R E V I E W Open Access
Decision-making in closure of oroantral
communication and fistula
, Karina Obreja
, Amira Begic
, Frank Schwarz
, Jürgen Becker
, Robert Sader
and Loutfi Salti
After removal of a dental implant or extraction of a tooth in the upper jaw, the closure of an oroantral fistula (OAF) or
oroantral communication (OAC) can be a difficult problem confronting the dentist and surgeon working in the oral and
maxillofacial region. Oroantral communication (OAC) acts as a pathological pathway for bacteria and can cause infection of
the antrum, which further obstructs the healing process as it is an unnatural communication between the oral cavity and
the maxillary sinus. There are different ways to perform the surgicalclosureoftheOAC.Thedecision-making in closure of
oroantral communication and fistula is influenced by many factors. Consequently, it requires a combination of knowledge,
experience, and information gathering. Previous narrative research has focused on assessments and comparisons of various
surgical techniques for the closure of OAC/OAF. Thus, the decision-making process has not yet been described
The present study aims to illustrate all the factors that have to be considered in the management of OACs and OAFs that
determine optimal treatment.
Keywords: Oroantral, Fistula, Flaps, Grafts, Maxillary sinus, Complication management, Oral surgery, Decision, Oroantral
Oroantral communication (OAC) acts as a pathological
pathway for bacteria and can cause infection of the an-
trum, which further obstructs the healing process as it is
an unnatural communication between the oral cavity and
the maxillary sinus. The oroantral fistula (OAF) develops if
the OAC remains open and becomes epithelialized. The
oroantral fistula has its origin either from iatrogenic
complications or from dental infections, trauma, radiation
therapy, or osteomyelitis .
Clinical decision-making determines the optimal strategy
in a particular clinical situation. Consequently, it requires a
combination of knowledge, experience, and information
gathering. Previous narrative research has focused on as-
sessments and comparisons of various surgical techniques
for closure of OAC/OAF . Thus, the decision-making
process has not yet been described comprehensively.
Clinical decision-making in closure of an OAC/OAF
depends on multiple factors that include the size of the
communication, time of diagnosis, presence of infection,
and clinician’s experience. Moreover, the selection of
management strategy is influenced by the quantity and
quality of tissue available for closure of OAF/OAC and
the potential placement of dental implants in the future
. The method presented is decision tree design. This
approach enables to recognize uncertainty in clinical
diagnosis and therapeutic decisions and hence develop
strategies to manage these uncertainties. The present
study aims to illustrate all the factors that have to be
considered in the management of OACs and OAFs that
determine optimal treatment.
Identifying the etiology of the OAC is essential to create
an effective procedure. Harrison demonstrated that the
bone lamella between the maxillary posterior teeth and
the maxillary sinus is occasionally 0.5 mm . Thus, the
first premolars accounted for 5.3% of OACs, the second
molars were the most frequently with an incidence of
45%, followed by the third molars 30% and the first
molars 27.2%. It was reported that about 2.2% of the first
molars apices perforated the maxillary sinus floor,
* Correspondence: email@example.com
Department of Oral Surgery and Implantology, Carolinum, Goethe
University, Frankfurt, Germany
Full list of author information is available at the end of the article
International Journal o
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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Parvini et al. International Journal of Implant Dentistry (2019) 5:13
followed by the second molars 2% of the described cases .
Due to the close relationship of the roots to the antrum and
partially very thin maxillary sinus floor, the extraction of the
upper molars and premolars, especially the extraction of the
first molars, is considered the most common etiology of
OAC [5–7]. Pathological lesions in the sinus, trauma, and
failed external sinus floor elevation and augmentation can
also lead to the formation of an OAC. Oroantral communi-
cation may be developed as a result of prevalence of the
inflammatory odontogenic pathologic processes through the
maxillary alveolar process to the Schneiderian sinus mem-
brane. Periodontal infections and other factors are the least
prevalent. Further complications of OAC may result from
the removal of cysts or tumors, implant placement, maxillo-
facial surgery (Le Fort osteotomies), and pathological proce-
dures like osteomyelitis. In addition to the size of the defect,
possible maxillary sinusitis, odontogenic infections, cysts,
tumors, foreign bodies in the maxillary sinus, and osteitis
and osteomyelitis changes also likely play a crucial role in the
formation of a chronic oroantral fistula. Furthermore,
improper treatment of OAC can produce maxillary sinusitis
and become chronic . Figure 1illustrates the etiologic
factors of OAC/OAF/chronic OAF.
