This document discusses the anatomy and pathology of the maxillary sinus and oroantral communications. It describes the location and drainage of the maxillary sinus and causes of sinusitis. Oroantral communications are defined as pathological connections between the oral cavity and maxillary sinus that can form due to dental procedures or trauma. Signs, testing methods, prevention, and management strategies are outlined for both acute communications and oroantral fistulas. Surgical techniques for repair include local soft tissue flaps, grafts, and use of the buccal fat pad flap. Immediate closure of communications less than 3 weeks old has a high success rate, while delayed or recurrent fistulas require surgical intervention.

1. Arrantxa Danielle M. Sumabat, DMD
Resident, Department of Oral & Maxillo Facial Surgery
Craniofacial Foundation of the Philippines

2. Maxillary Sinus
 The maxillary sinuses are
located beneath the cheeks,
above the teeth and on
either sides of the nose.
 It drains into the nose
through a hole located
about half way up the side
of the sinus wall called the
ostia.
 If the maxillary sinuses
become blocked they fill up
with liquid that often gets
infected (sinusitis). This
could cause toothache or a
dull aching pain under your
cheeks.

3. Oro – Antral Communication
 This is a common
complication,
which may occur
during an attempt
to extract the
maxillay posterior
teeth.
 This is easily
diagnosed by
dentist post
extraction.

4.  Observe bubbling of blood from post
extraction alveolus when patient tries
to exhale gently through their nose
while nostrils are pinched.
 If patient exhales through their nose
with great pressure, risk of causing
oroantral communication may occur,
even though communication may not
have occurred initially.
 Fluid comes out of the nose while
rinsing post extraction
 Fogging of the mouth mirror when
place directly on the extraction site
as the patient exhales through his
nose.
 Radiograph is usually used for
confirmation, and to determine the
extent of defect.
How to Test OAC?

5. Aetiology: OAC
 Displacement of impacted tooth or root tip
into the maxillary sinus during a removal
attempt
 Proximity of the root tips to the Sinus floor.
 Extensive bone removal for extraction of an
impacted tooth or root
 Extensive fracture of the maxillary tuberosity,
where a part of the maxillary sinus may be
removed.
 Presence of periapical lesion that has
eroded the bone wall of the maxillary sinus
floor.

6. Oro –Antral Fistula (OAF)
 Definition:
 Is a pathological
communication between
the oral cavity and
maxillary sinus
depending on its location
it maybe classified into:
○ Alveolo-sinusal,
○ palatal-sinusal and
○ vestibulo-sinusal.

7. OROANTRAL FITULA
 The term OAF is meant to indicate a canal
lined by epithelium that may be filled by
granulation tissue or by polyposis of the sinus
membrane, most frequently due to iatrogenic
oroantral communication.
 It must be emphasized that unlike the oro-
antral communication (OAC), OAF is
characterized by the presence of epithelium
arising from the oral mucosa and/or from the
antral sinus mucosa that, if not removed, could
inhibit spontaneous healing.

8. Aetiology
 OAF could be caused by dental infection,
osteomyelitis, radiation therapy, trauma or
following removal of maxillary cysts or
tumors.
 The extraction of maxillary posterior teeth
represents the most common etiology of
OAF due to the proximity of the bicuspid
apices and molars to the antrum.
 Alternatively, OAF might arise during
preparation of bone for insertion of a dental
implant as a consequence of poor surgical
planning.

9. Signs and Symptoms
 Unpleasant tasting discharge and odor
 Reflux of fluids and food into the nose
from the mouth
 Leakage of air
 Some patients may be asymptomatic

10. Preventive Measures

11. Management
 Immediate Management
 When exposure and perforation of the sinus is
small and the sinus is disease free, efforts
should be made to establish a blood clot in the
extraction site & preserve it in place.
 Sutures are placed to reposition the soft tissues,
and gauze pack is placed over the surgical site
for 1 – 2 hours. The patient is instructed to use
nasal precautions for 10-14 days.
 Includes: Opening mouth while sneezing, Not
sucking on straw or cigarettes, avoid nose
blowing.

12. Management
 Communication:
 During Endodontic Therapy:
- Infected Canal Ab Therapy, closure & filling
- Not infected Canal nothing (low risk of sinusitis)
• If sinusitis has occurred drainage through the
root canal.
 During tooth Extraction
- Prevention
- < 5mm noninvasive intervention (spontaneous
closure by blood clot)
- > 5mm surgical intervention

13. Management
 During dentoalveolar surgery
- Small noninvasive wound closure
- Large rotational flaps
- Extremely Large distant flaps (e.g tongue
flap) & grafts.
 Fistula
- Surgical closure is mandatory re gardless of
the defect

14.  Medications
 Antibiotics (Penicillins)
 Oral mouth rinse with antibiotics (Orahex Af)
 Anti Histamine
 Analgesics (NSAIDs)
 Oral Decongestants
○ Decolgen No-Drowse
○ Neozep Non-Drowsy
** Decongestant nasal sprays and nose drops should only be used
for about 5-7 days at a time. If they are used for longer than this
a rebound, more severe congestion of the nose often develops.
Oxymetazoline and xylometazoline nasal preparations are
thought to be more likely to cause rebound nasal congestion
because they are the strongest. Oral decongestants are not
thought to cause this problem when they are stopped.
Decongestant sprays and drops are thought to work better than
oral tablets or capsules.
Management

