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Oroantral Communication: Causes, Complications, Treatments and Radiographic Features. A Pictorial Review

Poster · May 2021

DOI: 10.13140/RG.2.2.26287.87204

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 Oroantral Communication: Causes, Complications, Treatments and
Radiographic Features. A Pictorial Review
Rama Shahrour1*, Priya Shah1, Thimanthi Withana1, Jennifer Jung1, Ali Syed1
1Oral and Maxillofacial Medicine and Diagnostic Sciences, Case Western Reserve University School of Dental Medicine, United States of America

Background 2D Imaging Modalities

Oroantral communication (OAC) is an unnatural space that forms between the maxillary sinus and oral cavity
following extraction of antral teeth, infection, or a number of different complications. If left untreated, OAC can
develop into oroantral fistula (OAF) or chronic sinus disease1,2. Figure 1 is an illustration depicting oroantral
communication at the palatal root of tooth #14.
Causes and Complications
Two-dimensional (2D) intra-oral and extra-oral radiographs can be used to diagnose OAC, particularly periapical (PA),
orthopantamographs (OPG or panoramic), and occipitomental (Water’s view) radiographs 3. 2D imaging modalities
illustrate the discontinuity of the maxillary sinus bony floor, the size of the bony defect, and the disruption of the sinus
border. PA radiographs can be particularly useful in the identification of foreign bodies dislodged into the maxillary
sinus 3. OPG and occipitomental radiographs aid in visualization of the maxillary sinus and the path of the oroantral
communication 3. Radiographic features of OAC that can be noted on 2D imaging modalities are the loss of cortical
plate of the sinus (Figure 3) and the consequent mucosal thickening (figure 2) which is suggestive of sinusitis. A
limitation of 2D imaging, however, is the superimposition of anatomical structures 8,3. Clinical correlation is necessary
Figure 5 Images of a 56-year-old male with a history of nasal trauma. (a) Axial view shows a breach in the posterior wall of the left maxillary sinus and polypoidal
mucosal thickening in the right maxillary sinus (arrows). Normal architecture of the sinus has changed due to trauma, causing narrowing of the sinus. (b) Coronal
for the confirmation of the diagnosis of OAC. view shows polypoidal mucosal thickening in the right maxillary sinus (arrows). Left maxillary sinus shows a loss of cortication in the lateral wall.

The most common cause of OAC is the extraction of maxillary posterior

teeth1. This may be due to the proximity of the roots to the floor of the
maxillary sinus and is exacerbated by thin sinus floors1. The incidence of
OAC following antral extractions is summarized in Table 1. Additionally,
2.2% of the first molar apices and 2% of second molar apices perforate the
maxillary sinus floor 3. OAC has a slight male predilection with a female-
to-male ratio of 1:1.52 4.
To avoid trauma or perforation of the maxillary sinus, caution should be
taken when removing teeth with bulbous roots or periapical abnormalities 3.
Enucleating tumors and cysts, orthognathic surgeries such
as LeFort osteotomies, trauma, pathological lesions1, and implant surgery,
failure of external sinus floor elevation and augmentation can all lead to the
Figure 2. Panoramic radiograph of a 73-year-old female. Oroantral Figure 3. Periapical radiograph showing the loss of
formation of an OAC 3. To avoid these complications, the surgical closure communication can be noted in the upper right quadrant in the extraction site cortical plate in the extraction site of tooth #3
Figure 6. The scan of a 56-year-old male. Note the breach of the posterior wall of the left maxillary sinus and the consequent narrowing of the sinus (arrow).
of OAC within 48 hours is recommended 2. If left untreated, OAC can act of tooth #3. Note discontinuity of the maxillary sinus floor (arrow). (arrow).
as an avenue for bacteria into the maxillary sinus, causing infections, Figure 1. Illustration of an oroantral
sinusitis or delayed healing 2. communication through the palatal root of
tooth #14 (arrow) 3D Imaging Modalities Conclusion
Three-dimensional (3D) radiographs, such as Computed Tomography (CT) and Cone Beam Computed Tomography Based on the various utilities of 2D and 3D radiographs, we can conclude that these imaging modalities should be used
Maxillary Tooth Second Molar Third Molar First Molar First Premolar
(CBCT), can be used to identify OAC, to determine the status of the soft tissue in the maxillary sinus and nasal cavity 3, in conjunction to diagnose and treat OAC and monitor potential OAC-associated soft tissue complications in the
Percentage 45% 30% 27.2% 5.3% and to identify sinus pathology (i.e. chronic sinusitis) 9. They are useful in identifying abnormalities of the sinus and maxillary sinus. Appropriate diagnosis will ultimately prevent unnecessary mental and financial burdens to patients.
Table 1. Incidence of OAC following the extraction of maxillary antral teeth. the thickening of the Schneiderian mucosal membrane of the maxillary sinus 9. CT and CBCT are an adjunct tool in
OAC diagnosis 3. They depict the discontinuity in the floor of the maxillary sinus, the size of the OAC, foreign
bodies, the bone and mucosa surrounding the OAC, and the status of the sinus mucosal lesion 3. These
References
Treatments radiographic findings are suggestive of oroantral communication. Clinical correlation confirmed the radiographic
diagnosis. Figure 4 depicts an OAC that is caused by extraction, while Figure 5 depicts an OAC that is caused by
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Figure 4. Multiplanar Reformatted view of a 63-year-old 3. Parvini P, Obreja K, Begic A, et al. Decision-making in closure of oroantral communication and fistula. Int J Implant Dent.
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Surgical Gingival suturing, soft tissue grafts and flaps, metal plates 5,6 cortication in the left maxillary sinus (arrow). (c) Coronal 5. Alonso-González R, Peñarrocha-Diago M, Peñarrocha-Oltra D, Aloy-Prósper A, Camacho-Alonso F, Peñarrocha-Diago M. Closure
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Non-surgical (arrows). On the right side, note the mucosal thickening at
No treatment and prolamine occlusion gel 6 the floor of the sinus. On the left side, note the Published 2015 Feb 1.
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Antibiotics (amoxicillin, clindamycin and moxifloxacin),
Pharmacological material (antrolith) can be noted. (d) Volume rendered fistulae due to dental procedures. Cochrane Database Syst Rev. 2018;8(8):CD011784. Published 2018 Aug 16.
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Table 2. Various treatment techniques of OAC. 9. Nedir, R., Nurdin, N., Paris, M., Hage, M. E., Najm, S. A., & Bischof, M. (2017). Unusual Etiology and Diagnosis of Oroantral
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