Medical history serves to identify patients who have a
higher risk to develop complications during or after
closure of OAC. Cardiovascular disease, diabetes, renal
dysfunction, and hematological disorders may increase
the risk of complications such as bleeding, infections,
and delayed tissue healing .
Signs and symptoms
The symptoms of an OAC can vary from purulent
discharge through the fistula to the patient’s subjective
feeling entry of oral liquids into the nostril on the same
side of the maxillary .Thepresenceofoneormoreof
the symptoms could be the indicator of an OAC or a fis-
tula (acute, chronic). However, some patients may not
present any of these findings if the perforation is too small
or closed by a large polyp. Untreated defect can cause
sinus contamination leading to infection, chronic sinusitis,
and impeded healing . A confirmatory and early diag-
nosis is therefore strongly recommended to permit
Figure 2demonstrates symptoms based on whether
the OAC is acute OAF or chronic OAF.
Clinical examination and diagnosis
Diagnosis represents the first decision-making about the pa-
tient. It determines all subsequent treatments and the course
of each patient. It mainly based on a comprehensive evalu-
ation of dental and medical examination and patient history,
specifically looking for diagnostic criteria for maxillary
Fig. 1 Represents etiology of OAC, OAF, and chronic OAF
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 2 of 11
sinusitis. Figure 3illustrates the steps of decision-making in
the diagnosis of antral perforation.
The large OAC is easily seen on the investigation (Fig. 4). At
a later stage, the antral polyp is seen through the defect.
The patient is instructed to try to exhale through a
blocked nasal airway. However, a negative test does not
exclude the possibility of antral perforation. It is worth
noting that the detection of small perforations is not always
The patient is asked to blow air into the cheeks against a
closed mouth. This test is considered a risk of antral compli-
cations due to the spread of microorganisms from the oral
cavity into the maxillary sinus.
Exploration of the perforation with probing
Attempt of probing the fistula is likely to result in sinus-
itis or widening of the fistula due to pushing of foreign
Fig. 2 Illustrates steps of decision-making in symptoms of OAC, OAF, and chronic OAF
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 3 of 11
bodies or bacteria into the maxillary sinus. . Further-
more, probing may lead to laceration of the sinus
membrane, which may sometimes be intact.
Radiographic features of OAC and OAF
Radiological investigation of the site of OAC and OAF is
required to validate the clinical findings and to investi-
gate the presence of foreign body within the antrum.
From an anatomical point of view, several different
radiographic investigations are required to show all areas
of the antral anatomy well because of the complexity of
its anatomy .
Radiologically, bone discontinuity of the floor of the
maxillary sinus is evident. Patients with OAF are most
susceptible to sinus infections. Therefore, radiological
investigation of the maxillary sinus is recommended.
Periapical film or panoramic radiography can provide an
idea about the bony defect size of the OAC and OAF.
Radiologically, they reveal the disruption of the border
of sinus. Periapical radiograph provides detailed infor-
mation about the bony radiographic changes owing to
Fig. 3 Illustrates steps of decision-making in diagnosis of antral perforation
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 4 of 11
its inherent technique quality. Moreover, it confirms the
presence and location of the foreign body that may have
been dislodged into the antrum [14,15]. The maxillary
sinus and the trajectory of the communication can be vi-
sualized by occipitomental and panoramic radiography.
However, periapical film and panoramic radiography
techniques give only a two-dimensional view of compli-
cated three-dimensional (3D) structures. In addition, the
structures are superimposed.
