A pedicled palatal periosteal flap for the closure of oro-antral fistula


Various surgical techniques have been developed for oro-antral fistula (OAF) closure, all of which have some drawback. Twenty consecutive patients with an OAF were enrolled in this prospective study. A trapezoid full-thickness flap extending from the palatal area to the buccal gingiva was raised, including the fistula at its centre. The palatal free end aspect was split into two layers and the deep periosteal layer was folded deep to the flap over the bony defect, thereby sealing the fistula. The superficial layer was returned to its primary position and sutured. The patients were followed for 3 months. Nineteen patients showed immediate OAF closure. One patient showed a residual oro-antral communication of 0.5 mm in diameter that resolved spontaneously within 4 weeks. The pain level (on a visual analogue scale) was highest at the first follow-up week, with a mean score of 5.5, which decreased to a mean level of 2.5 in the second week and 0 in the fourth week. The mean satisfaction level was 9.85 on a scale of 0–10 (10 representing total satisfaction). The pedicled palatal periosteal flap is a simple and effective surgical technique with high predictability and patient satisfaction levels, offering one more alternative for the treatment of OAF.

Oro-antral fistula (OAF) is a pathological communication between the oral cavity and the maxillary sinus . The primary cause of OAF is surgical intervention in the posterior maxillary premolar and molar region . While a primary oro-antral communication (OAC) with a small diameter of up to 5 mm may resolve spontaneously , persistent cases of OAC become lined with oral and respiratory epithelium, forming an OAF that mandates surgical intervention for closure .

The closure of OAF is a well-discussed challenge in the literature. A variety of surgical techniques have been developed, with recurrence rates of up to 33% , mainly due to wound contraction and postoperative infection. To increase the success rates of OAF closure procedures, the use of double-layered closure techniques has evolved , with the aim of providing sufficient tissue bulk and increased stability to the closing flap . Amongst the known techniques are buccal advancement flaps , palatal advancement flaps, rotational advancement flaps, hinged flaps , island flaps , and buccal pad of fat . Nevertheless, all techniques alter the original oral anatomy and may result in significant postoperative morbidity. This article introduces the pedicled palatal periosteal flap, a safe and easy-to-perform technique for the closure of OAF without affecting the original intraoral anatomy.

Patients and methods

Twenty consecutive patients suffering from OAF were assigned to a prospective study. The study was approved by the Institutional Ethics Review Board.

The preoperative work-up included the collection of demographic data, medical status, and relevant history of the OAF (aetiology, duration, and previous surgical closure attempts). The Valsalva manoeuvre and/or probing was performed to clinically confirm a patent OAF. A cone beam computed tomography (CBCT) scan was performed to determine the size of the underlying bony defect. Patients with an acute sinus infection were treated with medications and antral irrigations prior to the surgical intervention.

All patients were treated using the pedicled palatal periosteal flap technique by the present authors, in the Department of Oral and Maxillofacial Surgery of the Hebrew University – Hadassah Medical Centre, Jerusalem, Israel.

After surgery, the patients were followed weekly for 6 weeks and checked again after 3 months. OAF closure was inspected. Pain levels were recorded using a 0–10 visual analogue scale (VAS), with 0 representing no pain and 10 representing the highest level of pain. General satisfaction levels were graded using a 1–10 scale, with 1 representing total dissatisfaction and 10 representing total satisfaction.

Surgical technique

Under local anaesthesia using maxillary block and vestibular infiltration, a full-thickness trapezoid flap was raised from near the mid-palatal region extending to the buccal vestibule ( Fig. 1 A). Meticulous care was taken to avoid damage to the greater palatine artery, which might have been encountered during flap raising. The palatal base served as the short base of the trapezoid shaped flap ( Fig. 1 B). During mucoperiosteal flap elevation, the fistula tract was transected at the bone level, with no manipulation to fold or suture the gingival buttonhole fistula ( Fig. 1 C). The flap was split horizontally from the palatal free end up to 3 mm palatal to the fistula into two layers: a deep periosteal layer and a superficial palatal mucosa layer ( Fig. 1 D). The deep layer was folded buccally deep to the flap to form a submucosal coverage over the fistula at the bone level and was stabilized using buccal sling sutures lateral to the fistula ( Fig. 1 E). The superficial layer was returned to the original palatal position and sutured ( Fig. 1 F). An example of the full clinical surgical course is presented in Fig. 2 . Immediate examination by Valsalva manoeuvre and probing with a blunt instrument confirmed the primary waterproof closure of the fistula in all of the cases.

