Oroantral fistula

Oroantral fistula (OAF) is an epithelialised

oroantral communication (OAC).[1] OAC
refers to an abnormal connection between
the oral cavity and antrum (or maxillary
sinus).[1] The creation of an OAC is most
commonly due to the extraction of a
maxillary (upper) tooth (typically a
maxillary first molar) closely related to the
antral floor (floor of the maxillary sinus).[1]
A small OAC (up to 5mm wide) may heal
spontaneously but a larger OAC would
require surgical closure to prevent the
development of persistent OAF and
chronic sinusitis.[1]

Oroantral fistula

Maxillary sinus (medial view)

Specialty ENT surgery

Classification
Differences between OAC and OAF[1]
OAC    OAF   

Connection between oral cavity and Connection between oral cavity and antrum that has
antrum that is not epithelialised. epithelialised.

May develop immediately following the Develops from OAC that has  not healed
extraction of maxillary tooth that is spontaneously, has not been closed surgically, or initial
close to antral floor. attempts at surgical closure have failed.

Requires surgical closure if large to

Requires surgical treatment to remove and close the
prevent development of a persistent
fistula.
OAF and chronic sinusitis.

Signs and symptoms of an

OAC/OAF can include the
following
When looking in the mouth, a
communication in the upper jaw (i.e. a
hole) can be seen connecting the mouth to
the maxillary sinus.[2] Sometimes this can
be the only sign, as pain (+/- other
symptoms) is not always present.
Symptoms …

· Same side nose blockage (unilateral

nasal obstruction).[2] When an OAC or OAF
is present, the passage to the maxillary
sinus can results in infection and
inflammation in the maxillary sinus. This
subsequently results in mucus build up
presenting as a unilateral nasal blockage

· Sinusitis can progress – this can present

as a pain in the midface. Pain can be
referred to the upper teeth and be
mistaken for toothache[3]

· Fluid can flow from the mouth through

the communication and into the maxillary
sinus. The maxillary sinus is connected to
the nose and therefore fluid can come out
of the nostrils when drinking[2]

· Change in sounds produced from the

nose and the voice – specifically a
whistling sound whilst speaking[2]

· Taste can be affected[2]

Signs …

· Visible hole between mouth and sinus

· Fracture of the floor of the maxillary sinus

creating a communication to the oral
cavity (e.g. as seen following trauma).[2]
· Air bubbles, blood or mucoid secretion
around the orifice can be seen as air
passes from the sinus into the oral cavity
through the communication.

Diagnosis …

- Patient history - Diagnosis is usually

based on clinical examination and
reported symptoms. Therefore, a good
history and understanding of the patient’s
symptoms is key.

- Undertake a complete extraoral and

intraoral examination using a dental mirror
alongside good lighting. When assessing
the socket following an extraction look for
granulation tissue in the socket which may
represent normal healing. Assess for the
presence of visible an opening/hole
between the oral cavity and the maxillary
sinus.  

- Imaging can be useful. However,

radiographs only show if there is a breach
in the bony floor of the antrum. Even if
there is a breach in the bony floor then the
Schneiderian membrane may still be
intact. Depending on the size of the
potential communication and in what
context, a small radiograph inside the
mouth may be sufficient (a periapical) to
assess for any break in the bone of the
sinus floor which may indicate an OAC.

- Panoramic radiographs[2] can also be

used to confirm the presence of an OAC. If
simple radiographs are deemed not to give
enough information, cone beam computed
tomography (CBCT)[2] (special x-ray
equipment that can scan in 3 dimensions)
may be used.  Imaging can help locate the
communication, determine the size of it
and can give an indication as to whether
there is any sinusitis and foreign bodies in
the sinus.
- Normally clinicians should be cautioned
against probing or irrigating the site a
newly formed OAC as this may reduce the
chance of spontaneous healing.

