TABLE OF CONTENTS Jul 2002 - 2 comments

Diagnostic Dilemmas & Decisions: Chronic Oral-Antral Fistula Repair: A Case Report

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By: Nick Blanas, DDS, FRCD(C), Simon Weinberg, DDS, FRCD(C)
2002-07-01
Oral-antral communication formation is an uncommon, but established, complication of maxillary tooth extraction although other etiologic factors such as tumour, infection, trauma and surgery exist. Extraction of any maxillary tooth distal to the canine has the potential to lead to this complication.

Oral-antral fistula formation results when primary epithelial fusion of the sinus to the oral epithelium occurs before the closure of the oral defect by cells of its own origin. Thus, a permanent epithelialized tract forms, allowing persistent communication between the oral cavity and the sinus.1

The onset of symptoms can be immediate or delayed, and these can include localized pain, nasal regurgitation of oral fluids, hypernasal speech, air escape into the mouth and oral and/or nasal discharge. Some patients may remain completely asymptomatic.

Most traumatic oral-antral communications resolve without treatment. The likelihood of resolution is greater with small openings (<5mm) as opposed to larger defects.2 For this reason, most authors suggest immediate surgical repair of large openings only. The buccal sliding flap, the palatal island or pedicle flap are the most common techniques used to ablate communications. Whether or not surgery is employed, all patients with possible oral-antral communication following tooth extraction should be given instructions regarding avoidance of pressure build up within the paranasal sinus system and appropriate prescriptions for prophylactic sinus antibiotics and decongestants.

Regardless of which technique is employed, the absence of sinus infection or disease is essential for the success of any surgical repair. Long-standing communications predispose the maxillary sinus to infection and frequently result in chronic inflammation and polypoid degeneration of its mucosal lining. This report describes the case of a chronic oral-antral fistula and its repair, illustrating some of the principles of treatment.

CASE REPORT

A 36-year-old man was referred by his dentist for management of a long-standing oral-antral communication. The patient reported having left-sided sinus congestion, air escape into the mouth and nasal regurgitation of oral fluids. Teeth #26 and 27 had been extracted approximately 6 months earlier. On clinical examination, there was a 6mm oval opening in the crestal gingival at the #26 site (Fig. 1). At the depth of the hole, polypoid-like soft tissue could be seen.

A panoramic radiograph showed communication between the left maxillary sinus and the oral cavity at the left first molar site (Fig. 2). A periapical radiograph that had been taken prior to the extractions showed severe vertical bony defects associated with teeth #26 and 27 (Fig. 3).

After an extensive discussion regarding treatment alternatives, the patient elected to undergo surgical repair of his oral-antral communication, which was performed under general anaesthesia with nasal endotracheal intubation.

To begin with, the fistulous tract was excised, while maintaining as much healthy oral epithelium as possible. The underlying osseous defect was found to be approximately 1 cm in diameter (Fig. 4). Next, a sulcular incision and 2 divergent vertical releasing incisions in the mucosa were made so as to develop a broad-based buccal sliding flap. A series of ethmoid curettes were then used to remove the antral lining which appeared grossly inflamed and thickened, and which was submitted for histolopathologic assessment (Fig. 5). A sharp trochar was used to perform a transnasal antrostomy, with the opening into the nose at the level of the inferior meatus (Fig. 6). Approximately one metre of 1/4 inch, vaselined gauze was packed into the sinus, one end of which, was left extruding from the nose (Fig. 7). The palatal mucosa adjacent to the defect was then de-epithelialized in preparation for the final closure. Finally, the periosteum under the developed flap was incised, the flap was advanced over the defect and sutured with several interrupted 3-0 Vicryl sutures (Fig. 8).

The patient was discharged home later that same day along with appropriate instructions and prescriptions for antibiotics, analgesics and decongestants.

The packing material was removed without anaesthesia 24 hours later, without complication. At the 3-week follow up appointment, the patient did not have any complaints, and the inta-oral flap was found to be healing without evidence of breakdown (Fig. 9).

DISCUSSION

The maxillary sinus is a single, air-filled cavity, which occupies most of each of the paired maxillary bones, extending from the lateral nasal wall to the zygomatic process and from the floor of the orbit to the alveolar process. Its anatomic proximity to the maxillary teeth makes oral-antral communication a possibility any time a maxillary tooth distal to the canine is extracted. Teeth that are immobile, which have large, separate and divergent roots, which are previously endodontically treated or which are associated with periapical pathology present a greater risk, as do lone standing molars and teeth near pneumatized sinuses.

A thorough pre-operative clinical and radiographic assessment prior to maxillary tooth extraction improves the chance for prevention of this post-operative complication. High risk teeth should be extracted surgically and if there are any concerns, patients should be given all of the appropriate sinus instructions as well as prophylactic antibiotics and decongestants.

