An oroantral communication is an unnatural perforation between oral cavity and maxillary sinus. Oroantral fistula is an epithelized, pathological, communication between these two cavities. A fistulous tract present more than 14 days should be considered as chronic fistula.

1. GOOD MORNING

2. OROANTRAL
COMMUNICATION &
FISTULA
Presented By
Dr Kamini Dadsena

3. 1. Definition
2. Etiology
3. Pathogenesis
4. Sign and symptoms
5. Diagnosis
6. Management
7. Recent trends
8. Bibliography

4. • An oroantral communication is an unnatural
perforation between oral cavity and maxillary
sinus.
• Oroantral fistula is an epithelized, pathological,
communication between these two cavities. A
fistulous tract present more than 14 days should
be considered as chronic fistula.

5. 1. Extraction of teeth
2. chronic periapical infection
3. Surgery
4. Facial trauma
5. Malignant tumors
6. Syphilis,
7. Osteomyelitis

6. The most common precipitating factor of an OAC is
the extraction of posterior maxillary teeth, usually
the first or second molar. This post-extraction
complication occurs more likely if there is preexisting
periapical abnormality associated with
the offending tooth near the maxillary sinus or
extraction of maxillary molar teeth with widely
divergent roots. If these teeth are not carefully
removed by surgically sectioning the roots, the
floor of the sinus may be removed along with the tooth.
OACs can also occur as a result of implant
surgery, cyst and tumor enucleations, orthognathic
surgeries (Le Fort osteotomies), osteomyelitis,
trauma, and pathologic entities. To avoid
problems secondary to OACs (eg, infections of
the sinus), surgical closure is advisable within the
first 48 hours.3 If the larger OACs are left untreated
and allowed to stay patent, 50% of the patients will
experience sinusitis after 48 hours and 90% after 2
weeks.

7. Periapical infection or maxillary sinusitis
Infection of clot
Disintegration of clot
persistent communication
gets epithelized fistula formation
Persistence of fistula may cause acute or subacute
sinusitis

8. In patients with healthy sinuses, after an
extraction, most maxillary sinus perforations less
than 5 mm close spontaneously after the development
of a blood clot in the socket.2 If the sinus
communication is between 2 and 6 mm, a collagen
plug can be placed into the socket and secured in
place with figure-of-eight sutures across the
socket; larger openings do not heal spontaneously
and require a surgical procedure to close the resulting
oroantral opening.
OAF may result from either a known or an
unknown perforation of the maxillary sinus. Primary
epithelial fusion of the schneiderian membrane to
the oral epithelium may occur before the closure of
the defect by the cells of its own origin. Thus,
a permanent epithelialized tract forms, allowing
a persistent communication between the oral cavity
and the sinus.

9. • Escape of fluids from mouth to nose when patient
gargles or rinses mouth following extraction of
tooth
• Epistaxis may or may not be associated with
frothing at nostril
• Escape of air on sucking, inhaling or puffing of
cheek
• Enhanced column of air causes alteration in voice
and vocal resonance
• Excruciating pain in and around region of affected
sinus. Tenderness over cheek.

10. • Pain dull aching in and around antrum, earache,
frontal and parietal headache
• Persistent purulent, foul unilateral nasal discharge
• Unilateral fetid odor and taste
• Postnasal drip
• Nocturnal cough, hoarseness of voice, catarrhal
deafness
• Fever, in severe cases anosmia.
• Popping out of antral polyp seen as bluish red lump
extruding through fistula

11. Popping of an antral polyp through long-standing oroantral fistula

12. • Nose blow test
• Rinse the mouth

13. Compression of anterior nares,
followed by gentle blowing of nose (with mouth open),
causes a rise in intranasal pressure exhibited by the
whistling sound as air passes down the open passage.
Escape of air bubbles, blood or pus, etc. may appear at
the oral orifice. A wisp of cotton-wool held just below
the alveolar opening will usually be deflected by the
air stream. However, it is important that a suspected
antral defect at a site of recent extraction, should not be
explored with an instrument. Such a maneuver could
lead to breakdown
An intra oral periapical radiograph is taken with a silver
cone Maxillary sinus radiograph with or with out probe

14. Purpose
• To protect sinus from oral microbial flora
• To prevent escape of fluids and other contents
across communication
• To eliminate existing antral pathology
• To establish drainage through inferior meatus

16. Treatment of early cases
• Immediate surgery to achieve primary closure
• Simultaneous antibiotic to prevent sinus infection
Less than 5 mm opening closed spontaneously
2-6 place collagen plug nd place fig of 8 suture
Instruct the pt not to blow nose and not to do vigorous rinsing or gargle

17. Closure of accidental oro-antral communication in the dentulous arch

18. 1. Antibiotics: The prime objective is:
(i) Prevention of secondary infection at the site of wound,
and
(ii) Control of coexisting or pre-existing infection of antrum.
i. Penicillin and its derivatives
ii. In case, the organisms are resistant to penicillin, a broad
spectrum antibiotic is prescribed.
iii. The selection of antibiotic should be done on the basis of
culture and sensitivity testing:
iv. These are used until symptoms begin to subside. It can be
started with IV route, and later switched over to oral route.
Penicillin V 250 to 500 mg six hourly is adequate.

