Oroantral communication & fistula

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. Outline Definition Etiology Pathogenesis Sign and symptoms Diagnosis Management Recent trends Bibliography

4. Definition 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. Etiology Extraction of teeth chronic periapical infection Surgery Facial trauma Malignant tumors Syphilis, 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. Pathogenesis 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. Symptoms of fresh oroantral communication 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. Symptoms of oroantral fistula 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. Diagnosis 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. Management 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

15. 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

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

17. Supportive Measures 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 In case, the organisms are resistant to penicillin, a broad spectrum antibiotic is prescribed. The selection of antibiotic should be done on the basis of culture and sensitivity testing: 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.

18. Supportive Measures 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.

19. Supportive Measures 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.

20. Treatment of chronic oroantral fistula 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

21. (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

22. LOCAL FLAP PROCEDURES

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

24. 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.

25. Advancement flap Von Rehrmann in 1936 popularized by Berger in 1939

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

27. 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

28. 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

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

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

31. Ashley’s palatal pedicled rotational advancement flap

32. 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

33. Palatal island flap described by Henderson used to close larger defects Gullane and Arena freeing the vessels at the greater palatine foramen

34. 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

35. 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.

36. Combined local flaps A simple, transverse, bipedicled, buccopalatal flap can be used minimal mobility

37. Double-layered closures 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.

38. Distant flaps Tongue flap Temporalis flap Buccal fat pad flap

39. Tongue flap 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

40. 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

41. 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

42. Temporalis muscle flap 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

43. Buccal fat pad Egyedi in 1977 for OAF readily accessible and has an excellent blood supply.

44. 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

45. 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

46. Bone grafts 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

47. Alloplastic materials 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.

48. RECENT TRENDS 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.

49. Application of interseptal alveolotomy for closing oroantral fistula 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

50. Third molar transplantation 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

51. 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.

52. New technique for closure of an oroantral fistula using platelet-rich fibrin 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

53. Buccinator myomucosal island flap 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

54. References 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

55. Thank you