oroantral communication

1. OROANTRAL COMMUNICATION
and OROANTRAL FISTULA
DR Jameel kifayatullah
SENIOR LECTURER KHYBER COLLEGE
OF DENTISTRY PESHAWAR

2. Oroantral communication
• Oro-antral communication is an unnatural
communication between the oral cavity and
the maxillary sinus

3. Causes of OAC/OAF
• extraction of upper molar and premolar teeth (48%)
• tuberosity fracture
• dentoalveolar/periapical infections of molars
• implant dislodgement into maxillary sinus
• trauma (7.5%)
• presence of maxillary cysts or tumors (18.5%),
• osteoradionecrosis,
• flap necrosis
• dehiscence following implant failure
• as a complication of the Caldwell-Luc procedure.

4. Predictive Factors/Predisposing Factors
• Proximity of sinus floor / tuberosity
• Thickened tooth cement (hypercementosis) / tooth
fused to jaw bone (ankylosis)
• Infected teeth / long-standing decay
• Marked periodontitis / gum disease
• Lone-standing
• Previous history of OAC’s

5. TREATMENT OF OAC
• LESS THAN OR EQUAL TO 2 mm : noninvasive intervention
(spontaneous closure by blood clot)
• Ensure formation of clot by placing Gauze pack over
surgical site for 1-2 hours.
• Sinus precautions for 10-14 days(opening themouth while
sneezing,not sucking on straw/cigarettes,avoid nose
blowing)
• Antiobiotic(penicillin,nasal decongestant,systemic
decongestant for 7-10 days)
• Follow up after 48-72 hrs to see two things
• oroantral communication becomes evident(leakage of air
into mouth/fluid into nose) or
• symptoms of maxillary sinusitis sinusitis appear.

6. OROANTRAL COMMUNICATION
• If opening is of moderate size (2-6 mm)
measured by sizeable piece of bone comes out
with the toothplace gel foam into socket
and figure of 8 suture done over tooth socket.
• Sinus precautions
• Antiobiotic(penicillin,nasal
decongestant,systemic decongestant for 7-10
days)
• Follow up

7. OROANTRAL COMMUNICATION
• SINUS OPENING IS LARGER (7 mm or larger):
repair with flap procedure
Options:
• Buccal advancement flap
• Sinus precautions and medications

8. Sinus precautions
• DO NOT blow your nose for at least two weeks.
• DO NOT forcibly spit for one week.
• DO NOT smoke or use smokeless tobacco; smoking greatly inhibits the healing
process, especially in the sinuses.
• Sneeze with your MOUTH OPEN. If the urge to sneeze arises, do not sneeze through
your nose and avoid pinching nostrils.
• Drink without a straw for one week.
• Avoid swimming for one month and strenuous exercise (e.g. heavy lifting) for one
week.
• Gentle swishing with salt water may be done for one week, but do not rinse
vigorously.
• Slight bleeding from the nose is not uncommon and may occur for several days after
surgery.

9. Oro-Antral Fistula
• An oro-antral fistula (OAF) is an epithelialized pathological
unnatural communication between oral cavity and maxillary sinus.
• It develops when the oro-antral communication fails to close
spontaneously, remains patent and gets epithelialized.
• There is migration of oral epithelium into the defect.
• This epithelialization usually occurs when the perforation persists
for at least 48-72 hours.
• Within few days, the fistula gets organized and with the
epithelialization of the fistulous tract, osteitis of the surrounding
bony margins, presence of foreign bodies or development of
maxillary sinusitis, spontaneous healing is hampered which may
result in chronic fistula formation.

10. Oro antral fistula
• Szabo found out that 7-8 days is the average
time during which an oro-antral perforation
epithelialize and become a chronic fistulous
tract
• Experimental studies have confirmed the
clinical finding that a maxillary sinusitis is
present when an untreated oroantral
communication has persisted for more than
48 h (i.e. an oroantral fistula).

11. Basic principles
• There are 2 basic principles that must be
considered while operating for OAFs/OACs. The
first is that the sinus must be free of any type of
infection with adequate nasal drainage. The
second is that closure must be tension free and
consists of broad based, well vascularized soft
tissue flap over the intact bone. Successful
closure of the oro-antral fistula should be
preceded by the complete elimination of any
sinus pathology, the fistulous tract, sinus
infection, degenerated mucosa and diseased
bone

12. LATE TREATMENT
• CHRONIC OROANTRAL FISTULA:(small opening less than 5
mm)
MANAGEMENT OF CHRONIC SINUSITIS:
• ANTRAL IRRIGATION AND FISTULA EPITHELIUM
EXCISION/EL EVATION FROM BONY WALL
• NASAL DECONGESTANTS
• ANTIBIOTICS
• CLOSURE OF SMALL FISTULA WITH BUCCAL/PALATAL FLAP.
• MAXILLARY OSTEUM CLOSED: NASAL ANTROSTOMY
• Follow up for several weeks
• FAILED HEALING: USE ALTERNATE FLAP

13. CHRONIC OROANTRAL FISTULA(large
opening greater than or equal to 5 mm)
• Management of chronic sinusitis
• Nasal decongestants
• Closure with buccal fat pad,tongue,or temporalis
muscle flap
• Nasal antrostomy
• Sinus precautions
• FOLLOW UP
• FAILED HEALING:ALTERNATE FLAP

15. Criteria for selecting the surgical
approach to close OAF
• location of defect
• size of defect
• height of the alveolar ridge
• vestibular depth
• persistence of defect
• sinus inflammation or infection
• general health of patient.

16. Treatment modalities
Treatment modalities to repair the oro-antral
defects include
• local or free soft tissue flaps, with or without
autografts or alloplastic materials
• The buccal flap : suitable for closure of small and
mesial fistulas
• The palatal flap is a feasible option for repairing
OACs, more likely for defects in the premolar
area.
• The BFP is suitable for the closure of large
posterior OAC/OAFs.

17. TYPES OF BUCCAL MUCOPERIOSTEAL
FLAPS FOR OAF CLOSURE
• The procedures utilizing buccal
mucoperiosteal flap for closure include
straight-advancement flap
• rotation-advancement flap
• transverse flap
• sliding flap techniques

18. Types of Palatal Mucoperiosteal flaps
for OAF closure
• The procedures utilizing palatal
mucoperiosteum are
• straight-advancement flap
• rotational advancement flap
• hinged flap
• island flap procedures

20. Palatal Rotational Advancement Flap