Management of Large Oroantral Fistulas Caused by Medication-Related Osteonecrosis with the Combined Sequestrectomy, Buccal Fat Pad Flap and Platelet-Rich Fibrin

Abstract

Purpose: The aim of this retrospective study was to describe the efficacy of management of bisphosphonate-related maxillary osteonecrosis, which had resulted in an oroantral fistula formation, by performing sequestrectomy, platelet-rich fibrin (PRF) and buccal fat pad (BFP) flap.

Patient and methods: A total of 7 patients diagnosed with stage III maxillary medication-related osteonecrosis according to guidelines of the American Association of Oral and Maxillofacial Surgeons. All patients complained of persistent pain, swelling and purulent drainage with sinusitis. In order to keep the infection under control, the patients first received an antibiotic combination for 2 weeks. Then, sequestrectomy and bone debridement were performed under general anesthesia. After that, an antrectomy was performed via endoscopic sinus surgery in some cases. And the fistula was closed with BFP after or before the PRF application to the region depending on the size of the fistula.

Results: The fistula was successfully closed. After a mean follow-up of 16 months, no symptoms were seen in the patients.

Conclusions: The patients were successfully managed with a combined treatment consisted of sequestrectomy, PRF and BFP. We suggest that large defects arose from medication-related osteonecrosis of the jaw can be managed with such a combined approach in order to lessen the recurrence risk.

Keywords: Bisphosphonates; Buccal fat pad; Medication-related osteonecrosis of the jaw; Oroantral fistula; Platelet-rich fibrin; Sequestrectomy.

Fig. 1

Intraoral view of the patient revealed that swelling, mucosal ulceration, infection and bone exposure

Fig. 2

Sequestrotomy and curettage were performed first

Fig. 3

Centrifuge machine used in the study is seen. (DUO^® Quattro Centrifuge)

Fig. 4

Otained PRFs were placed in the region by forceps and adapted to the cavity with a sponge. Then, the BFP was covered and the region was primarily closed with sutures

Fig. 5

In cases with insufficient bone cavity, the PRFs were formed into a membrane and adapted to cover the BFP. And then, the mucosa was sutured

Fig. 6

Buccal fat tissue was extended on the cavity

Fig. 7

In this case, because the bone cavity was insufficient, PRF was applied as a membrane. The overlying mucosa was sutured over the fat pad tension-free flap closure was achieved

Fig. 8

No new oroantral communication was observed after an average of 18-month follow-up