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Decision-making in closure of oroantral communication and fistula

Authors:
  • Carolinum, Goethe-Universität Frankfurt am Main

Abstract and Figures

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 surgical closure of the OAC. The decision-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 comprehensively. 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.
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R E V I E W Open Access
Decision-making in closure of oroantral
communication and fistula
Puria Parvini
1
, Karina Obreja
1*
, Amira Begic
1
, Frank Schwarz
1,2
, Jürgen Becker
2
, Robert Sader
3
and Loutfi Salti
1
Abstract
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
comprehensively.
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
communication
Background
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 [1].
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 [2]. 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 clinicians 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
[3]. 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.
Etiology
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 [4]. 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: obreja@med.uni-frankfurt.de
1
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
f
Implant Dentistry
© 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
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.
Parvini et al. International Journal of Implant Dentistry (2019) 5:13
https://doi.org/10.1186/s40729-019-0165-7
followed by the second molars 2% of the described cases [4].
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 [57]. 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 [8]. Figure 1illustrates the etiologic
factors of OAC/OAF/chronic OAF.
Medical history
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 [9].
Signs and symptoms
The symptoms of an OAC can vary from purulent
discharge through the fistula to the patients subjective
feeling entry of oral liquids into the nostril on the same
side of the maxillary [10].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 [10]. A confirmatory and early diag-
nosis is therefore strongly recommended to permit
successful closure.
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.
Procedure
Intraoral examination
The large OAC is easily seen on the investigation (Fig. 4). At
a later stage, the antral polyp is seen through the defect.
Valsalva test
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
possible [11].
Cheek-blowing test
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. [12]. 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 [13].
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 [16]. 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
radiographic findings.
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 [10]. 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 [17]. 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 [18]. 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 [19]. Unilateral odontogenic sinus
infection is treated and cured by drainage and removal
of the odontogenic cause. Further factor is the outcome
desiredlikethechoiceforboneorbonesubstitute
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 [20]. The OAC must be closed within
2448 h as its persistence increase the possibility of
maxillary sinusitis [21].
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
Preoperative procedures
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 [16]. 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.
Operative procedures
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 [22]. It is
also possible to close the OAC simultaneous with an
immediate implant or to perform an external sinus
elevation [23,24](Fig.7ai).
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 [25]. It is of paramount
importance to close the oroantral fistula in a disease-free
sinus environment [26].
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 [27].
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 [10].
Local buccal soft tissue flaps are often indicated in the
closure of small to moderate size defects [28]. 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 [29]. 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
healing.
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
[10]. 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) [30].
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 [28].
Table 1 Techniques for closure OAC/OAF
Local soft
tissue flaps
Buccal
flaps
Buccal flap (Rehrmann flap)
Môczáir 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
tissue flap
Submucosal connective tissue
pedicle flap
Submucosal island flap
Random palatal flap
Grafts Free mucous graft
Subepithelial connective tissue graft
Autogenous
distant flaps
Tongue flap
Auricular cartilage
Septal cartilage
Temporalis muscle flap
Autogenous
bone grafts
Intraoral
Extraoral
Autogenous
fibrin
Platelet-rich fibrin
Allogenous Fibrin glue
Dura
Xenografts Collagen
Gelatin film
Bio Gide/Bio Oss
Synthetic materials/metals Gold
Aluminum
Tantalum
Polymethylmethacrylate
Hydroxyapatite
Root analogue
Titanium dental implant
Other techniques Tooth transplantation
Interseptal alveolotomy
Guided tissue regeneration
Prolamin gel
Splint
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
34 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 [30]. Collagen and fibrin materials
have received considerable attention for these are biologic-
ally competent and easy to use (Fig. 11 a, b) [28].
The failure rate of closure of large oroantral fistulas
increases owing to the large defect in the underlying
bone that supports the overlying flap [32]. Many tech-
niques are used to reconstruct this bony defect, includ-
ing metals, autogenous bone grafts, and nonporous
hydroxyapatite blocks.
