PMC6233470_01
The fistula is clinically examined with a wide, blunt instrument to detect the site of the opening in relation to the adjacent structure.. Note: Clinically, the opening looks more posterior than that shown on the radiograph.
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A 32-year-old, nonsmoker, systemically healthy man presents to our clinic with the chief complaint of an opening at the extraction site of the upper right first molar (Figure 1).
A preoperative panoramic radiograph was taken to detect the site of the fistula and the vertical bone height of the extracted tooth.. Note: The radiograph shows insufficient bone height to support clot formation and that the lining membrane is open directly to the crestal bone.
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Radiographs were taken, and a diagnosis of chronic OAF was acquired (Figure 2).
At the site of the first molar, a large bony defect was found after the flap was raised and the bone was exposed.. Note: The defect exhibited a very shallow bone height, which made stabilization of the blood clot difficult.
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Under local anesthesia, a three-sided flap was created; the bone was then exposed, and a large bone defect (greater than 5 mm) was found (Figure 3).
Slowly resorbable collagen membrane was placed as a first layer to close the bone opening and fixed in place with sutures to prevent dislodgment or being aspirated into the sinus.
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Slow-resorption collagen membrane extracted from bovine tendon containing collagen type I (Genoss, Gyeonggi-do, South Korea) was used to cover the bone defect and was fixed in place with nylon suture (Figure 4).
Multiple platelet-rich fibrin clots (more than one clot layered above each other) were placed as a second layer to cover the bony defect and enhance soft-tissue healing.
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PRF clot was placed above the collagen membrane in two layers (Figure 5).
The double-layer flap was closed using mattress and single interrupted sutures with a free-tension flap and eversion to avoid wound dehiscence.
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Horizontal and vertical mattress suturing was performed with interrupted stitches between layers (Figure 6).
Wound healing was evident after 2 weeks, and the sutures were partially removed.. Note: The fistula was closed, with no communication between the oral and nasal cavities.
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At 2 weeks, the wound matured, and signs of inflammation had disappeared; the sutures were partially removed (Figure 7).
Six weeks after surgery, complete wound healing with obvious hypertrophy of the soft tissue was observed.
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Gingival overgrowth and an increase in thickness were observed when the patient returned for further follow-up at 6 weeks after surgery (Figure 8).