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J Oral Maxillofac Surg66:1551-1555, 2008

Metal Plates and Foils for Closure ofOroantral Fistulae

Martin Steiner, DDS,* Alan R. Gould, DDS, MS,†

Daniel C. Madion, DDS, MD,‡ Matthew S. Abraham, DDS, MD,§

and James G. Loeser, DDS, MD¶

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arious surgical procedures and materials have beensed for closure of an oroantral fistula (OAF). Surgicalrocedures used include local flaps comprised of buc-al and palatal gingival,1 distant flaps, tongue,2 tem-oralis muscle,3 and buccal fat pad.4 Bone grafts har-ested from the iliac crest have also proven effective,5

s well as metals including gold and tantalum,6-11 and variety of synthetic materials such as block hydroxy-patite12 and Biogide resorbable membrane.13 A Med-ine search revealed 6 additional articles reporting these of gold plate for closure of OAF.14-19 There haveeen no reports in the literature describing use of anyetals other than tantalum, vitallium, and gold for

losure of OAF, although anecdotal reports indicatese of periapical film x-ray packet lead foil in therolius surgical procedure.10 The current article fo-uses on metals and corresponding surgical tech-iques used in the management of OAF, and likelyasis for successful outcome. Use of aluminum plateor closure of 8 cases is described, with 3 patientsaving OAF offered in detail. Relative advantages ofhis technique are explored.

aterials and Methods

Eight cases of OAF repair using 36-gauge pure alu-inum plates (K&S Engineering, Chicago, IL) are

temized in Table 1. All patients ultimately culminated

*Professor, Oral and Maxillofacial Surgery, University of Louis-

ille, Louisville, KY.

†Oral and Maxillofacial Pathologist, Private Practice, Crestwood, KY.

‡Chief Resident, Department of Oral and Maxillofacial Surgery,

niversity of Louisville, Louisville, KY.

§Fifth Year Resident, Department of Oral and Maxillofacial Sur-

ery, University of Louisville, Louisville, KY.

¶Fourth Year Resident, Department of Oral and Maxillofacial

urgery, University of Louisville, Louisville, KY.

Address correspondence and reprint requests to Dr Steiner: Oral

nd Maxillofacial Surgery, University of Louisville, 501 S Preston,

ouisville, KY 40201; e-mail: m0stei01@louisville.edu

2008 American Association of Oral and Maxillofacial Surgeons

278-2391/08/6607-0040$34.00/0

toi:10.1016/j.joms.2007.08.043

1551

n successful outcomes, with no evidence of residualinus infection and sinusitis.

Figure 1 diagrammatically illustrates the ideal caseor use of the protective metal plate to aid in closuref an OAF. In situations where there are teeth onither side of the fistula, buccal and palatal flapsypically have very narrow pedicles. Thus, blood sup-ly to these flaps is often limited. As indicated inigure 2, the metal is exposed at all times, and theuccal and palatal tissues are simply repositioned.igure 3 illustrates the basis for healing. When a peri-steal flap is elevated, only the outer layer of perios-eum is stripped, leaving the inner layer of periosteumdherent to the bone. This layer is protected by theositioned metal plate, allowing more efficient heal-

ng to take place. Healing typically proceeds over a 4-o 6-week period, and in the process reparative tissueypically displaces the metal from its initial position.he plate becomes very loose and at this point may beasily removed, revealing underlying healthy thickissue completely covering the previous opening.

Two patients illustrate the technique using an alu-inum plate for closure of an OAF. These are cases 1

nd 2 listed in Table 1. The first case (Figs 4-8) depictshe ideal indications for this procedure, wherein thestula is situated in the maxillary first molar regionnd a second premolar and second molar are presentFig 4). Antral washings are performed (Fig 5), andfter 2 consecutive clear washings the aluminumlate is placed as previously described (Fig 6). Sixeeks later the plate is noted to be loose because of

rowth of underlying reparative tissue. T h e plate isasily removed, revealing firm thick tissue filling theite of the former fistula (Figs 7, 8). The second caseFigs 9-13) shows performance of the procedure inimilar fashion with the same excellent results. Thestula is situated in the second molar region, and thehird molar is absent (Fig 9). A buccal fat pad techniqueould be used in this situation, but was not chosen for 2easons. The buccal fat pad technique is generally aore difficult surgical procedure, and it often results in

more uncomfortable postoperative course. Figures 10hrough 13 illustrate site preparation and placement of

he aluminum plate. The plate became loose after 6

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1552 METAL PLATES AND FOILS FOR CLOSURE OF OAF

eeks and was easily removed, revealing healthy tissuen place of the fistula.