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 [22]. However, bone grafts are recommended for
the closure of chronic OAF when soft tissue flap
closure fails [33].
It is recommended to use resorbable guided tissue re-
generation membrane when endosseous implant with
bone graft is considered [34]. 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 [35].
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 [31]. Moreover, an
acrylic surgical splint can be used successfully when a
surgical intervention is contraindicated because of
immunosuppression [1].
Postoperative procedures
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 [12].
Summary and conclusion
To the authorsknowledge, 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
patients 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 [37].
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.
Abbreviations
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
Acknowledgements
Not applicable.
Funding
No funding to declare.
Availability of data and materials
All data generated or analyzed during this study are included in this
published article.
Authorscontributions
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
manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Institutional consent form is obtained.
Competing interests
Puria Parvini, Karina Obreja, Amira Begic, Frank Schwarz, Jürgen Becker, Robert
Sader, and Loutfi Salti declare that they have no competing interests.
PublishersNote
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Author details
1
Department of Oral Surgery and Implantology, Carolinum, Goethe
University, Frankfurt, Germany.
2
Department of Oral Surgery,
Universitätsklinikum Düsseldorf, Düsseldorf, Germany.
3
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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... Upper molars and premolars extraction is considered the most common etiology of OAF. [1][2][3] The aim of the OAF management is to repair the defect, restoring the integrity of the sinus and oral cavity and preventing sinus infections. Small fistulas (<5 mm) can heal spontaneously. ...
... However, OAF larger than 5 mm or those that have not been resolved within 3 months usually requires surgical treatment. 1,2 Choice of the technique for OAF closure depends on multiple factors such as the size, time of diagnosis, infection, height of the alveolar ridge, vestibular depth, further prosthetic treatment, and surgeon's experience. 1 Many techniques have been described for OAF closure, including local and soft tissue flaps, grafts, alloplastic materials, biologics, and metals. However, a rational decision-making process must be followed to choose the most adequate technique. ...
... 1,2 Choice of the technique for OAF closure depends on multiple factors such as the size, time of diagnosis, infection, height of the alveolar ridge, vestibular depth, further prosthetic treatment, and surgeon's experience. 1 Many techniques have been described for OAF closure, including local and soft tissue flaps, grafts, alloplastic materials, biologics, and metals. However, a rational decision-making process must be followed to choose the most adequate technique. ...
Article
A novel surgical technique based on a combined approach to oroantral fistula closure using a double‐layered flap: greater palatine artery pedicled flap and buccal fat pad combination. Laryngoscope, 2022
... Moreover, particularly important in developing the correct treatment plan is radiological examination. Computed tomography (CT) or cone beam computed tomography (CBCT) evaluates not only alveolar and the sinus floor defect, but it also presents the mucosal transformations [5,6]. ...
... There are two most used flaps, those being the buccal advancement flap and the palatal rotational flap [5]. Recent studies recommend the use of the Bichat buccal fat pad flap for the closure of oro-antral communications [5,6]. ...
... The optimum treatment plan must consider a variety of aspects in context of these findings. The dimension, position of the communication, associated general conditions of the patients, associated sinus infection, postoperative instructions, and care are all critical for success [6]. ...