Computed tomography (CT) and cone beam com-
puted tomography (CBCT) scans are the gold standard
modality of radiological assessment to rule out the pres-
ence of maxillary sinusitis . Figure 5a shows a CBCT
of a molar with a periapical disease causing maxillary si-
nusitis, Fig. 5b shows the extracted molar, and Fig. 5c
shows a CBCT after a healing period of 3 months. Fur-
thermore, both modalities can be used to assess the size
of the fistula and to characterize the bone and mucosa
surrounding the perforation and the nature of the sinus
mucosal lesion [13,16]. CT may reveal air-fluid inter-
face, disruption of the floor of the antrum and foreign
body. Figure 3illustrates the steps of decision-making in
radiographic diagnosis of antral perforation and the
Decision-making in treatment of OAC and OAF
The objective of the management of OAC/OAF is the
closure of the defect and prevention of oral bacteria
and food debris penetrating the sinus. Oroantral com-
munication can cause sinus contamination leading to
infection, impeded healing, and chronic sinusitis . It
is possible that a small OAC of less than 2 mm in diam-
eter, without epithelialization and in the absence of
sinus infection, can heal spontaneously after a blood
clot is formed . However, defects that are larger
than 5 mm in diameter or those that present for more
than 3 weeks rarely heal spontaneously and typically
will require surgical intervention . Technical choice
of professionals for the closure of oroantral fistula can
be influenced by the clinical aspects of each defect (lo-
cation and size), further prosthetic treatment, and ex-
perience of surgeons . Unilateral odontogenic sinus
infection is treated and cured by drainage and removal
of the odontogenic cause. Further factor is the outcome
grafting technique if the dental implant has to be
placed in the near future. Moreover, in relation of OAC
to adjacent teeth, the height of the alveolar ridge, dur-
ation of OAC, existence of inflamed sinus, and the gen-
eral health of the patient should be taken into
consideration . The OAC must be closed within
24–48 h as its persistence increase the possibility of
maxillary sinusitis .
Fig. 4 Clinical OAC after the extraction of a molar
Fig. 5 aCBCT of a molar with a periapical disease causing a maxillary sinusitis. bExtracted molar. cCBCT after a healing period of 3 months
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 5 of 11
Preoperatively, drainage and irrigation with saline
through the OAC of the affected maxillary sinus should
be achieved in cases with sinus infection and degener-
ated mucosa . This procedure should be performed
until the lavage fluid is clear and no longer contains
inflammatory exudates (Fig. 6a, b). Nasal decongestants
shrink the nasal mucosa and keep the antral opening
patent for drainage.
Additionally, the use of appropriate antibiotics is ne-
cessary prior to surgery.
The size of the OAC and opening duration are cru-
cial prognosis factors in treatment. However, primary
suturing the gingiva with a figure-of-eight suture
closes the communication effectively. When this does
not provide adequate closure, a soft tissue closure
using a buccal or palatal flap is indicated . It is
also possible to close the OAC simultaneous with an
immediate implant or to perform an external sinus
Prior to surgical treatment of oroantral communica-
tion, a previous diagnostic is achieved to exclude the
presence of a foreign body and/or inflammatory changes
of the mucous membrane . It is of paramount
importance to close the oroantral fistula in a disease-free
sinus environment .
In case of fully developed fistulae, excision of the fistu-
lous epithelial tract must be achieved, mucosa should be
debrided up to the well-perfused tissue, and the infected
bony structures should be curetted .
Fig. 6 aDrainage through the OAC. bIrrigation with saline through the OAC
Fig. 7 aPre-operative X-ray. bTooth 26. cPerforation of the Schneiderian membrane. dPerforation after elevating the Schneiderian membrane.
eCovering the perforation with a collagen membrane and fibrin glue. fAugmentation and implant inserted. gRepositioning of the buccal bone.
hCovering of the OAC with the BFP. iPost-operative X-ray vs 3 years post
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 6 of 11
Fig. 8 Decision tree for the closure of OAC and OAF including suggested treatment options based upon size, location, and time of diagnosis of
OAC and OAF
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 7 of 11
Many techniques have been described for the closure
of oroantral fistula, including local and soft tissue flaps.