Case nos. 7 and 8 represent the same patient, who

IGURE 1. Placement of metal plate over fistula in an ideal caseor barrier protection.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

IGURE 2. Flaps repositioned over metal without tension. Theetal is visible at all times.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

Table 1. ALUMINUM PLATE USED FOR CLOSURE OF OA

Case Origin of Fistula Locatio

: 64 years, female Tooth extraction Maxillary left fir: 53 years, male Tooth extraction Maxillary left sec: 39 years, female Tooth extraction Maxillary left sec: 64 years, male Tooth extraction Maxillary right fi: 60 years, female Tooth extraction Maxillary left thi: 64 years, female Tooth extraction Maxillary left thi: 51 years, male Tooth extraction Maxillary left sec: 51 years, male Tooth extraction Maxillary right fi

teiner et al. Metal Plates and Foils for Closure of OAF. J Oral M

eveloped bilateral OAF after extraction of all maxillarySM

eeth. These fistulae were treated on the same surgicalisit. After 6 weeks the aluminum plates were removed.he left side showed freshly healed tissue covering therevious fistula. On the right side there still remainedsmall perforation 3 mm in size. The patient was told

o return in 2 weeks for further evaluation. At thisisit the fistula had been completely covered byealthy tissue (Fig 14).

iscussion

Concerning the described cases, use of an alumi-um plate was necessitated by the temporary inabilityo obtain a 36-gauge gold plate. Use of 32-gauge goldlate was attempted in 1 case; however, the materialroved unsatisfactory as it was too rigid, preventingxfoliation as healing proceeded. Further, at $125 forpennyweights, this material was deemed too expen-

ive. In contrast, aluminum plate was highly cost

IGURE 3. Inner layer of periosteum is still present to initiateroliferation of tissue.

istulaDurationof Fistula Outcome

ar alveolus 0.5 mo Healed in 14 wksolar alveolus 1 mo Healed in 6 wksolar alveolus 1.25 mo Healed in 5 wkslar alveolus 14 mo Healed in 6 wkslar alveolus 5 mo Healed in 5 wkslar alveolus 4.5 mo Healed in 6 wksolar alveolus 2 mo Healed in 6 wkslar alveolus 2 mo A 3 mm fistula was still present

after aluminum plateremoval, but completelyhealed after 2-wk recall visit

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STEINER ET AL 1553

ompetitive at $3.29 for a package of 3 18 � 12 cm6-gauge sheets. Aluminum plate demonstrated muchf the same physical characteristics as 36-gauge goldlate, including appropriate malleability and softness.he latter property permitted timely displacement

rom the treated site as the area filled with reparative

FIGURE 4. Fistula present in the first molar area in case no. 1.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

FIGURE 5. Antrum washings in case no. 1.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

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issue. It was found that this material could be easilyrimmed to dimensions suitable for coverage of thesseous defect. Aluminum is compatible with humanissues, and is combined with titanium in Ti-6Al-4Vlloy.20

Bellinger6 described use of tantalum wire sutures,oil, and plates for mandibular fracture repair, andoncluded that tantalum was accepted by the bodyecause of its inertness and lack of interference withhe normal tissue reparative process. McClung andhipps7 reported use of tantalum foil for closure of anAF in 1951. Tantalum foil, 0.00025-inch thick and 1

nch in diameter, was used to cover an OAF in aaxillary first molar region. Flaps were re-approxi-ated, allowing slight exposure of the foil. After 9eeks the mucosal edges of the flaps retracted expos-

IGURE 6. Initial placement of aluminum plate with flap closure inase no. 1.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

FIGURE 7. Case no. 1 6 weeks after initial surgical closure.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

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1554 METAL PLATES AND FOILS FOR CLOSURE OF OAF

ng a large portion of the foil which was then re-oved. The bony defect was observed to be filledith new healthy tissue. In 1952, Budge8 published aescription of closure of an OAF using 32-gauge tan-alum plate. The plate overlapped the buccal andingual aspects of the fistula by 8 mm and 12 mm,espectively. The sutured mucoperiosteum providedncomplete coverage of the plate. The tantalum is toe removed in 30 days following insertion. Levy in9539 used cast vitallium for closure of an OAF. Twenty-our carat 36-gauge gold plate was used by Crollius10

n 1956 for repair of an OAF. The author indicatedhis to be the metal of choice for this procedureecause of its properties of malleability and soft-ess, and the ease with which it can be annealed.e also stated that gold, tantalum, and additional

IGURE 8. Immediately after removal of the aluminum plate inase no. 1.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

IGURE 9. Case no. 2 with fistula in the area of the maxillary leftecond molar.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

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etals have proved to be compatible with bodyissues. Zide and Karas12 reported use of a hydroxy-patite block for closure of OAF. They used thelock as a mechanical protective covering of theAF to allow normal reparative healing. Within 3eeks the block became loose and was removed.hey indicated that a disadvantage of the techniqueas cost, with a minimum of $100 for each block.

urther, an inventory of blocks must be maintainedo allow for size selection.

