**8. Flaps for management of oroantral communication**

### **8.1 Background**

Oroantral communication/fistula is an unnatural communication between the oral cavity and the maxillary sinus. These complications occur most commonly during the extraction of upper molar and premolar teeth (48%). The major reason is the anatomic proximity or projection of the roots within the maxillary sinus [25]. Other causes of oroantral communication/fistula include tuberosity fracture, dentoalveolar/periapical infections of molars, implant dislodgement, maxillary sinus, trauma (7.5%), presence of maxillary cysts or tumors (18.5%), osteoradionecrosis, flap necrosis, and dehiscence following implant failure [25, 26]. Two basic principles must be considered while operating for Oroantral communication/fistula. First, the sinus must be free of any types of infection with adequate nasal drainage. Second, closure must be tension-free and consists of broadly based, wellvascularized soft tissue flaps over the intact bone. Successful closure of the oroantral fistula should be preceded by the complete elimination of any sinus pathology, the fistulous tract, sinus infection, degenerated mucosa, and diseased bone [27].

#### *Flap Techniques in Dentoalveolar Surgery DOI: http://dx.doi.org/10.5772/intechopen.91165*

Advantage

*Oral Diseases*

Limitations

**7.7 Palatal flap**

Advantage

exposure

Limitations

**8.1 Background**

bone [27].

**222**

extended mesially to the canine

adequate surgical field

• This flap is useful in teeth with a generous mesiodistal width, affording an

• The narrow neck needs careful releasing, careful adaptation, and suturing

• This flap may be not suitable in narrow mesiodistal distance between teeth

A festoon flap is performed at the gingival margins on the palatal side. This flap is used in periapical surgery of the palatal roots of the maxillary molars. Palatal releasing incisions are not necessary. If any such incisions are made, they should be performed between the canine and premolar, representing the vascularization limit between the nasopalatine artery and the anterior palatine artery, or distal to the second molar behind the emergence point of the anterior palatine artery [24].

• Useful in cases in which the palatal roots of molars or lateral incisors require

• If the flap needs to be expanded to gain greater visibility, the incision can be

• Chance of hematoma formation may jeopardize the blood supply of the flap

Oroantral communication/fistula is an unnatural communication between the oral cavity and the maxillary sinus. These complications occur most commonly during the extraction of upper molar and premolar teeth (48%). The major reason is the anatomic proximity or projection of the roots within the maxillary sinus [25]. Other causes of oroantral communication/fistula include tuberosity fracture, dentoalveolar/periapical infections of molars, implant dislodgement, maxillary sinus, trauma (7.5%), presence of maxillary cysts or tumors (18.5%), osteoradionecrosis, flap necrosis, and dehiscence following implant failure [25, 26]. Two basic principles must be considered while operating for Oroantral communication/fistula. First, the sinus must be free of any types of infection with adequate nasal drainage.

Second, closure must be tension-free and consists of broadly based, wellvascularized soft tissue flaps over the intact bone. Successful closure of the oroantral fistula should be preceded by the complete elimination of any sinus pathology, the fistulous tract, sinus infection, degenerated mucosa, and diseased

• This flap may cause pain and discomfort for the patient postoperatively

**8. Flaps for management of oroantral communication**

The most common flap procedures may be categorized into local flaps, distant flaps, and grafting. The flaps involving rotating or advancing soft tissues include buccal flap, palatal flap, submucosal tissue flap, and buccal fat pad and tongue flap [26]. The procedures utilizing buccal mucoperiosteal flap for closure include straight-advancement flap, rotation-advancement flap, transverse flap, and sliding flap techniques, and those utilizing palatal mucoperiosteum include straightadvancement flap, rotational advancement flap, hinged flap, and island flap procedures [26]. Double-layer closure utilizing local tissues includes the combination of inversion and rotational advancement flaps, double overlapping hinged flaps, double island flaps, and superimposition of reverse palatal and buccal flaps. However, the studies over the last 50 years point out the lack of consensus for a uniformly successful procedure [28].

Here we illustrate the most common flaps used for closure of oroantral communication/fistula: the buccal flap and the palatal pedicle flap techniques.

#### **8.2 Buccal advancement flap**

It has been described [14, 29] the use of a buccal flap with a thin layer of buccinator muscle to close an oroantral defect. Later, [30] reported a buccal sliding flap technique, which is still in use, as a tool to close small to medium size (<1 cm) lateral or mid-alveolar fistulas, located either laterally or in the middle of the alveolar process. Krompotie and Bagatin [13] reported the immediate closure of an oroantral communication by a rotating gingiva-vestibular flap. This technique can also be employed for closing oroantral fistulas. It is a modification of a vestibular flap in order to avoid lowering of the vestibular sulcus, an event that takes place normally when using vestibular flaps. Two vertical release incisions are made to provide a flap with dimensions suitable for closure of the antral communication (**Figure 34**).

Incision removal of the epithelial lining of the palatal mucosa behind the communication might also be required. The flap with a trapezoidal shape consists of both epithelium and connective tissues and is positioned over the defect using mattress sutures from the buccal flap to the palatal mucosa.

Advantage

• It is possibly utilized in cases of severly resorbed alvealr ridge, and the fistula is located in a more mesial area [31]

Limitation

• Loss of vestibular depth buccally

**Figure 34.** *The buccal advancement flap is used to close OAC (arrow).*