15. Remember
 Most of the minor communications,
having a diameter of 1-2mm, heal
spontaneously in the absence of
infection. When chronic oroantral fistula
defects are wider than 5mm and persist
for more than 3 weeks, a secondary
surgical intervention is required

16. Immediate Management

17. Factors that determine Surgical
Techniques
1. Whether it is a new communication or
fistula.
2. Location and size of the defect
3. Anatomical relationship between the defect
and the neighboring teeth
4. Height of the alveolar ridge
5. Duration of the sinus exposure
6. Presence or absence of sinusitis
7. General health status of the patient

18. Buccal Advancement Flap
Technique
 Indications:
- Minor communication
- Buccal Defect
 Advantages
- Simplicity
- Lower post – operative pain and discomfort
 Disadvantage
- Thin flap (increase chances of dehiscence)
- Limited extent
- Loss of vestibular depth
- Scaring may cause impaired mobility
** Not preferred for large communication and recurrent
fistula

21. Buccal Advancement Flap
Techniques

22. Palatal Flap Technique
 Advantage
- More tissue attachment without
tension
- Firmer and more resistant to trauma
& infection
- Could be used with large defect
- Preserve the buccal vestibular depth
- Good vascularization
 Disadvantage
- Denudation of the palatal surface
- Greater post-op pain
- More complicated technique
- Appearance of roughness at the
donor site (epithelialization)
- Possible flap necrosis
- Interfere with wearing partial denture
for covering the hard palate

23. Palatal Pedicle Flap

24. Buccal & Palatal Flap

25. Buccal Fat Pad Flap
 The use of this type of flap has
limited clinical usage and for
many years has been
considered a risky procedure
due to the possibility of
traumatizing the pterygo-
maxillary space.
 This is commonly used for
OAF due to its location which
is anatomically favorable, easy
and minimal dissection with
which it can be harvested and
mobilized. The fat pad
provides a good rate of
epithelialization and low rate of
failure.

26. Buccal Fat Pad
 Is a biconvex disc of vascularized fat
lying behind the zygomatic arch.
 There are four processes, the buccal
process, the pterygoid process, the
superficial process and the deep
temporal process. These extend from
the body to the surrounding tissue
spaces such as the
pterygomandibular space and the
infratemporal space.
 6 The arterial supply to the BFP
depends on small branches of the
maxillary, superficial temporal and
facial arteries.
 The size of the BFP is fairly constant
among individuals, regardless of the
overall body weight and fat
distribution.

27. How to reach BFP?
 In order to reach the BFP an incision of the posterior
mucosa must be made in the area of the zygomatic
buttress, followed by a light in incision of the periosteum
and the fascial envelope of the buccal pad.
 A gentle dissection with fine curved artery forceps
exposes the yellowish-colored buccal fat. The buccal fat
pad flap, preferably of the pedicled type, has been used
most commonly for the closure of the OAF. This is due
to the location of the buccal fat pad which is
anatomically favorable, to the easy and minimal
dissection with which it can be harvested and
mobilized. The fat pad provides a good rate of
epithelialization and a low rate of failure

28. Buccal Fat Pad Flap Techniques

29. Points to Remember
 According to the literature and to the author’s clinical
experience, any communication between the maxillary
sinus and the oral cavity lasting for more than three weeks
should be surgically closed in order to avoid further
medical problems.
 Immediate repairs of the acute oroantral defect have a
uniformly high success rate approaching 95% that
decreases to 67% in cases of delayed closure. An
important role in the healing process is played by the
presence of sinus diseases.
 An important role in the healing process is played by the
presence of sinus diseases. In these cases the advice of a
specialist will help to deal with complications.

30. Points to Remember
 Treatment modalities to repair the oroantral
fistula include local or free soft tissue flaps,
with or with or without autogenous grafts or
alloplastic implants.
 The closure of an oroantal communication
of any origin, can be achieved by different
techniques. Particular emphasis should be
made in choosing most appropriate
surgical technique to use.

31. References
 Use of the buccal fat pad in maxillary and sinus grafting of
the severely atrophic maxilla preparatory to implant
reconstruction of the partially or completely edentulous
patient: technical note.Liversedge RL, Wong K
Int J Oral Maxillofac Implants. 2002 May-Jun; 17(3):424-8.
 Andrea Enrico Borgonovo, Frederick Valerio
Berardinelli.2012. Surgical options in Oroantral Fistula
Treatment. The Open Dentistry Journal.2013
 Closure of Oroantral Communications: A Review of the
Literature. Susan H. Visscher, Baucke van Minnen,.2010,
Journal of Oral and Maxillofacial Surgery.
 Hupp, J.R, Edward Ellis III and Tucker, M.R.(2009) –
CONTEMPORARY Oral and Maxillofacial Surgery,
Missouri: Mosby
 Fragiskos, D.F. (1965) – Oral Surery, Heidelberg: Springer
- Verlag