Article
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Introduction: an oro-antral communication is defined as a permanent pathological connection between the maxillary sinus and the septic oral cavity. Several flaps can be used for the closure (buccal flap, palatal flap, combination techniques) but relapses occur often in case of a large defects and underlying general conditions. Bichat fad pad flap is a multipotent pedicled fatty tissue that is easily accessible from the oral cavity that can be used for the closure of medium-sized defects, even in immunocompromised patients due to its stem cell capacity. Materials and methods: the medical information of the patients diagnosed with oro-antral communications who were admitted and treated in the Oral and Maxillo-Facial Clinic Targu Mures, between 2013 and 2020 were analyzed. A database containing general information, reported causes, associated diseases, surgical methods used during admission, and relapses, was created. The information was statistically processed. The written consent and ethical approval were obtained. Results: the study shows that from a total of 140 cases, 72 were treated using buccal advancement flap, 49 using Bichat fat pad flap, and 19 using palatal flaps. The dimensions of the communications ranged between 0.3 cm and 1.5 cm. Several statistically significant results could be found when comparing the surgical methods. Of the 72 patients treated with buccal advancement flaps, 25 presented relapses as opposed to the patients treated with Bichat fat pad flaps who showed no complications, p < 0.05. Analysing this aspect further, all large defects (10 cases) ranging from 0.6 cm to 1.5 cm treated with advancement buccal flaps (Rehrmann flaps) showed relapses (p < 0.05). Considering the general conditions, out of 7 patients who received radiotherapy 4 presented relapses, as opposed to the healthy patients, p < 0.05. Regarding the reintervention for the relapsed cases, the majority of the cases treated a second time with buccal advancement flap (5 out of 7 cases) failed as opposed to the Bichat fat pad flap with no further relapses (p < 0.05). Conclusions: the most frequently used surgical treatment is the buccal flap, which also has the highest relapse rate. Both primary treatment with Bichat fat-pad flap and re-treatment of relapses using this flap have had 100% success rates, even in patients with general associated conditions, in contrast with patients treated by using the buccal flap. The dimensions of the oro-antral communication and general conditions are crucial factors for the success of the surgical treatment.
... To validate the clinical findings, radiological investigation of the OAC and OAF site is necessary [2,11,13,14]. A panoramic radiograph and a blond CT scan can determine the size, location, and degree of sinus involvement [13]. ...
... To validate the clinical findings, radiological investigation of the OAC and OAF site is necessary [2,11,13,14]. A panoramic radiograph and a blond CT scan can determine the size, location, and degree of sinus involvement [13]. ...
... A rational decision-making process should be followed for OAC/OAF closure rather than haphazardly performing the available technique [13]. For this, several factors should be considered, the most important of which are the age, size, and location of the defect as well as its relationship to the adjacent teeth and the height of the alveolar ridge [15]. ...
Article
Full-text available
Introduction and importance: The oro-antral communication (OAC) is a pathological opening between the maxillary sinus and the oral cavity. When it does not close spontaneously or if it is not treated, it remains permeable and epithelializes to develop into an oro-antral fistula (OAF) and can cause maxillary sinusitis. Cases presentation: The authors present through 5 clinical cases the different steps of the surgical protocols opting for the buccal fat pad flap and the advanced buccal flap to treat OAF/OAC. Clinical discussion: Surgical closure of the OAC within 48 h is recommended to avoid complications. Several alternative techniques have been described over the years for the management of the OAC and OAF, with their advantages and limitations. The most commonly used surgical flaps are of two types: the advanced buccal flap and the buccal fat pad (BFP) flap. Conclusion: The adequate availability of the advanced buccal flap and the buccal fat pad (BFP) flap in the majority of patients, the easy handling, the minimal donor site morbidity as well as the excellent blood supply make them perfect flaps for the closure of OAF/OAC. However, follow-up remains a key point and very important to avoid complications. The present case series was limited by the small number of patients and the authors recommend a study with larger groups.
... And without a tight and perfect closure and adequate postoperative care, the oroantral communication could be occurred after surgery. Because the surgical incision is on or near the alveolar crest, the occlusal approach is easier to make this communication due to the close location between the suture and the tooth dislocation passage [15,16]. In the buccal approach, the tooth dislocation passage is on the buccal side, which is away from the suture. ...
