Treatment of Long-Standing Communications Medical Assignment Help

Treatment of Lon’g-Stariding Communications

Successful treatment and closure of the oroantral communication requires extensive surgery. Aggressive antibiotic treatment is lso necessary. If the fistula has developed’ next to the root of an adjacent tooth, closure is further complicated and, to be successful, removal of the tooth may be necessary. Surgeons use various techniques to close oroantral fistulas .or communications. Some techniques involve mobilization and rotation of large mucosal flaps to cover , the osseous defect with soft tissues, the margins of which are sutured over and therefore supported by intact bone. , The mucosal flaps must be designed to have a good blood supply and to alter the surrounding anatomy to the smallest extent possible. If sinus disease exists, it may be necessary to remove diseased tissues from the sinus using Caldwell-Luc procedure through the ateral maxillary wall above the apices of the remaining teeth. The Caldwell-Luc procedure includes the creation of an opening into the nose at the level of the sinus floor beneath the inferior turbinate to allow drainage of secretions  of the sinus mucosa into the nasal cavity. This porttoa of the procedure is termed nasal antrostomy. Other methods of closing oroantral fistulae include buccal flap advancement (Fig. 19-13), palatal flap advancement (Fig. 19-14), and advancement of both palatal and facial flaps over a metallic-foil plate. This plate is adapted to the contour of the alveolar process in the fistulous tract area and Interposed between th~ alveolar bone and verlying mucosal flaps (Hg. 19-15 on pages 4?1-433). The metal foil technique provides a );.hysical barrier over the osseous defect and also a more stable };I,atform tc support the mucosal flaps.  Regardless of the technique used, it must be remember that the osseous defect surrounding the fistula is always much larger than the clinically apparent soft tissue deformity. Surgical planning of closure technique must be adjusted accordingly,

alveolar process. Incision for closure of fistula with buccal flap advancement procedure is ouUined. The fistulous tract Itself wiI be excised. In addition, the margins of flap are wide enough to rest on bone when advanced to cover osseous defect. B, Elevated buccal flap. Rap-is released to depth of labial YeStlbuIe.If necesSary, periosteum may be incised on deep surface of flap to allow advancement of soft tissue to cover osseous defect without placing flap under tension. C, Advanced anG sutured buccal flap. Rap must be positioned with minimal tension and Its margins supported by underlying bone to ensure adequate closure of fistulous defect. 0, Crou-sectIon of buccal flap closure of oroantral fistula. Buccal flap has been elevated and underlying periosteum Incised to Improve mobility of flap. Continued

alveolar process. Incision for closure of fistula with buccal flap advancement procedure is ouUined. The
fistulous tract Itself wiI be excised. In addition, the margins of flap are wide enough to rest on bone
when advanced to cover osseous defect. B, Elevated buccal flap. Rap-is released to depth of labial
YeStlbuIe.If necesSary, periosteum may be incised on deep surface of flap to allow advancement of soft
tissue to cover osseous defect without placing flap under tension. C, Advanced anG sutured buccal
flap. Rap must be positioned with minimal tension and Its margins supported by underlying bone to
ensure adequate closure of fistulous defect. 0, Crou-sectIon of buccal flap closure of oroantral fistula.
Buccal flap has been elevated and underlying periosteum Incised to Improve mobility of flap.
Continued

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FIG. 19-14 Palatal flap closure of· oroantral communications. A, Diagrammatic illustration of oroat"Itrai fistuloUs tract in right maxillary alveQlar process In region of second molar, which is to be dosed with rotatjon of palatal flap. Anterior' palatine artery must be included in flap to provide adequate blood supply to transpositloned soft tis.;ues.• , Soft tissues surrounding oroantral opening are excised, exposing underlying alveolar bOne around osseous defect. Palatal flap is outlined, incised, and elevated from anterior to posterior. Flap snould be full thickness of mucoperiosteum, should have broad posterior base, and should include'anterior palatine artery. Its width should be sufficient to cover entire defect around oroa~~tr!!opening, and its length must be adequate to allow rotation of flap and repositioning over defect without placing undue tension on flap. C, Palatal flap has been rotated to cover !>Sseousdefect in alveolar process and sutured in'place, Exposed bone on palate, Which remains after rotation of flap, will heal by secondal) intentil)O with minimal discomfort to patient and little or . . no alteration In normal soft tissue anato~.

FIG. 19-14 Palatal flap closure of· oroantral communications. A, Diagrammatic illustration of
oroat”Itrai fistuloUs tract in right maxillary alveQlar process In region of second molar, which is to be
dosed with rotatjon of palatal flap. Anterior’ palatine artery must be included in flap to provide adequate
blood supply to transpositloned soft tis.;ues.• , Soft tissues surrounding oroantral opening are
excised, exposing underlying alveolar bOne around osseous defect. Palatal flap is outlined, incised, and
elevated from anterior to posterior. Flap snould be full thickness of mucoperiosteum, should have
broad posterior base, and should include’anterior palatine artery. Its width should be sufficient to cover
entire defect around oroa~~tr!!opening, and its length must be adequate to allow rotation of flap and
repositioning over defect without placing undue tension on flap. C, Palatal flap has been rotated to
cover !>Sseousdefect in alveolar process and sutured in’place, Exposed bone on palate, Which remains
after rotation of flap, will heal by secondal) intentil)O with minimal discomfort to patient and little or
. . no alteration In normal soft tissue anato~.

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FIG. 19- 14--cont' d D, Large oroantral communication in left maxilla that developed after reo moval of second molar tooth. E, Pa'lat~1 flap outlined. Flap is posteriorly based and receives its blood supply from anterior palatine neurovascular bundle. Width of flap is much larger than clinical oroantral communication.' F, Palatal flap is elevated and readied for transposition laterally to cover osseous oroantral defect. Buccal mucosa has also been elevated to facilitate suturing of flap. Larye size of osseous defect is demonstrated. Continued

FIG. 19- 14–cont’ d D, Large oroantral communication in left maxilla that developed after reo
moval of second molar tooth. E, Pa’lat~1 flap outlined. Flap is posteriorly based and receives its
blood supply from anterior palatine neurovascular bundle. Width of flap is much larger than
clinical oroantral communication.’ F, Palatal flap is elevated and readied for transposition laterally
to cover osseous oroantral defect. Buccal mucosa has also been elevated to facilitate suturing
of flap. Larye size of osseous defect is demonstrated.
Continued

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contrd E,Metallic-foil patch has been positioned between alveolar process and deep surface of buccal and palatal mucoperiosteal flaps. Foil is entirely supported on its margins by underlying bone. Mucoperiosteal flaps are repositioned  and. approximated over foil. F, Oroantral fistula of several weeks’ duration in riqht posterior maxilla that developed secondary to removal of retained first molar tooth root. G, Elevation of 11Irgebuccal and palatal mucoperiosteal flaps has been corn-: pleted. Large size ‘of exposed alveolar . osseous defect is demonstrated. H, Titanium foil patch has been adapted. over defect in alveolar process. Foil is inserted beneath facial and. palatal mucosa and covers mini

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