Oro antral communication / fistula

Dr Zakiah Mat Ripen

Dept of Oral & Maxillofacial Clinical Sciences
Faculty of Dentistry
University of Malaya
 ORO-ANTRAL
COMMUNICATION / FISTULA
ANATOMY
 • Paranasal sinuses

ANATOMY
Relevance of antrum to Dentistry
• Tooth / root in the antrum
• Other dental foreign body in antrum
• OAC / OAF
• Dental pathology presenting as antral pain
• Antral pathology presenting as dental pain
• Oral pathology spreading to antrum
• Antral pathology spreading to oral structures
• Antral floor augmentation for implant
• Maxillary fractures / orthognathic surgery
OAC /OAF
Definition

• Oro-antral communication (OAC)

• Abnormal connection between the oral cavity and maxillary antrum

• Oro-antral fistula (OAF)

• A persistent epithelialized communication between maxillary antrum and oral
cavity.
Aetiology of OAC/OAF
• Dental Origin • Non-dental origin
• Post dental extraction
• Dentoalveolar / tooth
implant surgery
• Chronic infections
• Cyst/tumour enucleations
• Orthognathic surgery
• Sinus surgery
• Pathology (Benign or
Malignant)
• Osteomyelitis
• Osteonecrosis
• Osteoradionecrosis
• Drug induced osteonecrosis
Predisposing factors Dental extraction

Extraction of upper molar teeth (premolars – molars)

Large and unfavourable shaped roots extending into the OAC/F
sinus
Large sinus/ lowered sinus floor
Difficult extraction
Presence of periapical lesion (granuloma/cyst)
Bone loss due to periodontitis
Local infections (abscess)
Systemic health (DM, HIV, Immunosuppressed)
Advanced age
Pre existing disease in the sinus
 Presence of periapical lesion

Pneumatization
Incidence

• Ehrl, 1980
• 9-year period in Hessen, Germany
• OAC detected in –
• 1 / 180 first molar extractions
• 1 / 280 second molar extractions
• True incidence higher
• Many smaller OAC undetected
Suspect OAC / OAF??

• Tooth, root or apical

fragment being extracted
suddenly disappears into
socket

• Large alveolar bone

fragment or tuberosity is
attached to extracted
tooth
Signs and symptoms

• Escapes of fluids from the nose

• Ipsilateral Epistaxis
• Escape of air from mouth into the nose (Inability to suck straw /
smoke cigarette/blow out cheek/ whistle)
• Enhance column of air → alteration of vocal resonance → change in
the voice
• Excruciating pain in and around the region of the affected sinus
• Symptoms maybe immediate or delayed
• Blood clot blocking aperture breaks down
• Antral lining breaks upon blowing nose
Later Symptoms of OAF

• Ipsilateral foul-smelling discharge

• Foul, salty or sweetish taste in mouth
• Nose feels blocked
• Smell &taste worse when nose is blown
• Pain … especially on moving head
• Other symptoms of maxillary sinusitis
• Painless lump … prolapsed antral lining
Confirming OAC /OAF

• Confirmatory tests
• Nose blowing test
• Probing the socket

• Disadvantages / Risks
• Clot blown out
• Antral lining torn
• Oral flora / debris pushed into antrum
Imaging

• Intraoral radiograph
• Periapical view
• Dental Panoramic Tomography (DPT)
• Occipito-Mental View (OMV)
• Cone Beam Computed Tomography (CBCT)
Indications:

• Only indicated if root or foreign bodyin antrum suspected

• To determine whether root is in:
• Socket
• Buccal or palatal soft tissues
• Antrum … if so, where in antrum
• Close to socket
• Far from socket
 Intraoral Periapical View (IOPA)

DPT
CBCT
TREATMENT
Oroantral Communication

• Most undetected OAC

• Heal spontaneously

• If OAC large enough to be detected

• Unlikely to heal spontaneously
• Must be closed as soon as possible
Oroantral Communication

• Close OAC within 48 hours to:

• Avoid socket & antral infection
• Avoid chronic changes in antral lining
• Accelerate healing
• Increase success rate of closure
Management of OAC
• Sinus precaution (10 – 14 days)
• Opening mouth while sneezing
• Not sucking on straw and cigarette
• Avoid nose blowing

• Medicines:
• Antibiotic / analgesics
• Nasal decongestants Steam inhalation
Flaps To Close Socket
• Buccal advancement flap
• von Rehrmann
• Palatal rotation / transposition flap
• Ashley
• Buccal fat pad
• Others …
Medications
• Antibiotics
• Analgesics
• Nasal decongestant
• Ephedrine nose drops
• Pseudoephedrine nose drops
Post-op Instructions
• Do not blow nose !!!
• Soft diet
• Avoid traumatising flap
• Do not brush teeth in op site
• Use mouthwash
• No swimming
• No smoking
• No playing wind instruments
 CASE 1
Closure of OAF with Buccal Fat Pad
Investigation (ICAT CBCT)
Identification of sinus Antrum toileting with Chlorhexidine
Removal of fistulous tract Full mucoperiosteal flap raised
Identification of buccal fat pad Advancement of buccal fat pad
Buccal fat pad closure of fistula Anchoring of buccal fat pad
Suturing of buccal fat pad as first layer Full mucosa suturing
Post op review
Case 2
OMV
Case 3
Others

Combination
Treatment Considerations

• Immediate or delayed treatment?

• Presence of root or foreign body in antrum?
• Presence of maxillary sinusitis?
• Do you have necessary skills & equipment?
• Is patient suitable / prepared for surgery?
THANK YOU