Management of oroantral fistula

1. Management of Oroantral
Fistula
Dr. Saleh Bakry
Assistant Professor of Oral and Maxillofacial Surgery

2. ORO - ANTRAL FISTULA
• It is an abnormal epithelized communication between maxillary sinus and
oral cavity through perforation in the sinus wall

3. Types of OAC
1. Alveolar
• The commonest type.
• It usually follows traumatic dental extraction.
2. Sublabial
• Arise as a complication of Caldwell-luc operation.
3. Palatal
• Malignancy.
• Following a maxillotomy operation.
• Trauma.

4. Etiology:
• After extraction or pushing of a root into the sinus during trial to
remove it from the socket.
• Massive trauma to the middle third of the face.
• After surgical excision of a large cyst or tumor related to the sinus.
• Osteomyelitis of the maxilla.
• During implant surgery.

5. Symptoms of Fresh Oroantral Communication:
Remember 5 Es
• Escape of fluids from the nose.
• Epistaxis (Unilateral).
• Escape of air from mouth into the nose.
• Enhanced column of air  alteration in vocal resonance  change in the
voice.
• Excruciating pain in and around the region of the affected sinus.

6. Symptoms of Established Oroantral Fistula
(late stage): Remember 5 Ps
• Pain.
• Purulent nasal discharge.
• Post nasal discharge.
• Possible sequelae of general systemic toxaemic condition Fever, malaise.
• Popping out of an antral polyp.

7. Signs of Fresh Oroantral Communication:
• Root disappeared.
• +ve nasal blowing test.

8. Signs of Established Oroantral Fistula (late
stage):
• Signs and symptoms of sinusitis and rhinitis.
• Escape of air or fluid through nostril.
• Development of a lump (Polyp).
• Discharge of foul smelling pus from the orifice.

9. Confirmation of presence of oro antral
communication fistula
• If large; Assessed by inspection.
• If small: nose blowing test.
 Compression of anterior nares & gently blow nose produces a
whistling sound, escape of air bubble blood or pus. At the oral orifice.

10. Diagnostic Approach
Clinical Examination:
• Inspection of the extraction site under sufficient light revealed empty alveolus.
• If a nose-bleed occurs immediately after tooth or root loss, the tooth or root is certainly in the
maxillary sinus.
• Patient is instructed to hold his nose and gently blow while examining the area of suspected
perforation
• If opening has occurred through sinus lining, the blood present in the socket will bubble.
Radiographic Examination:
• Periapical view:
• Water’s view.

11. Treatment:
• Immediately after the opening is created.
• Delayed as in case of long standing fistula or failure of attempted primary
closure.

12. I. Immediate Treatment of Oroantral
Communication

13. 1. If the patient has a healthy sinus, a pin-hole oroantral communication (less
than 4 mm) will heal spontaneously
• Flaps are not always necessary
• A figure of 8 sutures should be made over the socket to hold the blood clot
• Place pressure by a gauze pack over the socket for 1-2 hours.
• Standard precautions:
• Opening of the mouth while sneezing
• Avoiding nose-blowing, straw or cigarettes sucking
• Avoiding any other situation that may produce negative pressure changes between the nasal
passages and oral cavity.
• Antibiotic and nasal decongestant for 7 - 10 days to prevent infection and to enhance sinus
ventilation.

14. 2. If oroantral communication is more than 4 mm:
• Done by simple reduction of the buccal and palatal socket walls, and undermining
the wound margins to allow light approximation of the buccal and palatal soft tissue
flaps to close the defect without tension.
• It could be supported with small palatal relaxing incision.
• Protective acrylic splint could be used to provide a barrier to the in entry of food
particles.

15. II. Treatment of delayed cases

16. 1. Surgical preparation:
• The sinus infection should be treated by antibiotics and nasal
decongestants.
• Enlarging and excision of the fistulous tract if it is small and not allowing
proper drainage.
• Daily irrigation of the sinus with warm sterile saline.

17. 2. Surgical Procedure:
The graft bed is first prepared by:
• Cutting away sufficient amount of tissue to expose bone of the entire
circumference of the fistula.
• Removal of diseased bone.

18. 3. Types of flap
• Local flaps
• Distant flaps.
• Grafting (Hard tissue closure).

19. I. Local Flaps
Flaps contain tissues lying adjacent to the defect and usually match the mucosa at
the recipient site in color, texture and thickness.
Advantages
• Low morbidity.
• High success rate.
Disadvantages:
• Restricted for closure of relatively moderate sized fistulae not subjected to several
trials of closure.

20. Types of Local Flaps
1. The Buccal Flap Technique.
• Moczair-buccal sliding flap.
• Rehrmann-buccal advancement flap.
• Buccal transposition flap.
2. The Palatal Flap Technique.
• Palatal transposition flap.
• Palatal submucosal flap.
• Palatal island flap.
• Palatal submucosal island flap.
• Hinged (inversion) flap.
3. Buccal and palatal
• Bipedicle (bridge) flap.