When faced with an oral-antral communication immediately following tooth extraction, a decision must be made whether to allow for spontaneous healing or whether to surgically close the defect. In the chronic setting, debridement of the sinus, improved drainage via a transnasal antrostomy and packing of the sinus to prevent haematoma formation are essential for the success of any repair procedure performed. Of paramount importance, as always, is the timely application of sound surgical judgement.

Dr. Blanas is Associate in Dentisty, Faculty of Dentistry, University of Toronto, and Staff Oral and Maxillofacial Surgeon, Department of Dentistry, Sunnybrook and Women's College Health Sciences Centre.

Dr. Weinberg is Professor Emeritus, Faculty of Dentistry, University of Toronto and Staff Oral and Maxillofacial Surgeon, Toronto General Hospital. He is Oral Health's editorial board member for oral and maxillofacial surgery.

Oral Health welcomes this original article.

REFERENCES

1. Wells DL, Capes JO, Powers MP: Complications of Dentoalveolar Surgery. In Fonseca RJ (ed): Oral and Maxillofacial Surgery, vol 1. Toronto, W.B. Saunders, 2000, p 432.

2. Bergman SA: Basic Principles of Dentoalveolar Surgery. In Peterson LJ (ed): Principles of Oral and Maxillofacial Surgery, vol 1. Philadelphia, Lippincott-Raven, 1997, pp 96-97.

Photos

FIGURE 7--1/4 inch vaselined gauze being packed into the sinus; one end left extruding from the left nostril.
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Caption: FIGURE 7--1/4 inch vaselined gauze being packed into th...
FIGURE 8--Buccal sliding flap sutured in place.
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Caption: FIGURE 8--Buccal sliding flap sutured in place.
FIGURE 9--Clinical appearance 3 weeks post-op.
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Caption: FIGURE 9--Clinical appearance 3 weeks post-op.
FIGURE 1--Opening in oral mucosa at the #26 site.
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Caption: FIGURE 1--Opening in oral mucosa at the #26 site.
FIGURE 2--Panoramic radiograph showing osseous defect at the #26 site.
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Caption: FIGURE 2--Panoramic radiograph showing osseous defect a...
FIGURE 3--Periapical radiograph showing severe vertical bony defects associated with teeth #26 and 27.
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Caption: FIGURE 3--Periapical radiograph showing severe vertical...
FIGURE 4--Osseous defect revealed after fistulous epithelium excised and flap elevated.
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Caption: FIGURE 4--Osseous defect revealed after fistulous epith...
FIGURE 5--Excised sinus lining displaying features of polypoid degeneration.
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Caption: FIGURE 5--Excised sinus lining displaying features of p...
FIGURE 6--Trochar being used to create transnasal antrostomy.
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Caption: FIGURE 6--Trochar being used to create transnasal antro...




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Reader Comments

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ANITA. Barber

I also have an chronic oral antral fistula ehic a yearh has been untreated for over and a half and have found out that I now need to ha
. HAve plastic surgery for the fisula opening is over 5 cm. Since I do not have an obturator to to cover the opening I use OB tampons to cover the opening.
I believe this case is beyond text book and should be well followed due to the rarety of this condition.
IF INTERESTED please. Contact me.
-

Posted March 27, 2012 11:03 PM


kim C. Buckel

I have had a persistent Oral-Antral Fistula since 12/1/09. It started with a small chip in my second to last upper left molar. I have had four surgeries over that time period. My last surgery was 11/16/09 at the Cleveland Clinic where the doctor did a pedicle flap using the inside if my left cheek. My fistula seemed totally closed for one week. Then there was a small hole still left. The doctor put a couple more stitches in on 12/23/09 and then again on 1/11/2010. I went back to Cleveland Clinic on 7/7/2010 and the doctor showed us that there is a very tiny hole and said to come back in 3 months and he could put a couple more stitches in again. Because of the small hole still left I have chronic sinus inflammation. They did a culture inside my left nostril that showed some bacteria and some yeast. The recommendation I got after the culture came back was to use a nettie pot 2 times a day and nose spray. I have been doing this for about 12 days. I do have some thick mucous that comes down the back of my throat several times a day. I live in Chesterfield Missouri (St. Louis) and have not found a specialist in my area to help me with my problem. The next step would a bone graft. My dentist has told me that a bone graft won't take until the fistula is totally sealed. I am willing to go anywhere in the U.S. I also have a lot of pain inside my mouth where the fistula is along with numbing and burning sensation on left side of my upper lip. I will be very grateful for any help. My phone number is 314-469-6341. Thank you, Kim C. Buckel

Posted July 21, 2010 02:32 PM


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