Steiner11 provided description of the use of goldlate for OAF repair in 1960. He summarized thedvantages of using the surgical procedure described

IGURE 10. Area debrided and prepared for placement of alu-inum plate.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

FIGURE 11. Initial placement of aluminum in case no. 2.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

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y Crollius10 for closure of an OAF: 1) simplicity ofhe surgery; 2) minimal postsurgical scarring render-ng revision procedures unnecessary; 3) lack of post-urgical obliteration of the mucobuccal fold, in con-rast to several buccal flap procedures; 4) eliminationf palatal defects and their sequela; 5) elimination oflood supply such as those that characterize the pal-tal pedicle procedure; and 6) elimination of the needor a protective stent.

This article has summarized our experience with 8ases in the use of aluminum plate as a protectivearrier in facilitating resolution of OAF. Favorablease outcomes, as well as ready availability and low

IGURE 12. Six weeks after placement of an aluminum plate inase no. 2.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

IGURE 13. Immediately after removal of aluminum plate reveal-ng firm healthy tissue.

2teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

ost of the aluminum plate, render this an idealhoice for the treatment of patients with OAF.

eferences1. Archer WH: Oral and Maxillofacial Surgery, Vol II, (ed 5).

Philadelphia, PA, Saunders, 1975, p 16072. Peterson LJ: Principles of Oral and Maxillofacial Surgery (ed 2).

London, Decker, 2004, p 7753. Alpert B: Temporal flap. Personal communication. March 19904. Stajcic Z: The buccal fat pad in the closure of oro-antral com-

munications. J Craniomaxillofac Surg 20:193, 19925. Whitney JHS, Hammer WB, Elliot MD, et al: The use of cancel-

lous bone for closure of oroantral and oronasal defects. J OralSurg 38:679, 1980

6. Bellinger DH: Preliminary report on the use of tantalum inmaxillofacial and oral surgery. J Oral Surg 5:108, 1947

7. McClung EJ, Chipps JE: Tantalum foil used in closing antro-oralfistulas. US Armed Forces Med J 7:1183, 1951

8. Budge CT: Closure of an antraoral opening by use of thetantalum plate. J Oral Surg 10:32, 1952

9. Levy AT: Vitallium implant closure of an oral-antral opening.J CA Dent Assoc 29:373, 1953

0. Crollius WE: The use of gold plate for the closure of oro-antralfistulas. Oral Surg Oral Med Oral Pathol 9:836, 1956

1. Steiner M: Oroantral closure with gold plate: Report of a case.J Oral Surg 18:514, 1960

2. Zide MF, Karas ND: Hydroxylapatite block closure of oroantralfistulas. J Oral Maxillofac Surg 50:71, 1992

3. Ogunsalu C: A new surgical management for oro-antral commu-nication: The resorbable guided tissue regeneration membrane—Bone substitute sandwich technique. W Ind Med J 54:261, 2005

4. Rothenberg F: Gold-plate operation for oroantral fistulas. DentProg 1:270, 1961

5. Fredrics HJ, Scopp IW, Gerstman E, et al: Closure of oroantralfistula with gold plate: Report of case. J Oral Surg 23:650, 1965

6. Salman L, Salman SJ: Oro-antral closure using gold plate. NYState Dent J 32:51, 1966

7. Rose HP, Allen LJ: Gold plate used for closing a fistula into themaxillary sinus. Dental Digest 74:427, 1968

8. Shapiro DN, Moss M: Gold plate closure or oroantral fistulas.J Pros Dent 27:203, 1972

9. Stajcic Z, Todorovic L, Pesic V, et al: Tissucol, gold plate, the buccalfat pad, and the submucosal palatal island flap in closure of orantralcommunication. Deutsche Zahnarztliche Zeitschrift 43:1332, 1988

FIGURE 14. Bilateral fistula healed.

teiner et al. Metal Plates and Foils for Closure of OAF. J Oralaxillofac Surg 2008.

0. Misch CE: Implant Dentistry (ed 2). St Louis, MO, Mosby, 1999,p 275