Article
Full-text available
Background Extracting wholly impacted maxillary 3rd molars faces difficulty due to the narrow surgical field, adjacent teeth resistances and risk of oroantral communication. This study is designed to introduce and evaluate the applicability of a novel method-buccal rotation to extract maxillary 3rd molars. Materials and methods In this cohort study, from October 1st 2020 to September 30th 2021, 72 wholly impacted maxillary 3rd molars were included. Based on the crowns with coronal 1/3, middle 1/3, apical 1/3 of the adjacent teeth roots, teeth were classified into position I, II, III. Based on the angles < 30°, ≥ 30°but < 60°, ≥ 60° to the adjacent teeth, teeth were classified into angulation A, B, C. Traditional method and novel method-buccal rotation were applied based on the surgical simulations. Surgical results were recorded. To analyze the data, Chi-square test was applied. Results 82.00% of teeth in position I and 50.00% in position II were designed to use traditional method, 83.33% in position III were using the novel method ( p < 0.05). 81.25% of teeth in angulation A and 52.63% in angulation B were designed to use traditional method, 80.00% in angulation C were using the novel method ( p < 0.05). Four cases got temporary complications. Conclusion Buccal rotation was applicable to extract the deep impacted maxillary third molars with large angles towards the adjacent teeth.
... The most common cause is the extraction of the posterior maxillary teeth (80%), due to the close anatomical relationship between the sinus floor and the root apexes of the premolar and molar teeth (2). Other etiological factors are trauma (2-5%), benign or malignant tumors (5-10%) and maxillary cysts (10-15%) (3). Failure to treat an OAC can cause the fusion of the Schneiderian membrane with the oral mucosa leading to the formation of an oroantral fistula (OAF). ...
Article
Full-text available
Aims Oroantral communication (OAC) represents an opening between the maxillary sinus and the oral cavity most commonly caused by the extraction of maxillary posterior teeth (80%). The aim of the present study was to evaluate the efficacy and reliability of treating OACs using plasma-rich fibrin (PRF). Also, the most significant recent papers on the topic are briefly summarized in order to compare the surgical procedure and results Materials and methods A retrospective study was conducted in the Maxillofacial Surgery Unit of the Federico II University of Naples from April 2017 to December 2020. A total of 102 OAC patients with a lesion of a diameter of 5 mm or more were enrolled in the study and surgically treated, 63 patients were treated with PRF alone; 39 patients were treated with a buccal flap or buccal fat pad. Results Locoregional healing of the surgical area was observed between 3 and 4 weeks in all patients, no recurrences were recorded. At 6 months the mucous membrane of the maxillary sinus is completely regenerated and resumes normal muco-ciliary functions. Conclusion Surgical treatment of OAC with PRF is a less invasive surgical technique than using mucous flaps or buccal fat pad. PRF is an autologous material that contains growth factors and allows to preserve the height of the vestibular sulcus. The results of our study showed that PRF can be easily performed and guarantees excellent results in the treatment of OACs with a diameter equal to or greater than 5 mm with a low risk of complications.
... 17 Implants displaced or with transfixation inside the maxillary sinus and nasal cavity are interpreted as foreign bodies, favoring the occurrence of complications such as sinusitis and oroantral fistula, which may even lead to death. 18,19 The larger the diameter of the nasopalatine canal, the greater the incidence of perforation, which can lead to damage to the nasopalatine nerve and sensory loss in the region. 20 One of the most frequent events at dental clinics is compression or laceration of the inferior alveolar nerve during the installation of dental implants, 21 which diminishes the patient's quality of life, influencing daily orofacial activities, as well as causing issues such as persistent sensory loss, chronic pain, and even depression. ...
Article
Purpose: This study evaluated the prevalence of dental implant positioning errors and the most frequently affected oral regions. Materials and methods: A sample was obtained of CBCT images of 590 dental implants from 230 individuals who underwent diagnosis at a radiology center using cone-beam computed tomography from 2017 to 2020. The following variables were considered: thread exposure, violation of the minimum distance between 2 adjacent implants and between the implant and tooth, and implant contact with anatomical structures. Descriptive data analysis and the Pearson chi-square test (P<0.05) were performed to compare findings according to mouth regions. Results: Most (74.4%) of the 590 implants were poorly positioned, with the posterior region of the maxilla being the region most frequently affected by errors. Among the variables analyzed, the most prevalent was thread exposure (54.7%), followed by implant contact with anatomical structures, violation of the recommended distance between 2 implants and violation of the recommended distance between the implant and teeth. Thread exposure was significantly associated with the anterior region of the mandible (P<0.05). The anterior region of the maxilla was associated with violation of the recommended tooth-implant distance (P<0.05) and the recommended distance between 2 adjacent implants (P<0.05). Implant contact with anatomical structures was significantly more likely to occur in the posterior region of the maxilla (P<0.05). Conclusion: Many implants were poorly positioned in the posterior region of the maxilla. Thread exposure was particularly frequent and was significantly associated with the anterior region of the mandible.
