Baucke van Minnen

Closure of Oroantral Communications: A Review of the Literature

An oroantral communication (OAC) is an open connection between the oral cavity and maxillary sinus. The maxillary sinus takes up a large part of the body of the maxilla, generally extending into the alveolar process bordering the apices of the posterior teeth. OACs are usually caused by extraction of maxillary posterior teeth. 1,2 The thinness of the antral floor in that region ranges from 1 to 7 mm. 3 Although the incidence is relatively low (5%), 4,5 OACs are frequently encountered due to the large number of extractions. OACs may close spontaneously especially when the defect has a size smaller than 5 mm. 6 Nevertheless, to our knowledge, it has never been actually proven that small OACs (5 mm) will heal by themselves. Also, it is difficult to determine the size of the OAC clinically. To prevent chronic sinusitis and the development of fistulas, it is generally accepted that all of these defects should be closed within 24 to 48 hours. 7

Current therapyClosure of Oroantral Communications: A Review of the Literature

An oroantral communication (OAC) is an open connection between the oral cavity and maxillary sinus. The maxillary sinus takes up a large part of the body of the maxilla, generally extending into the alveolar process bordering the apices of the posterior teeth. OACs are usually caused by extraction of maxillary posterior teeth. 1,2 The thinness of the antral floor in that region ranges from 1 to 7 mm. 3 Although the incidence is relatively low (5%), 4,5 OACs are frequently encountered due to the large number of extractions. OACs may close spontaneously especially when the defect has a size smaller than 5 mm. 6 Nevertheless, to our knowledge, it has never been actually proven that small OACs (5 mm) will heal by themselves. Also, it is difficult to determine the size of the OAC clinically. To prevent chronic sinusitis and the development of fistulas, it is generally accepted that all of these defects should be closed within 24 to 48 hours. 7

Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants

To avoid increasing the risk of thromboembolic events, it is recommended that treatment with anticoagulants should be continued during dentoalveolar operations. We have evaluated the incidence of bleeding after dentoalveolar operations in a prospective study of 206 patients, 103 who were, and 103 who were not, taking anticoagulants. Seventy-one were taking thrombocyte aggregation inhibitors and 32 vitamin K antagonists. Patients were treated according to guidelines developed at the Academic Centre for Dentistry Amsterdam (ACTA), The Netherlands. The operations studied included surgical extraction (when the surgeon had to incise the gingiva before extraction), non-surgical extraction, apicectomy, and placement of implants. Patients were given standard postoperative care and those taking vitamin K antagonists used tranexamic acid mouthwash postoperatively. No patient developed a severe bleed that required intervention. Seven patients (7%) taking anticoagulants developed mild postoperative bleeds. Patients taking vitamin K antagonists reported 3 episodes (9%) compared with 4 (6%) in the group taking thrombocyte aggregation inhibitors. Among patients not taking anticoagulants, two (2%) developed mild bleeding. The differences between the groups were not significant. All bleeding was controlled by the patients themselves with compression with gauze. We conclude that dentoalveolar surgery is safe in patients being treated with anticoagulants provided that the conditions described in the ACTA guidelines are met.

Closure of Oroantral Communications Using Biodegradable Polyurethane Foam: A Feasibility Study

PURPOSE The aim of this study was to assess the feasibility of biodegradable polyurethane (PU) foam for closure of oroantral communications (OACs). PATIENTS AND METHODS Ten consecutive patients with OACs (existing <24 hours) were treated with PU foam. Standardized evaluations were performed at 2 weeks and 8 weeks after closure of the OAC. RESULTS In 5 patients, the OACs were closed successfully without complications. Three patients developed sinusitis, which was conservatively managed with antibiotics in 2 cases. In 1 case the sinus was reopened for irrigation, after which a buccal flap procedure was performed. In 2 patients the OAC recurred and was surgically closed with a buccal flap after thorough irrigation. CONCLUSION In this feasibility study, closure was achieved in 7 of the 10 patients without further surgical intervention. Complications of the procedure using PU foam may be related to the fit of the foam in the socket and the size of the perforation. In general, closure of OACs with biodegradable polyurethane foam is feasible and has the potential to spare a large number of patients with OACs a surgical procedure. Furthermore, in case the treatment with PU foam fails to close the OAC, the attending physician can always fall back on the standard surgical procedure.

