Oroantral fistula

Oroantral communication

Dr. Naveed Iqbal

Introduction

• OAC is a complication of surgery which result in a connection between oral cavity and maxillary sinus. Removal of maxillary molars may occasionally results in oro antral communication.

• Formation of OAC may result in chronic maxillary sinusitis and formation of chronic oro antral fistula.

• Oro antral fistula is characterized by formation of epithelized tract between maxillary sinus and oral cavity.

Risk factors for OAC

• Maxillary molar roots in close proximity to maxillary sinus.

• Pneumatization of sinus. ( development of air filled spaces in bone).

• Divergent, hypercementosis of roots.• Little or no bone between maxillary sinus and

tooth.• Fracture of maxillary tuberosity• Displacement of roots in to maxillary sinus.

Radiographic assessment

Prevention

• Perform a carefull preoperative radiographic examination

• Use surgical extraction if there is possibility of OAC.

• Avoid excessive apical pressure to elevate fractured roots.

• Avoid excessive force to remove maxillary molars.

Diagnosis of OAC

Diagnosis

• Examine the tooth once it is removed if a section of bone is attached with root ends surgeon should assume that communication is present. However if small amount of bone or no bone is attached communication may exist any way.

• Nose blowing test (valsalva Test) can also be used.

• Take radiograph

Size of OAC

• After diagnosis guess the size of communication.

• If no bone is attached to roots size of communication is likely to be 2 mm or less.

• If piece of bone is removed with tooth size of opening is measureable.

Management of OAC

• Management of OAC is depend on 2 factors • 1. Size of communication small size communications

heals better, large size communication > 5mm may result in chronic oro antral fistula.

• 2. preoperative condition of maxillary sinus. If maxillary sinus is infected before surgery even small communication will not heal. Take history of sinusitis. If patient has maxillary sinusitis OAC will heal poorly and chronic oro antral fistula results.

Management of OAC

• If size of OAC is 2mm or less in diameter no additional surgical treatment is required.

• Surgeon should ensure that high quality blood clot is formed in the socket and advise patient sinus precautions so that clot will not dislodge.

• Surgeon must not probe into sinus through socket because it may introduce foreign bodies and bacteria into sinus, it may also lacerate sinus membrane.

Management of OAC

• If opening is of moderate size 2 to 6mm additional measures are required to maintain blood clot in the socket.

• Figure of eight suture should be placed over the socket. Some surgeon also place gel foam in the socket to enhance clotting.

• Advise sinus precautions, give antibiotics amoxil or clindamycin for 5 days, nasal decongestants, oral decongestant for opening of ostium of maxillary sinus.

Figure of 8 suture

Management of OAC

• If size of sinus opening is 7 mm or large, surgeon should consider repair of OAC with a flap procedure.

• Most commonly used flap for small opening is buccal advancement flap. Closure should be performed as soon as possible preferably on the same day.

• Advise drugs and sinus precautions.• Maintain follow up.

Sinus Precautions• Do Not drink with a straw.• Do Not blow your nose.• Use all medications as directed. ... • Do Not play any wind instruments.• Do Not smoke cigarettes, pipes, or cigars.• Do Not open your mouth widely.• Do Not sneeze through your nose. ... • Avoid swimming and strenuous exercise for at least one week.• Eat a soft or liquid diet. Chew on the opposite side of your mouth as

much as possible. • Continue to brush your teeth but avoid the surgical area. Rinse three

times a day with warm water. • It is not uncommon to have a slight amount of bleeding from your nose

for several days.

Buccal advancement flap

Buccal Advancement FlapAdvantages and disadvantages

• •Broad base providing good blood supply.• •Periosteum scored parallel to base of flap to allow

greater mobilisation of flap.• •OAC / OAF mucosa excised.• •Alveolus reduced in height.• •Palatal mucosa incised & mobilised.• •Flap brought across defect & secured with sutures.• •There must be no / minimal tension on the flap.• •Disadvantage of reduction of buccal vestibular depth;

reshapes in 4 -8 weeks as flap adapts to underlying bone.

Palatal pedicle flap

Palatal pedicle flap• Advantages of insured vascularity (greater palatine

vessels)& thickness of tissue more like crest of ridge.• •OAC / OAF mucosa excised.• •Buccal mucosa incised & mobilised.• •Flap brought across defect & secured with sutures.• •There must be no / minimal tension on the flap.• •Allows for the maintenance of the vestibular sulcus

depth.• •Indicated in cases of unsuccessful buccal flap closure.• •Disadvantage of raw surface of palatal bone left behind