Article
Full-text available
Oroantral fistula (OAF) is the most common etiology for odontogenic maxillary sinusitis that can be caused by tooth extractions, failed maxillary sinus lifts, bone grafts, and poor positioning of dental implant fixtures. A 52-year-old man presented with an OAF and maxillary sinusitis after implant placement and bone grafting. The authors treated the patient with modified endoscopic sinus surgery to obtain OAF closure and provided dental implant placement procedures afterward. The authors also treated 8 other similar cases with favorable outcomes. In this study, the authors report the know-how of implant placement procedures in patients with OAF and maxillary sinusitis.
Article
The extraction of teeth carries a risk of associated complications, some of which may be predicted, providing an opportunity for them to be prevented or their effects minimised. Prior to embarking on any extraction, the dentist must be confident that they are able to deal with any complication that may arise. This paper provides an overview of the complications of dental extraction which are commonly encountered, considers the factors which predispose to them arising, suggests how the risk of them occurring can be reduced, and describes how they should be managed.
Article
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Abstract An oroantral fistula (OAF) is a pathological abnormal communication between the oral cavity and the maxillary sinus which may arise as a result of failure of primary healing of an OAF, dental infections, osteomyelitis, radiation therapy, trauma, or iatrogenic complications. With the presence of a fistula, the maxillary sinus is permanently open. Microbial flora passes from the oral cavity into the maxillary sinus, and the inflammation of the sinus occurs with all potential consequences. In literature, various techniques have been proposed for closure of OAFs. Due to the heterogeneity of the data and techniques found, we opted for a narrative review to highlight the variety of techniques discussed in the literature. Techniques of particular interest include the bone sandwich with resorbable guided tissue regeneration (GTR) membrane and platelet-rich fibrin (PRF) used alone as both a clot and a membrane. The great advantage of these techniques is that no donor site surgery is necessary, making the outcome valuable in terms of time savings, cost and, more importantly, less discomfort to the patient. Additionally, both bony and soft tissue closure is performed for OAF, in contrast to flaps, which are typically used for procedures in the sinus area. The reconstructed bony tissue regenerated from these techniques will also be appropriate for endosseous dental implantation.
Article
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Oro-antral communication and fistula can occur as a result of inadequate and improper treatment. Inadvertent communication with the maxillary sinus can occur during certain surgical procedures in the maxillary posterior region. Though, spontaneous healing may occur in defects which are smaller than 2 mm but larger communications require immediate attention and should be treated without delay, in order to avoid sinusitis and further complications leading to patient discomfort.
Article
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Many congenital and acquired defects occur in the maxillofacial area. The buccal fat pad flap (BFP) is a simple and reliable flap for the treatment of many of these defects because of its rich blood supply and location, which is close to the location of various intraoral defects. In this article, we have reviewed BFP and the associated anatomical background, surgical techniques, and clinical applications. The surgical procedure is simple and has shown a high success rate in various clinical applications (approximately 90%), including the closure of oroantral fistula, correction of congenital defect, treatment of jaw bone necrosis, and reconstruction of tumor defects. The control of etiologic factors, size of defect, anatomical location of defect, and general condition of patient could influence the prognosis after grafting. In conclusion, BFP is a reliable flap that can be applied to various clinical situations.
