert Haas, MD, DMD Department of Oral Surgery Dental
15. Raghoebar GM, Batenburg RH, Timmenga NM, Vissink A,
Reintsema H. Morbidity and complications of bone grafting of School University of Vienna, Austria Waehringerstrasse 25A
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Magnetic resonance evaluation of the disk before and after

arthroscopic surgery for temporomandibular joint
disorders (Ohnuki T, Fukuda M, Iino M, Takahashi T,

Following is a revised version of Table VI from “Mag- Table VI Preoperative versus postoperative disk mor-
netic resonance evaluation of the disk before and after phology according to group
arthroscopic surgery for temporomandibular joint dis- Successful group*
orders” (Ohnuki T, Fukuda M, Iino M, Takahashi T, Postoperative disk morphology†
2003;96:141-8). Enlargement
Preoperative disk of posterior Even total no.
morphology† band thickness Biconvex of TMJs
Enlargement of 1 0 9 10 (31.3%)
posterior band
Even thickness 0 1 0 1 (3.1%)
Biconvex 0 0 21 21 (100%)
Total 1 (3.1%) 1 (3.1%) 30 (93.8%) 32 (100%)
Unsuccessful group*
Postoperative disk morphology†
Preoperative Enlargement
disk of posterior Even total no.
morphology† band thickness Biconvex of TMJs
Enlargement of 1 1 8 10 (90.9%)
posterior band
Even thickness 0 0 0 0 (0.0%)
Biconvex 0 0 1 1 (9.1%)
Total 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).