OROANTRAL FISTULA

1. OROANTRAL
COMMUNICATION
and
OROANTRAL
FISTULA
• SURGERY II :
MAXILLOFACIAL SURGERY
• MOHAMMAD ABUSAD
• SEU

2. Oroantral
communication
• Oro-antral communication is
an unnatural communication between th
e 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. 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.

8. 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).

9. 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

10. 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

11. 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

13. 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.

14. 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.

15. 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

16. 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

18. Palatal Rotational Advancement
Flap

19. Oronasal
fistula
(ONF)
Oronasal fistula (ONF) is probably the
commonest complication associated with
cleft palate surgery. The two main
symptoms associated with ONF are nasal
regurgitation and speech problems,
mainly hypernasality. The site and size of
the fistula are variable and so are the
causes. ONF develops primarily because
of repair under tension and in some cases,
especially in adults, as a result of
postoperative infection.

20. CLASSIFICATION OF (ONF)
• fistulas may be classified as
• small (< 2mm)
• medium (3-5mm)
• large (>5mm)
• According to the location, fistulas are
described
• as anterior fistula
• midpalatal fistula
• fistula at the junction of the soft palate and
hard palate and soft palate fistula.

21. AETIOLOGY
OF (ONF)
The primary cause of development
of ONF is repair under tension.
However, there are some palatal
clefts which are quite wide and the
available tissue to repair the palate
seems inadequate. In these cases,
the chance of development of ONF is
higher though in experienced hands
they can be prevented. Besides
these, inadvertent use of diathermy,
particularly near the greater palatine
pedicle can compromise the blood
supply of the mucoperiosteal flap
and can result in an ONF.

22. SURGICAL
TREATME
NT OF
ONF
Surgical principle
Preferably the fistula should be closed in
two layers. Both the layers should have
well-vascularised tissue and the suturing
should be free of tension. There are also
reports in literature wherein closure of ONF
was effected in three layers.[9] As an
intermediate layer, cartilage, bone and
acellular dermal matrix have been used.

23. SURGICAL
TREATMENT
OF ONF Figure

24. SURGICAL
TREATMENT O
F ONF
Mucosal/myomucosal flap from the under-surface of
the lip
This is particularly helpful for anterior fistulas where
there is deficiency in oral mucoperiosteal layer. The
flap can be transported into the palate through the
alveolar cleft and can reach 3-4 cm into the palate.
Similar flaps can be taken bilaterally in case of bilateral
cleft lip and palate to close anterior fistulas on either
side of the premaxilla [Figure ].

25. SURGICAL TR
EATMENT OF
ONF

26. Thank you