ORO-ANTRAL FISTULAORO-ANTRAL FISTULA

Dr.V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY SURGEON

REG NO: 4118 TAMILNADU –INDIA(ASIA)

ETIOLOGYETIOLOGY

CLINICAL FEATURESCLINICAL FEATURES

DIAGNOSISDIAGNOSIS

MANAGEMENTMANAGEMENT

ETIOLOGYETIOLOGY

Extraction - maxillary teethExtraction - maxillary teeth

Eg: canine, premolars and Eg: canine, premolars and molars molars

- peri apical pathology- peri apical pathology

- impacted teeth- impacted teeth

- blind instrumentation- blind instrumentation More prone in adultsMore prone in adults Facial trauma – middle third of facial Facial trauma – middle third of facial

skeletonskeleton

ETIOLOGY (Contd)ETIOLOGY (Contd)

SurgerySurgery - maxillary cyst- maxillary cyst - tumours of maxillary jaw- tumours of maxillary jaw - implant dentures- implant dentures - partial maxillectomy- partial maxillectomy OsteomyelitisOsteomyelitis Syphilis – gumma of palateSyphilis – gumma of palate Malignant granulomaMalignant granuloma

SYMPTOMSSYMPTOMS

RegurgitationRegurgitation Unilateral epistaxisUnilateral epistaxis Alteration of vocal resonanceAlteration of vocal resonance Inability to blowout cheekInability to blowout cheek Unpleasant tasteUnpleasant taste Nocturnal cough Nocturnal cough Frontal headacheFrontal headache MalaiseMalaise Anosmia Anosmia

SIGNSSIGNS

A] RECENTLY CREATED FISTULAA] RECENTLY CREATED FISTULA

B] ESTABLISHED ORO-ANTRAL FISTULAB] ESTABLISHED ORO-ANTRAL FISTULA

Recently created fistulaRecently created fistula Bone adhering to toothBone adhering to tooth Attempted extraction of upper teeth Attempted extraction of upper teeth

suddenly disappearssuddenly disappears

SIGNS (Contd)SIGNS (Contd)

Established Oro-Antral FistulaEstablished Oro-Antral Fistula RhinitisRhinitis Discharge of foul smelling pusDischarge of foul smelling pus Polyp in antrumPolyp in antrum Tenderness over maxillaTenderness over maxilla Flushing of cheek with edemaFlushing of cheek with edema Ear ache (referred from antrum)Ear ache (referred from antrum)

DIAGNOSISDIAGNOSIS HistoryHistory Signs & symptomsSigns & symptoms Radiographs – IOPA, OPG, PNS view, Radiographs – IOPA, OPG, PNS view,

Occlusal radiograph, CT Occlusal radiograph, CT scanscan

Nasal blow testNasal blow test

- compress anterior nares- compress anterior nares

- gently blowing down the nose (open - gently blowing down the nose (open mouth)mouth)

- escape air bubbles, blood at oral orifice- escape air bubbles, blood at oral orifice Cotton wool – deflected by air streamCotton wool – deflected by air stream

MANAGEMENTMANAGEMENT

IMMEDIATE TREATMENT FOLLOWING IMMEDIATE TREATMENT FOLLOWING CREATION OF OAFCREATION OF OAF

TREATMENT OF DELAYED CASESTREATMENT OF DELAYED CASESImmediate treatment following OAFImmediate treatment following OAF Primary closurePrimary closure AntibioticsAntibiotics - Pencillin V 250 mg Qid- Pencillin V 250 mg Qid -ampicillin or -ampicillin or

oxytetracyclline oxytetracyclline

Immediate treatment Immediate treatment (contd)(contd)

Local decongestantsLocal decongestants

Eg: Ephedrine nasal drops (0.5 % Eg: Ephedrine nasal drops (0.5 % intra nasally every 3 hrs)intra nasally every 3 hrs)

Steam inhalationSteam inhalation AnalgesicsAnalgesics Antral lavage – warm sterile normal Antral lavage – warm sterile normal

salinesaline Denture plateDenture plate

Treatment of delayed casesTreatment of delayed cases

Treatment of OAF within 24 hrsTreatment of OAF within 24 hrs Edges of wound are freshenEdges of wound are freshen Primary closurePrimary closure Nasal dropsNasal drops InhalationsInhalations AntibioticsAntibiotics Analgesics Analgesics