Article
Full-text available
Oroantral communication (OAC) is a common complication following extraction of maxillary premolar and molar teeth. This is due to the close anatomic proximity of the roots of these teeth to the maxillary sinus. The most frequent methods utilized in the office described in the literature to close an oroantral communication involve the use of a buccal or palatal rotational advancement flap or use of the buccal fat pad. These surgical procedures require appropriate surgical skill and training to manage this type of complication and are associated with donor sit morbidity, such as avascular flap necrosis that can lead to soft tissue graft failure to close the OAC, infection and extreme postoperative patient discomfort. The goal of this case report is to describe a technique to close the OAC with a non-resorbable high-density polytetrafluoroethylene (dPTFE) membrane (Osteogenics, Lubbuck, TX) that leads to predictable soft tissue regeneration and consistent closure of the OAC.
Article
Full-text available
Background: An oro-antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro-antral fistula. Various surgical and non-surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re-implantation of third molars. Non-surgical techniques include allogenic materials and xenografts. Objectives: To assess the effectiveness and safety of various interventions for the treatment of oro-antral communications and fistulae due to dental procedures. Search methods: We searched the Cochrane Oral Health Group's Trials Register (whole database, to 3 July 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2015, Issue 6), MEDLINE via OVID (1946 to 3 July 2015), EMBASE via OVID (1980 to 3 July 2015), US National Institutes of Health Trials Registry (http://clinicaltrials.gov) (whole database, to 3 July 2015) and the World Health Organization (WHO) International Clinical Trials Registry Platform (http://www.who.int/ictrp/en/) (whole database, to 3 July 2015). We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria: We included RCTs evaluating any intervention for treating oro-antral communications or oro-antral fistulae due to dental procedures. We excluded quasi-RCTs and cross-over trials. We excluded studies on participants who had oro-antral communications, fistulae or both related to Caldwell-Luc procedure or surgical excision of tumours. Data collection and analysis: Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results: We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro-antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro-antral communication.The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro-antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro-antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure.We did not find trials evaluating any other intervention for treating oro-antral communications or fistulae due to dental procedures. Authors' conclusions: We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro-antral communications in the study were successfully closed by one month after surgery. Large, well-conducted RCTs investigating different interventions for the treatment of oro-antral communications and fistulae caused by dental procedures are needed to inform clinical practice.
Article
Full-text available
Background: Removing a tooth from the jaw results in the occurrence of oroantral communication in beneficial anatomic conditions or in the case of a iatrogenic effect. Popularized treatments of the oroantral communication have numerous faults. Large bone defect eliminates the chance to introduce an implant. Purpose of this work was assessment of the usefulness of autogenous bone graft and PRF in normal bone regeneration in the site of oroantral communication. Material and methods: Bone regeneration in the site of oroantral communication was assessed in 20 patients. Bone defects were supplemented autogenous bone graft from mental protuberance in 14 cases and from oblique line in 6 cases. The graft was covered with a PRF membrane. Results: In the study group in all cases closure of the oroantral communication was observed. The average width of the alveolar was 13 mm and the average height was 12.5 mm. In 3 patients an average increase of alveolar height of 1.5 mm was observed. Conclusions: This method may be the best option to prepare alveolar for new implant and prosthetic solutions.