19. 2. Nasal decongestants: vasoconstrictor nasal drops
and sprays and inhalations. These encourage the
drainage of pus and secretions. These do not interfere
with ciliary action. The available preparations are:
(i) Ephedrine nasal drops (0.5%), instilled intranasally every 2
to 3 hours
(ii) Steam inhalations
(iii) Benzoin and menthol inhalations- inhaled for 10 minutes
twice a day.

20. 3. Analgesics: Nonsteroidal anti-inflammatory agents:
• (i) Aspirin 500 mg 1 to 3 tablets 4 times daily.
• (ii) Paracetamol 500 mg three times daily,
• (iii) Ibuprofen 400 mg three times daily.

21. • Caldwell Luc operation is classic recommended
surgery in cases of chronic maxillary fistula,
indicated for removal of inflammatory tissue
and sinus mucosa when irreversibly damaged
by infection

22. (A)semilunar incision, (B) Creation of bony window with drill, (C) Perforation area
for window, (D) Enlarging the bony window at the anterior maxillary wall with
rongeur or bur

24. • Many small defects can be closed with a buccal
flap.
• Two types have been recommended: the
advancement flap and the sliding flap.

25. TRAPEZOIDAL SLIDING BUCCAL FLAP
• Moczair
Disadvantages
• The raw surface that
remains anteriorly
• Large amount of gingival
attachment needed to
facilitate the shift
It produce minimal change in buccal vestibular depth.
Distal shift is facilitate by incising periosteum at the base of flap
Which may result in gingival recession and possible periodontal ds.
Most suitable in edentulous arch.

26. ADVANCEMENT FLAP
Von Rehrmann in 1936
popularized by Berger in
1939

27. Laskin and Robinson described a modification of the buccal flap

28. Oroantral fistula closure by buccal advancement
flap. Modified Rehrmann’s procedure: (A) OAF, (B
and C) Outline of buccal flap, (D and E) Reflection of
buccal mucoperiosteal flap. Relieving incision high
up through the periosteum, (F) Sagittal section—
Rehrmann buccal flap, (G) Modified Rehrmann flap
with de-epithelialization of the margin of the buccal
flap, which is tucked under the palatal flap over the
periosteum. This ensures double layer closure.
Buccal and some palatal alveolar bones are reduced
with rongeurs, (H) Initial mattress suturing to pull
the margin of the flap and then interrupted suturing
is carried out

29. Advantages
• Broad base providing a good blood supply
• No denuded area being left, and requiring no
rotation.
• Flap allows a simultaneous Caldwell-Luc procedure
to be performed either directly or through a small
incision extended anteriorly from the base of the
flap into the region of the canine fossa.
Disadvantage
• Reduction in the depth of the buccal vestibule

30. Based on greater palatine vessel, first described by
Ashley in 1939
• Types
• Straight advancement flap
• Rotational advancement flap
• Hinged flap
• Island flap

31. Advantages
• Insured vascularity.
• Good thickness of tissue
• Resembles attached gingival
Disadvantages
• Occasional need for rotation, risk of
decreasing blood supply
• Raw surface heal secondarily

34. Ashley’s palatal pedicled rotational advancement
flap for closure of oroantral fistula (A) Circular excision of
tissue
around the fistula, (B) Palatal rotational advancement
flap based on
the greater palatine vessels. The kinking of the flap may
be minimized
by excision at the lesser curvature of the flap (dark area)
Kruger’s
modification, (C) Final closure. Raw palatal area can be
protected by
placing iodoform gauze pack

35. • described by Henderson
• used to close larger defects
• Gullane and Arena
• freeing the vessels at the greater palatine
foramen

37. • James has suggested that sectioning of the island
should be done last so that the tissue can still be
used as a rotational advancement flap or
returned to its original site

38. HINGE FLAP
• The mucoperiosteum on the palatal aspect of
the oroantral fistula can be used as a hinge
flap to close small openings
• it has a minimal blood supply that limits size
of flap.