- Valsalva test (nose blowing test)[4] The

patient is asked to pinch their nostrils
together and open their mouth and then
blow gently through the nose. The clinician
must observe if there is passage of air or
bubbling of blood in the post extraction
alveolus as the trapped air from closed
nostrils is forced into the mouth through
any oroantral communication. Gentle
suction applied to the socket often
produces a characteristic hollow sound.
However, there are differing opinions
about the appropriateness of carrying out
this test.  It can be argued that by
performing this test, a small OAC may be
made bigger thus preventing spontaneous
healing.

Causes

Extraction of maxillary teeth …

The maxillary sinus is known for its thin

floor and close proximity to the posterior
maxillary (upper) teeth.[1][5] The extraction
of a maxillary tooth (typically a maxillary
first molar which lies close to the lowest
point of antral floor although any premolar
or molar can be affected) is the most
common cause of an OAC (which can then
progress to an OAF as described above).[1]
Extraction of primary teeth are not
considered a risk of OAC due to the
presence of developing permanent teeth
and the small size of the developing
maxillary sinus.[1]

Other causes …

Other causes of an OAC are: maxillary

fractures across the antral floor typically
Le Fort I, displacement of posterior
maxillary molar roots into antrum and
direct trauma.[5] An OAC can happen for
many other more unusual reasons, such
as acute or chronic inflammatory lesions
around the tip of a tooth root which is in
close proximity with the maxillary antrum,
destructive lesions/tumours of the maxilla,
failure of surgical incisions to heal (e.g.
Caldwell-luc antrostomy), osteomyelitis of
the maxilla, careless use of instruments
during surgical procedures, Syphilis,
implants and as a results of complex
surgery (for example removal of a large
cysts or resections of large tumours
involving the maxilla.[6][7][8]

Diagnosis
Clinical examination and x rays can help
diagnose the condition. For examples :

Valsalva test (nose blowing test):[9] Ask

the patient to pinch the nostrils together
and open the mouth, then blow gently
through the nose. Observe if there is
passage of air or bubbling of blood in
the post extraction alveolus as the
trapped air from closed nostrils is
forced into the mouth through any
oroantral communication. Gentle
suction applied to the socket often
produces a characteristic hollow sound.
Perform a complete extra- and intra-oral
examination using a dental mirror under
good lighting, look for granulation tissue
in the socket and openings into the
antrum.
Panoramic radiograph or paranasal
computed tomography can help to
locate the fistula, the size of it and to
determine the presence of sinusitis and
other foreign bodies. Other methods like
radiographs (occipitomental, OPG and
periapical views) can also be used to
confirm the presence of any oroantral
fistulas.
To test the patency of communication
the patient is asked to rinse the mouth
or water is flushed in the tooth socket.
 Unilateral epistaxis is seen in case of
collection of blood in the sinus cavity.
Do not probe or irrigate the site, because
it may lead to sinusitis or push foreign
bodies, such as contaminated
fragments, or oral flora further into the
antrum. Hence, leading to the formation
of a new fistula or widen an existing
one.

Complications
OAF is a complication of oroantral
communication. Other complications may
arise if left untreated. For example:

Candidal infection[9][10]
 Chronic maxillary sinus infection of
bacterial origin[11]
Osteomyelitis[12]
Rhinosinusitis[13]
Sinus pathology[9]

Therefore, OAF should be dealt with first,

before treating the complications.