Other techniques include grafts, allogenous, xenografts,
alloplastic materials, and other methods like guided tis-
sue regeneration (GTR) or immediate implantation of a
dental implant (Fig. 8) (Table 1).
A rational decision-making process has to be followed
for the closure of OAC/OAF rather than randomly prac-
ticing the available technique. Clinically, the well-per-
fused flap demonstrates a wider base and is well
vascularized. The site of anastomosis should be free of
tension and situated over the intact alveolar bone leaving
at least 5 mm from the margin of fistula .
Local buccal soft tissue flaps are often indicated in the
closure of small to moderate size defects . It worth
noting that the reduction of buccal vestibular height fol-
lowing the closure by buccal flap (Rehrmann flap) makes
it difficult to use prosthesis in the future (Fig. 9). For fur-
ther implant treatment after performing Rehrmann
plasty, it could be necessary to perform an apical repos-
ition flap or an apical reposition flap combined with free
gingival graft (FGG) to increase the width of keratinized
mucosa. OAF can be closed successfully with the buccal
advancement flap in cases where vestibular obliteration
will not be a complication . Other options are free
gingival grafts (FGG) from the palate or free connective
tissue grafts (CTG) in the premolar area or pedicled
connective tissue grafts (CTG) in the molar area. These
two methods should be preferred in view of later im-
plantation because the depth of the vestibulum remains
in the original position. The free mucosal graft is more
uncomfortable for the patient due to secondary wound
Borgonovo et al. proposed the use of the buccal flap
for the closure of oroantral fistulae of moderate size,
provided that not too posteriorly located; the palatal
flap is best used in the case of fistulae located in the
premolar teeth area; and the buccal flap combined
with displacement of the buccal fat pad (BFP) is ap-
propriate for fistulae located in the third molar area
. Ideally, a combination of BFP with buccal ad-
vancement flap technique can be used to cover BFP
and as additional tissue in cases of deficient BFP for
closure (Fig. 10 a, b) .
Given the limitations of local flaps option for closure
OAF, distant flaps and bone grafts can be used with
success in the closure of large defects or in cases where
local flaps have failed .
Table 1 Techniques for closure OAC/OAF
Buccal flap (Rehrmann flap)
Buccal advanced flap
Buccal fat pad flap
Pedicled buccal fat pad
Buccal flap combined with displacement
of the buccal fat pad
Palatal flaps Palatal flap
Palatal rotation-advancement flap
Palatal pedicled flap
Anteriorly based palatal flap
Palatal hinged flap
Palatal mucoperiosteal rotation flap
Palatal straight advancement flap
Palatal pedicled island flap
Modified submucosal connective
Submucosal connective tissue
Submucosal island flap
Random palatal flap
Grafts Free mucous graft
Subepithelial connective tissue graft
Temporalis muscle flap
Allogenous Fibrin glue
Bio Gide/Bio Oss
Synthetic materials/metals Gold
Titanium dental implant
Other techniques Tooth transplantation
Guided tissue regeneration
Biostimulation with laser light
Fig. 9 Closure by Rehrmann flap
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 8 of 11
Application of alloplastic, biological material, or
immediate implantation for the closure of OAC is usu-
ally indicated in the closer of OAC with a diameter of
3–4 mm provided that the maxillary sinus is uninfected
or no foreign body is within the antrum [31,23].
Among the various synthetic materials, Bio-Oss-Bio--
Gide Sandwich technique has yielded excellent results for
OAF closure. The technique achieves both bony and soft
tissue closure, by contrast with only soft tissue closure ob-
tained by local flaps . Collagen and fibrin materials
have received considerable attention for these are biologic-
ally competent and easy to use (Fig. 11 a, b) .