Article
Background: An oro-antral communication is an unnatural opening between the oral cavity and maxillary sinus. When it fails to close spontaneously, it remains patent and is epithelialized to develop into an oro-antral fistula. Various surgical and non-surgical techniques have been used for treating the condition. Surgical procedures include flaps, grafts and other techniques like re-implantation of third molars. Non-surgical techniques include allogenic materials and xenografts. This is an update of a review first published in May 2016. Objectives: To assess the effectiveness and safety of various interventions for the treatment of oro-antral communications and fistulae due to dental procedures. Search methods: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 23 May 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 4), MEDLINE Ovid (1946 to 23 May 2018), and Embase Ovid (1980 to 23 May 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We also searched the reference lists of included and excluded trials for any randomised controlled trials (RCTs). Selection criteria: We included RCTs evaluating any intervention for treating oro-antral communications or oro-antral fistulae due to dental procedures. We excluded quasi-RCTs and cross-over trials. We excluded studies on participants who had oro-antral communications, fistulae or both related to Caldwell-Luc procedure or surgical excision of tumours. Data collection and analysis: Two review authors independently selected trials. Two review authors assessed trial risk of bias and extracted data independently. We estimated risk ratios (RR) for dichotomous data, with 95% confidence intervals (CI). We assessed the overall quality of the evidence using the GRADE approach. Main results: We included only one study in this review, which compared two surgical interventions: pedicled buccal fat pad flap and buccal flap for the treatment of oro-antral communications. The study involved 20 participants. The risk of bias was unclear. The relevant outcome reported in this trial was successful (complete) closure of oro-antral communication.The quality of the evidence for the primary outcome was very low. The study did not find evidence of a difference between interventions for the successful (complete) closure of an oro-antral communication (RR 1.00, 95% Cl 0.83 to 1.20) one month after the surgery. All oro-antral communications in both groups were successfully closed so there were no adverse effects due to treatment failure.We did not find trials evaluating any other intervention for treating oro-antral communications or fistulae due to dental procedures. Authors' conclusions: We found very low quality evidence from a single small study that compared pedicled buccal fat pad and buccal flap. The evidence was insufficient to judge whether there is a difference in the effectiveness of these interventions as all oro-antral communications in the study were successfully closed by one month after surgery. Large, well-conducted RCTs investigating different interventions for the treatment of oro-antral communications and fistulae caused by dental procedures are needed to inform clinical practice.
Article
Platelet-rich fibrin is a blood concentrate system used for soft tissue and bone tissue regeneration. In the last decade, platelet rich fibrin (PRF) has been widely used in different indication fields, particularly in oral and maxillofacial surgery. This review is aimed to investigate the level of scientific evidence of published articles related to the use of PRF for bone and soft tissue regeneration in dentistry and maxillofacial surgery. An electronic literature research using the biomedical search engine "National Library of Medicine" (PubMed-MEDLINE) was performed in May 2017. A total of 392 articles were found, 72 of which were classified for each indication field. When comparing PRF with biomaterials vs biomaterial alone in sinus lift (5 studies; IIa), no statistically significant differences were detected. Socket preservation and ridge augmentation using PRF significantly enhanced new bone formation compared to healing without PRF (seven studies Ib, IIa, IIb). Reepithelialization and bone regeneration was achieved in 96 of 101 patients diagnosed with medication-related osteonecrosis of the jaw (5 studies, III). In periodontology, PRF alone (six studies; Ib, IIa, IIb) or its combination with biomaterials (six studies; Ib, IIa, IIb) significantly improved the pocket depth and attachment loss compared to a treatment without PRF. Over 70% of the patients were part of studies with a high level of scientific evidence (randomized and controlled prospective studies). This published evidence, with a high scientific level, showed that PRF (38 articles) is a beneficial tool that significantly improves bone and soft tissue regeneration. However, the clinical community requires a standardization of PRF protocols to further examine the benefit of PRF in bone and soft tissue regeneration in reproducible studies, with a higher scientific level of evidence.
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Patients often present to their dental providers with reports of posterior maxillary pain. The etiology of their symptoms may be either an acute or chronic situation, and the examining dentist's primary focus is usually to rule out dental pathosis. Rhinosinusitis should be an important consideration on the list of differential diagnoses when evaluating patients with posterior maxillary pain. The American Academy of Otolaryngology standardized the terminology for paranasal sinus infections in 1996 and offered guidelines for evaluation and treatment of sinusitis. This article highlights these guidelines for diagnosing and treating patients with rhinosinusitis. It also includes a review of sinus anatomy and of the special considerations for iatrogenic sinus exposure as well. Dental providers who understand the relationship between the maxillary sinus and the oral structures are better prepared to arrive at an accurate diagnosis. The astute dental provider will ensure a rapid and positive outcome for this group of patients with rhinosinusitis.