OROANTRAL COMMUNICATION

SUMITAHOUSE OFFICER

OROANTRAL COMMUNICATION:

Communication between the maxillary sinus and oral cavity . It is one of the complication which can occur when doing extraction of upper molars .

ETIOLOGY:1. Extraction of maxillary posterior teeth2. Roots of tooth are widely divergent

3.Maxillary molar roots in close proximity to maxillary sinus

4.Destruction of portion of sinus floor by periapical lesion

5.Perforation of sinus floor and sinus membrane with injurious use of instruments

6.Little or no bone between maxillary sinus and tooth

7.Fracture of maxillary tuberosity

SIGN AND SYMPTOMS1. Unpleasant tasting discharge and odor2. Reflux of fluids and food into nose from the mouth3. Leakage of air

PATIENTS AT HIGH RISK

4. Extraction of maxillary 2nd molar 5. Periapical infection6. Approximation of the maxillary sinus floor from

teeth apices

DIAGNOSIS:1. Examine the tooth once it is removed , if a section

of bone is attached with root ends , surgeon should assume that communication is present

2. Nose blowing test: this test involves pinches the nostrils

together to occlude the patient’s nose and asking the patient to blow gently through the nose ,while the surgeon observes the area of tooth extraction .

If communication exist , there will be passage of air through the tooth socket and bubbling of blood in the socket.

3. take radiograph

4.After diagnosis see the size of communication

PREVENTION

MANAGEMENTThe best treatment can be achieved

through:1.Careful observation2.Radiographs3. Do not probe the defect4.Promote good blood clot5.Place suture

Management depends upon size of opening1. If the communication is small (2mm in

diameter or less) – no surgical treatment is necessary

The surgeon should take measures to ensure the formation of high quality blood clot in the socket and advise to take sinus precautions to prevent dislodgement of the blood clot.

2. If opening between mouth and sinus is of moderate size (2-6mm)

ensure the maintenance of the blood clot in the area • figure of eight suture should be placed over the

socket • Advise sinus precautions• Antibiotics usually amoxicillin or clindamycin –prescribed for5 days• A decongestant nasal spray-prescribed to shrink the nasal Mucosa.Maintain follow up

3. If the sinus opening is large ( 7mm or larger)

the surgeon should consider having the sinus communication repaired with a flap procedure

The most commonly used flap for small opening is the buccal flap

PROCEDURE:1. elevate the buccal flap , base should be broad with adequate width to cover the communication 2. flap must be free of tension3.repositiong of the flap across the extraction site4.flap sutured inposition

BUCCAL FLAP

COMPLICATION1.Postoperative maxillary sinusitis

2.Formation of chronic oroantral fistula

POSTOPERATIVVE MAXILLARY SINUSITIS: When an Oroantral communiaction is

created, this allows the flow of food, smoke or fluid from the mouth, via the maxillary sinus and into the nose.

Not just these but also bacteria, fungi and viruses. This can set up a maxillary sinusitis, which depending on how long the communication lasts for, may either yield an acute/chronic maxillary sinusitis.

Maxillary Sinusitis (1):

Sinusitis pain may occur in the cheek, around the eye or in the forehead.

Sometimes the pain may be felt in the upper teeth and mistaken for toothache.

Feel malaise, with a headache and perhaps a stuffy nose.

Discharge of pus into the nose is not noticed until beginning to recover.

Maxillary Sinusitis (2): Swelling of the face over the sinus

sometimes occurs but is not usually marked.

Some patients have repeated infections and go on to develop chronic sinusitis.

Nasal discharge from the back of the nose down the throat may occur.

Often the condition will flare up, with acute pain.

OROANTRAL FISTULAOroantral fistula is characterized by formation of

epithelized tract between maxillary sinus and oral cavity When chronic Oroantral fistula Defects are wider Than 5mm and persistFor more than 3 weeks A secondary surgical Intervention is required-buccal flap-palatal flap

TREATMENT Before closure of oroantral fistula, it is

imperative to eliminate any acute or chronic infection within the sinus.

This may require frequent irrigation of the fistula and sinus combined with the use of antibiotics and decongestants .

BUCCAL FLAP PROCEDURE1. Buccal flap has been elevated 2. The epithelium lining the fistula has

been excised , the periosteum is released

3. Tension free flap has been closed across the defect .

4. Suture placed

BUCCAL PEDICLE FAT FLAP Pedicled buccal fat pad flaps have been

recommended for the closure of fistulas and communications.

Among the advantages of this technique are the low morbidity rate, maintenance of the vestibular sulcus depth, the low incidence of failure, and the good flap vascularization .

when fat tissue is exposed to the oral environment, it becomes epithelialized and is gradually replaced by fibrous conjunctive tissue within a 30-40-day postoperative period, without any functional damage to the treated site.

A larger buccal flap is elevated and defect is covered by pedicled portion of the buccal fat pad with closure of mucoperiosteal flap Case of oroantral communication closure using a pedicled buccal fat pad graft.

(A) Late bucco-sinusal fistula in the 15-16 tooth area.

(B) Circular incision around the fistula and mucosa displacement on the fistulous path.

(C) Absorbable 4-0 catgut suture on the right maxillary sinus mucosa.

(D) Buccal fat pad dragging into the fistula site.

(E) 4-0 silk suture in isolated places around the fat tissue.

(F) Tissue repair in the 30-day postoperative follow-up.

PALATAL FLAP Palatal flap is often used to close n oroantral

fistulaPROCEDURE:1.Soft tissue surrounding the oroantral opening is

excised, exposing underlying alveolar bone around the osseous defect

2.The full thickness palatal flap is outlined and elevated

3.Advantages of insured vascularity (greater palatine vessels)& thickness of tissue more like crest of ridge.

4.Allows for the maintenance of the vestibularsulcus depth.

5. Flap is rotated to ensure that there is no tension on the flap when positioned to cover the osseous defect

6. Flap rotation and closure7.Suture placed8.Follow up9.Indicated in cases of unsuccessful buccal flap

closure

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