The failure rate of closure of large oroantral fistulas
increases owing to the large defect in the underlying
bone that supports the overlying flap . Many tech-
niques are used to reconstruct this bony defect, includ-
ing metals, autogenous bone grafts, and nonporous
Considering autogenous bone grafts as the technique
of choice for closure large OAF, donor site morbidity,
anatomic and structural problems, and increased level
of bone resorption during healing should be borne in
mind . However, bone grafts are recommended for
the closure of chronic OAF when soft tissue flap
closure fails .
It is recommended to use resorbable guided tissue re-
generation membrane when endosseous implant with
bone graft is considered . More recently, a high-
density polytetrafluoroethylene (PTFE) membrane is
used to close an OAC. This technique showed a
complete closure of the OAF due to the good regener-
ation of the soft tissues directly over the OAC .
Furthermore, single-stage alveolar augmentation with
autogenous bone graft and platelet-rich fibrin (PRF) has
found its application as a non-invasive contemporary
technique for the closure of OAF [25,36].
Non-surgical closure of OAC with absorbable poly-
glactin/polydioxanon implant can be applied in higher
risk patients with blood disorders . Moreover, an
acrylic surgical splint can be used successfully when a
surgical intervention is contraindicated because of
Oral care, a diet of soft foods, analgesics (e.g., non-ster-
oidal anti-inflammatory drugs (NSAIDS)) and nasal de-
congestants are recommended postoperatively. Further,
nose blowing, sneezing with a closed mouth, and vigorous
sports should be avoided .
Summary and conclusion
To the authors’knowledge, decision-making in the clos-
ure of OAC and OAF has not been previously reported.
With the above mentioned steps, it is possible to close
an oroantral communication or fistula by different tech-
niques with particular emphasis on choosing the most
relevant technique. A comprehensive clinical and radio-
graphic examination and consideration of the patient
history serve to assess the severity of the OAC and the
patient’s treatment needs. The criteria of severity of clos-
ure of OAF include the size, time of diagnosis of OAF,
improper treatment of sinus infection preoperatively, ep-
ithelialization of the fistulous tract, and excessive tension
on the flap impeding blood supply for healing .
Fig. 10 aClosure by the buccal fat pad. bHealing after 3 months closure by buccal fat pad
Fig. 11 aHealing after closure by oxidized cellulose. bHealing after 14 days
Parvini et al. International Journal of Implant Dentistry (2019) 5:13 Page 9 of 11
Technical criteria of complexity include the location of
OAF, quantity and quality of tissue at the site of OAF,
size, vestibular depth, and clinical experience. The article
first provides a summary of the management consider-
ations and diagnostic modalities for the closure of OAC
and OAF and then presents a framework for decision-
making in their closure.
BFP: Buccal fat pad; CBCT: Cone beam computed tomography; CT: Computed
tomography; CTG: Connective tissue grafts; FGG: Free gingival graft; FMG: Free
mucosal graft; GTR: Guided tissue regeneration; OAC: Oroantral communication;
OAF: Oroantral fistula; PRF: Platelet-rich fibrin; PTFE: Polytetrafluoroethylene
No funding to declare.
Availability of data and materials
All data generated or analyzed during this study are included in this
PP made major substantial contributions to conception and design of the
manuscript, did the literature research and interpretation of the literature
research, and contributed all clinical cases. KO was a major contributor in
writing the manuscript. FS has made substantive intellectual contributions.
AB has made intellectual contributions. JB has made substantive intellectual
contributions. RS has made substantive intellectual contributions. LS was a
major contributor in the writing of the manuscript and interpretation of the
literature research, figures, and table. All authors read and approved the final
Ethics approval and consent to participate
Consent for publication
Institutional consent form is obtained.
Puria Parvini, Karina Obreja, Amira Begic, Frank Schwarz, Jürgen Becker, Robert
Sader, and Loutfi Salti declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Department of Oral Surgery and Implantology, Carolinum, Goethe
University, Frankfurt, Germany.
Department of Oral Surgery,
Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
Department for Oral,
Cranio-Maxillofacial and Facial Plastic Surgery, Medical Center of the Goethe
University Frankfurt, Frankfurt am Main, Germany.
Received: 1 November 2018 Accepted: 5 February 2019
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