39. • A simple, transverse, bipedicled, buccopalatal
flap can be used
• minimal mobility

40. • Inversion and rotational advancement flaps,
double overlapping flaps, double island flaps,
and superimposed reverse palatal and buccal
flaps. The use of two-donor site results in
increased surgical time and larger denuded area.

41. • Tongue flap
• Temporalis flap
• Buccal fat pad flap

42. • Tongue flaps ere introduced for intra oral
reconstruction by Lexer in 1909
• Described by Guerro- Santos and Altamirano in 1966
for closure of oroantral fistula.
• The excellent blood supply, pliability of the flap, and
the ability to achieve primary closure of donor sited
make use of tongue flap versatile

43. • The tongue flap can be anteriorly or posteriorly
based, the dorsum of tongue
• Lateral flaps have the better proximity to location
of fistula
• Anteriorly based flap has disadvantage of
tethering

45. Use of the tongue flap for intra oral reconstruction;
report of 16 case
Kim, Yeo and Kim
J Oral Maxillofac Surg 1998; 56: 716-719
16 patients were treated with tongue flap four of them
for oronasal fistula and one for oroantral fistula was
successful in all patients

46. • Because of proximity to oral cavity, the safety of
vascular pedicle, its pliability, minimal functional
and esthetic sequel used in one stage closure of
oroantral communication

47. BUCCAL FAT PAD
• Egyedi in 1977 for OAF
• readily accessible and
has an excellent blood
supply.

48. • It is accessed via horizontal vestibular incision in the
third molar region. The fat pad is the gently teased
out of its bed and advanced into defect, where it is
sutured in place.
• Although both split thickness skin grafts and
lyophilized porcine dermis have been used to cover
the flap, this is unnecessary because the transpose
fat become epithlialized in 2 to 3 weeks

49. Use of pedicled buccal fat pad in closure of oroantral
communication; analysis of 75 cases
Dolanmaz et.al.,
Seventy five patients ere treated with pedicled buccal
fat pad for closure of oroantral communication 52
immediately after extraction and 23 chronic cases
6 months follow up showed uneventful healing in all of
patients. Though partial necrosis was found in one
case did not effect the final healing
Quintessence international 2004: 35(3) ; 241-426

50. • requiring a second surgical procedure
• disadvantage is the risk of exposure of the bone
graft on the antral side that can result in
infection, loss of the graft and persistence of
fistula

53. • A variety of alloplastic and Allogenic materials
have been used to close oroantral fistula, including
gold foil, tantalum, polymethylmethacrylate,
lyophilized porcine collagen, hydroxyapatite block
and fibrin glue.

54. • Allotransplants of fascia lata and duramater is
described by Guven in 1995
A Caldwell-Luc procedure, with nasal antrostomy, is
indicated in only those few cases where severe
sinusitis is present prior to the antrum being
exposed.

55. • New use of Deans technique- Preprosthetic
interseptal alveolotomy to close OAF
• Mid crestal incision – minimal reflection and
tunneling of buccal and palatal flap
• Removal of intermedullary septal bone, vertical
osteotomy distally and proximally and compression
with digital pressure to create green stick fracture.
Approximating the bone and the soft tissue flaps.
successfully done in 4 cases
J Oral Maxillofac Surg 1995; 53; 1392-1396

56. Yoshimasa K, Sano K, Nakamura M,Ogasawara T.
Use third molar transplantation for closure of the
oroantral communications after tooth extraction: a
report of 2 cases.
Oral Surg Oral Med Oral Pathol 2003: 95: 409–415

57. YOSHIMASA et reported two cases of using third
molar transplantation with closed apices for the
closure of an OAC after tooth extraction.
They presented satisfactory results of closing
the communication and restoring masticatory
function, and no problems were noted during the
first year of clinical follow- up.

64. Bhaskar Agarwal, Sandeep Pandey, Ajoy Roychoudhury
All IndiaInstitute of Medical Sciences, New Delhi, India
British Journal of Oral and Maxillofacial Surgery 54 (2016) e31–e32

66. Described by Zhenmein used the flap for cleft palate
and periorbital defects
Buccinator myomucosal island flap for postablative
maxillofacial reconstruction: a report of 4 cases
Anastassov, Schwartz and Rodriguez
J Oral Maxillofac Surg 2002 ;60; 816-821

67. • Oral And Maxillofacial Surgery Clinics Of North
America 1999 Vol 11
• Maxillary Sinus And Its Dental Implications Gowen
Baxter James
• Text Book Of Oral Surgery Neelima Malik
• J Oral Maxillofac Surg 74:704.e1-704.e6, 2016
• British Journal of Oral and Maxillofacial Surgery 49
(2011) e86–e87

68. THANK YOU