Retrospective Study on the Treatment Outcome of Surgical Closure of Oroantral Communications

PURPOSE A retrospective cohort study concerning the surgical closure of oroantral communications (OACs) was carried out to facilitate a comparison between treatment outcomes of conventional surgical treatment and new strategies for closure of OACs. Data were statistically analyzed to gather insight into possible predictor variables of recurrent OAC. PATIENTS AND METHODS A cohort of patients treated for an OAC from 2004 through 2008 was reviewed. Recorded data included patient age and gender, location and duration of OAC, method of removal of the (pre)molar, presence of maxillary sinusitis, disturbed wound healing, and surgical treatment method. Data analysis included descriptive and multivariate logistic regression analyses with recurrence of OAC as the outcome variable. RESULTS In total, 308 patients were included in the sample, of which 28 patients (9.1%) required a second intervention to repair an OAC. Of these 28 patients, 4 patients needed a third intervention, making the total number of recurrent OACs 32 (10.4%). In most cases (60.7%), a buccal advancement flap according to the method of Rehrmann was used to close the perforation. Multivariate regression analysis showed a 15 times higher risk of recurrence with maxillary sinusitis at follow-up. CONCLUSIONS Overall results of the study showed that OACs recur in about 1 of 10 patients and requires a second intervention after surgical closure. New strategies should therefore result in an equal or better treatment outcome to be considered a suitable treatment option. Furthermore, it was demonstrated that the presence of maxillary sinusitis at follow-up is an important determinant of the treatment outcome of OAC repair.

Closure of oroantral communications using biodegradable polyurethane foam: a long term study in rabbits.

An oroantral communication (OAC) is an open connection between the oral cavity and maxillary sinus. Closure of OACs is commonly performed with a surgical procedure using a mucoperiosteal flap. An alternative technique using synthetic biodegradable polyurethane (PU) foam for closure of OACs is presented. This PU foam is composed of hard urethane segments, and soft segments made of D/L lactide (50/50), epsilon-caprolactone, and 5% polyethyleneglycol (PEG). To evaluate the use of PU foam for this application, OACs were created in the edentulous part of the maxilla in 21 rabbits, after which PU foams were fitted in the defects. Results showed complete healing of the oral mucosa after 4-10 weeks, healing of the antral mucosal lining after 6 months and complete bony regeneration after 1 year. No reopening of the defects occurred and no maxillary sinusitis was observed. Degradation of the PU foam had not yet reached completion 1 year after implantation. In conclusion, PU foam with 5% PEG provides adequate closure of an OAC in the rabbit model to support healing of the oral and maxillary sinus mucosa. Longer time intervals are needed to assess the complete degradation of the PU foam.

Donor site morbidity of anterior iliac crest and calvarium bone grafts: A comparative case-control study

PURPOSE Notwithstanding its donor site morbidity, autogenous bone graft harvesting is still considered the gold standard for cases of extreme resorption of the alveolar ridge. The aim of this study was to assess donor site morbidity of calvarium and anterior iliac crest harvesting. MATERIAL AND METHODS A total of 27 edentulous patients who had undergone calvarial bone harvesting were matched with 27 edentulous patients in which anterior iliac crest bone was harvested. All patients had been treated between March 2011 and December 2013. Patients were matched according to age, sex, and duration of follow-up. Donor site morbidity was assessed by medical records, patient questionnaires, and physical examination. Patients were recalled to assess persisting morbidity of the harvesting procedure. RESULTS Exposure of the dura occurred in three patients in the calvarial group. Postoperative pain (based on a visual analog scale) after harvesting was significantly higher in the anterior iliac crest group. Scars were significantly longer and contours deficits were significantly more prominent after calvarial harvesting, although not bothersome to the patients. Long-term pain was negligible in both groups, and satisfaction with the procedure did not differ. CONCLUSION Both harvesting techniques were accompanied by low long-term donor site morbidity and high patient satisfaction.