Prevention
Whilst in some circumstances, preventing
development of an OAF following
extraction of a tooth can be difficult,
careful assessment is important. The
following should be considered prior to
carrying out any dental treatment:[1]

Size of the antrum and proximity to

teeth – this can be assessed
radiographically
Shape and size of teeth and roots – this
can be assessed radiographically
Presence of periapical pathology – this
can be assessed radiographically
The age of the patient
The patient’s past dental history

If the above factors are assessed as

increasing the risk of OAC development,
the clinician should take appropriate steps
to carefully remove the tooth in question,
possibly carrying out a surgical extraction
and in an appropriate setting.[1] Hence, in
such cases:

Avoid using too much of apical pressure

during tooth extraction
Perform surgical extraction with roots
sectioning
Consider referral to OMFS at local
hospital[1]

Treatment
The primary aim of treatment of a newly
formed oroantral communication is to
prevent the development of an oroantral
fistula as well as chronic sinusitis. The
decision on how to treat OAC/OAF
depends on various factors. Small size
communications between 1 and 2 mm in
diameter, if uninfected, are likely to form a
clot and heal by itself later.
Communications larger than this require
treatments to close the defect and these
interventions can be categorised into 3
types: surgical, non-surgical and
pharmacological.[14][15]

Surgery …

Surgical methods are required if a large

defect is present or if a defect persists.[16]
Surgery involves creating a flap utilising
local tissue to close the communication.
There are a number of different flaps that
can be used such as the buccal
advancement flap, the buccal fat pad flap,
a combination of the two and a palatal
flap.[16] The flap used is dependent on the
size and position of the defect.

Buccal advancement flap …

The buccal advancement flap is the most

commonly used due to its simplicity,
reliability and versatility.[16] It involves
cutting a broad based trapezoid shaped
mucoperiosteal flap with two vertical
incisions.[16] The flap is cut buccally, is
three sided and extends to the full depth of
the sulcus.[1]

Buccal fat pad flap …

The buccal fat pad flap is also a popular

option due to its high success rate.[17] It is
a simple procedure where the buccal
extension of the anatomical fat pad is
used for closure.[2] These two flaps can be
used in combination where the buccal fat
pad covers the communication followed
by a further covering via the buccal
mucosal flap described above.[2] This
double layer flap has advantages over a
single layer as it provides stable soft
tissue covering, reduces the incidences of
wound breakdown and defect recurrence
as well as reducing the risk of
postoperative infection.[2]

Sutures, either non-resorbing or slowly

resorbing, are generally used in the
surgical repairs of OAC.[1]

Non-surgical interventions …

Ultimately, surgery is usually required to

close an OAC/OAF. However, if surgery is
not immediately available then non-
surgical methods can be used to
encourage the growth of oral mucosa
between the oral cavity and the antrum.[1]
The aim of these methods is to protect the
blood clot within the socket and help to
prevent infection. One option is
construction of a denture with an acrylic
base plate or extension of the patient’s
existing denture to protect the socket and
support the clot.[1] These options are
particularly helpful in patients who smoke
as it provides protection from smoke
inhalation. The socket can also be sutured
over with mattress sutures if there is
adequate soft tissue available.[1]
Medication …

Medications may be needed as an adjunct

to assist the closure of the defect.
Antibiotics can help control or prevent any
sinus infections. Preoperative nasal
decongestants usage can reduce any
existing sinus inflammation which will aid
surgical manipulation of the mucosa over
the bone.[18]

Postoperative care …

Following all methods of OAC/OAF

closure, the patients are instructed to
avoid activities that could produce
pressure changes between the nasal
passages and oral cavity for at least 2
weeks due to risk of disruption to the
healing process. Nose blowing and
sneezing with a closed mouth are
prohibited. A soft diet is also often
advocated during this period. Following
surgery, nasal decongestants and
prophylactic antibiotics are often
prescribed to prevent postoperative
infection.

References
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 Elsevier/Churchill Livingstone. ISBN 978-0-
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. DeFreitas J, Lucente FE (December 1988).
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 9. Jadhav KB, Mujib BA, Gupta N (January
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11. Bell G (August 2011). "Oro-antral fistulae
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1 . Parvini P, Obreja K, Sader R, Becker J,
Schwarz F, Salti L (December 2018).
"Surgical options in oroantral fistula
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External links
Classification D
ICD-10: J32.0;
K13.70 •
MeSH: D009957

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