21. A. The Buccal Flap Technique
1. MOCZAIR-BUCCAL SLIDING FLAP:
• A mucoperiosteal flap slides distally a distance of one tooth for closure of
an oroantral fistula.
• It leaves an area of exposed bone at the anterior incision of the flap.
• Advantage: preserving the buccal vestibular height.
• Disadvantage: scarring of the anterior releasing incision.
• This flap is recommended for edentulous patient.

22. A. The Buccal Flap Technique
2. REHRMANN ADVANCEMENT BUCCAL FLAP
Procedures:
• Two divergent incisions are made from each side of the fistula and a buccal
mucoperiosteal flap is raised.
• A horizontal releasing incision is made as high as possible through the taut periosteum
to allow advancement of the flap and to create a water-tight closure of the oroantral
fistula without tension.
Advantages:
• Quick, simple and successful technique.
• Large oroantral fistula can be closed
Disadvantage:
• Obliteration of the buccal sulcus rendering the subsequent prosthodontic procedures
more difficult.
• It is unstable due to cheek movements.

23. B. The Palatal Flap Techniques
1. THE PALATAL TRANSPOSITION FLAP:
Procedures:
• Full thickness incision to outline the flap with its base posteriorly.
• Flap reflection without injury to G.P. Artery.
• The flap is rotated 90° to cover the defect.
• Exposed bone is left to heal by secondary intention and covered by periodontal pack or
palatal stent.
Disadvantage:
• It takes 2-3 month for the palate tissues to granulate.
• Difficult to gain homeostasis.
• Longer healing period.

24. 2. PALATAL SUBMUCOSAL FLAP
• Modification of the above flap.
• Divide palatal flap into 2 layers:
 Mucosal layer → close donor site.
 Submucosal C.T layer → close defect.

25. 3. PALATAL ISLAND FLAP
• It is a pedicled graft (on Greater Palatine artery) composed of mucosa or
submucosa to cover oroantral or oranasal defect.
Indication:
• Large defect.
• Persistent fistula.
4. PALATAL SUBMUCOSAL ISLAND FLAP
• The same steps like above.
• But the island of mucosa and submucosal C.T is splitted into submucosal
graft pedicled on G.P.A.

26. 5. Hinged flap
Indication:
• It is used in combination with another palatal flap as secondary flap to:
1. Provide 2 layers of closure.
2. Act as lining of nose or antrum.

27. C. The Combined Buccal and Palatal Flap
Technique
BIPEDICLE BRIDGE FLAP
Indication:
• If an edentulous space surrounds the defect.
Procedure:
• Two vertical incisions are made palataly and buccally cross over the crest
of the ridge.
• Full-thickness reflection of the flap over the defect.

28. II. DISTANT FLAP
• Tongue flap
• Buccal fat of pad
• Buccinators myomucosal island flaps
• Temporalis myofascial flap.

29. 1. Tongue flap
Indication:
• Useful when the recipient bed may be compromised, such as in cases of:
• post-radiation
• Excessive scar tissue due to multiple surgical procedures.
Classification of Tongue flap
• Classified according Base: Anteriorly based or posteriorly based.
• Classified according Site: lateral or dorsal flap.
• Classified according Thickness: partial or thickness flap.

30. Complications of tongue flap procedures:
• Hematoma formation
• Sloughing of the flap
• Temporary loss of tongue taste sensation
• Narrow tongue

31. 2. BUCCAL PAD OF FAT
Advantage:
• Little decrease in vestibular depth.
• Low morbidity.
• Abundant tissue.
Indication:
• Used to close large oral defect up to 50-60 mm

32. III. GRAFTING (HARD TISSUE
CLOSURE)Indication:
• Presence of bony defect > 5mm in diameter.
• Failure of conservative soft tissue closure.
• Need for reconstruction of alveolar ridge before prosthesis.
Types:
I. General types of bone grafts
• Autograft, allograft, xenograft, alloplast with or without the use of guided
regeneration
II. Other techniques
• maxillary 3rd molar transplantation in place of the extracted 1st molar

33. POST-OP CARE FOR OROANTRAL
COMMUNICATION
Sinus precautions (10-14 days)
• opening mouth wide while sneezing.
• not sucking on a straw / cigarette.
• avoid nose blowing.
• others provide pressure changes between the nasal passage and oral cavity.
medicine administration (7-10d)
• antibiotics and antihistamine/analgesic/antiseptic M.
• decongestant nasal spray/ analgesic.
Wearing surgical stent (7-10 d)
Suture removal (14d)

35. THANK YOU