Dexmedetomidine versus Midazolam in Procedural Sedation: A Systematic Review of Efficacy and Safety

Objectives To systematically review the literature comparing the efficacy and safety of dexmedetomidine and midazolam when used for procedural sedation. Materials and Methods We searched MEDLINE, EMBASE and COCHRANE for clinical trials comparing dexmedetomidine and midazolam for procedural sedation up to June 20, 2016. Inclusion criteria: clinical trial, human subjects, adult subjects (≥18 years), article written in English, German, French or Dutch, use of study medication for conscious sedation and at least one group receiving dexmedetomidine and one group receiving midazolam. Exclusion criteria: patients in intensive care, pediatric subjects and per protocol use of additional sedative medication other than rescue medication. Outcome measures for efficacy comparison were patient and clinician satisfaction scores and pain scores; outcome measures for safety comparison were hypotension, hypoxia, and circulatory and respiratory complications. Results We identified 89 papers, of which 12 satisfied the inclusion and exclusion criteria; 883 patients were included in these studies. Dexmedetomidine was associated with higher patient and operator satisfaction than midazolam. Patients receiving dexmedetomidine experienced less pain and had lower analgesic requirements. Respiratory and hemodynamic safety were similar. Conclusions Dexmedetomidine is a promising alternative to midazolam for use in procedural sedation. Dexmedetomidine provides more comfort during the procedure for the patient and clinician. If carefully titrated, the safety profiles are similar.

Feasibility of conical biodegradable polyurethane foam for closure of oroantral communications.

PURPOSE To assess the feasibility of a conically shaped biodegradable polyurethane (PU) foam for closure of oroantral communications (OACs). PATIENTS AND METHODS In 10 consecutive patients, fresh OACs (present for <24 hours) were closed with PU foam. Standardized evaluations were performed at 2 and 8 weeks after closure of the OAC. Success was considered permanent closure of the OAC. RESULTS No complications were observed in 7 of the 10 patients. Of the other 3 patients, 1 developed a maxillary sinusitis that was successfully managed with antibiotics and the OAC recurred in 2 patients. CONCLUSIONS Permanent closure of the OAC using PU foam was accomplished in 8 of 10 patients. The results obtained in the present study were more favorable than in a previous feasibility study. Therefore, the alterations in the treatment protocol were maintained for additional research of this new and straightforward treatment strategy. In general, closure of OACs with biodegradable PU foam is feasible and has the potential to make surgical treatment unnecessary for a large number of patients with OACs.

Diagnostic reliability of low dose multidetector computed tomography and cone beam computed tomography in maxillofacial trauma - an experimental blinded and randomized study

OBJECTIVES To assess the diagnostic reliability of low dose multidetector CT (MDCT) and cone beam CT (CBCT) for zygomaticomaxillary fracture diagnosis. METHODS Unilateral zygomaticomaxillary fractures were inflicted on four out of six fresh frozen human cadaver head specimens. All specimens were scanned using four MDCT and two CBCT imaging protocols of which the radiation exposure was systematically reduced. A blinded diagnostic routine was simulated at which 16 radiologists and 8 oral and maxillofacial (OMF) surgeons performed randomized image assessments. We considered the findings during an open operative approach of the zygomatic region as the gold standard. RESULTS Zygomaticomaxillary fractures were correctly diagnosed in 90.3% (n = 130) of the image assessments. The zygomatic arch was most often correctly diagnosed (91.0%). The zygomatic alveolar crest showed the lowest degree of correct diagnosis (65.3%). Dose reduction did not significantly affect the objective visualization of fractures of the zygomaticomaxillary complex. The sensitivity and specificity also remained consistent among the low dose scan protocols. Dose reduction did not decrease the ability to assess dislocation, comminution, orbital volume, volume rendering and soft tissues. OMF surgeons considered the low dose protocols sufficient for treatment planning. CONCLUSIONS Dose reduction did not decrease the diagnostic reliability of MDCT and CBCT for the diagnosis of zygomaticomaxillary fractures.