Fig. 1
Schematic diagram of the pedicled palatal periosteal flap surgical technique: (A) full-thickness incision; (B) trapezoid flap outline; (C) flap raising and fistulectomy at the bone level; (D) flap splitting into deep periosteal layer and superficial palatal mucosa layer; (E) deep (periosteal) layer folded buccally using buccal sling sutures; (F) flap sutured in its primary palatal position.

Fig. 2
Case presentation (patient number 3): (A) 20 mm/10 mm oro-antral fistula in the buccal vestibule molar area; (B) raising the trapezoidal full-thickness palatal flap; (C) fistula dissection at the bony level; (D) splitting the flap; (E) deep periosteal layer and superficial mucosal layer; (F) buccal sling suture and periosteal layer folded buccally; (G) flap sutured in its primary position; (H) tissue healing at 2 weeks after surgery.

Postoperative medical coverage included amoxicillin for 5 days (Moxypen; Teva Pharmaceutical Industries, Petach Tikva, Israel), chlorhexidine gluconate mouthwash for a week (Tarodent; Taro Pharmaceutical Industry, Haifa, Israel), and an anti-congestion oxymetazoline nasal spray for 5 days (Alrin; Teva Pharmaceutical Industries, Petach Tikva, Israel).


Twenty otherwise healthy patients (13 male, seven female) with a mean age of 51 years (range 29–88 years) and a mean OAF duration of 34.2 weeks (range 12–61 weeks) were included in the study. Dental extraction was the leading cause of OAF formation (nine patients), followed by misplaced dental implants (seven patients) and open sinus lift (lateral window approach) procedure (four patients).

Five of the patients had undergone one prior unsuccessful OAF closure attempt before admission to our department, four had undergone two pre-admission attempts, and one had experienced three such attempts.

The mean soft tissue fistula size was 6.9 mm (range 3–13 mm) and the mean bony defect was 11.8 mm (range 5–23 mm). Patient demographics and fistula features are presented in Table 1 .

Table 1
Patient demographic characteristics and features of the fistula.
No. Sex Age (years) Aetiology of OAF Fistula size (mm) Bony defect (mm) Prior OAF closure attempts Fistula duration (weeks)
1 M 39 Misplaced dental implant 3 6 0 52
2 F 34 Misplaced dental implant 4 9 1 32
3 F 88 Misplaced dental implant 11 20 2 61
4 M 47 Open sinus lift procedure 8 15 2 40
5 M 43 Dental extraction 5 10 2 36
6 M 46 Dental extraction 10 14 0 12
7 F 52 Open sinus lift procedure 4 8 0 31
8 M 43 Open sinus lift procedure 5 9 2 25
9 M 73 Open sinus lift procedure 7 14 3 22
10 M 33 Dental extraction 6 8 0 16
11 M 29 Dental extraction 7 9 0 19
12 F 45 Misplaced dental implant 6 9 0 39
13 M 56 Misplaced dental implant 10 22 1 33
14 F 55 Dental extraction 6 9 1 48
15 F 48 Dental extraction 6 10 0 55
16 M 67 Misplaced dental implant 13 23 0 20
17 F 59 Misplaced dental implant 7 11 0 33
18 M 51 Dental extraction 7 11 1 41
19 M 60 Dental extraction 9 14 1 50
20 M 52 Dental extraction 4 5 0 19
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Aug 10, 2020 | Posted by in Oral and Maxillofacial Surgery | Comments Off on A pedicled palatal periosteal flap for the closure of oro-antral fistula
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