Oroantral communication and oroantral fistula

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. C auses 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: B uccal 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 

14. 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.

15. 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.

16. 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

17. 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