Treatment (contd)Treatment (contd)

Treatment of OAF seen for more than Treatment of OAF seen for more than 24 hrs24 hrs

Allow gingival edges of OAF to heal – Allow gingival edges of OAF to heal –

3 weeks3 weeks AntibioticsAntibiotics Local decongestantsLocal decongestants analgesicsanalgesics

Treatment (Contd) Treatment (Contd)

OAF for more than a monthOAF for more than a month

Enlarge fistula for pus dischargeEnlarge fistula for pus discharge

Sinus irrigation daily with normal Sinus irrigation daily with normal salinesaline

Irrigate until washings are clearIrrigate until washings are clear

Surgical proceduresSurgical procedures LOCAL FLAPSLOCAL FLAPS DISTANT FLAPSDISTANT FLAPS GRAFTSGRAFTS

LOCAL FLAPSLOCAL FLAPS

Buccal flapsBuccal flaps Advancement flapAdvancement flap Rotated flapRotated flap Sliding flapSliding flap Transverse flap Transverse flap

Salient features of buccal Salient features of buccal flapflap

Simple to performSimple to perform Blood supply is goodBlood supply is good Flap is thinFlap is thin Application is limited – previously Application is limited – previously

operated casesoperated cases Scarred tissue – reduced mobilityScarred tissue – reduced mobility

Advancement flapAdvancement flap

Von Rehrmann in 1936Von Rehrmann in 1936 Simple procedureSimple procedure Donor site closes with no raw areaDonor site closes with no raw area Reduces buccal vestibular heightReduces buccal vestibular height Requires careful manipulations – thin Requires careful manipulations – thin

flapflap Reduces flap mobility – previously Reduces flap mobility – previously

operated casesoperated cases Poor healing – previously operated Poor healing – previously operated

casescases

Advancement flap (contd)Advancement flap (contd)

Incision around fistulous trackIncision around fistulous track Edges are freshenedEdges are freshened Incise 2.5 cms away from fistula on Incise 2.5 cms away from fistula on

either sideeither side buccal sulcus – gingival marginbuccal sulcus – gingival margin Single stroke down to boneSingle stroke down to bone Base of the flap should broader than Base of the flap should broader than

tiptip Suture flap across fistulaSuture flap across fistula

Buccal sliding flapBuccal sliding flap

Moczair Moczair Suitable for edentulous patientsSuitable for edentulous patients Dentogingival detachment – facilitate Dentogingival detachment – facilitate

to shiftto shift Periodontal diseasePeriodontal disease Distal shift of flapDistal shift of flap Raw area in mesial aspectRaw area in mesial aspect

Transverse flap Transverse flap

SCHUCHARDTSCHUCHARDT Mucoperiosteum overlying Mucoperiosteum overlying

edentulous ridgeedentulous ridge Buccal vestibular height – not Buccal vestibular height – not

affectedaffected Flap does not offer greater mobilityFlap does not offer greater mobility Raw area over donor siteRaw area over donor site

Buccal fat pad (BFP)Buccal fat pad (BFP)Advantages Advantages Simple & easySimple & easy Rich blood supplyRich blood supply Morbidity and failure rate is very lowMorbidity and failure rate is very low Well accepted by patientWell accepted by patient

DisadvantagesDisadvantages Can only be used onceCan only be used once Limitation of mouth openingLimitation of mouth opening

Buccal fat pad (contd)Buccal fat pad (contd)

Procedure Procedure Incision – superior vestibular sulcus Incision – superior vestibular sulcus Mucosa, buccinator fibers, maxillary Mucosa, buccinator fibers, maxillary

periosteum & BFPperiosteum & BFP Pull the fatPull the fat Rotate, transferred & suturedRotate, transferred & sutured

Bipedicled flapBipedicled flap

Egyedi Egyedi Minor anterior fistula Minor anterior fistula Bilateral blood supplyBilateral blood supply Donor site – primary closureDonor site – primary closure Reduces vestibular sulcular heightReduces vestibular sulcular height

Palatal flapsPalatal flaps Straight advancementStraight advancement Rotational advancementRotational advancement Hinged Hinged Island Island

Advantages of palatal flapsAdvantages of palatal flaps Thicker than buccal tissueThicker than buccal tissue Abundant blood supplyAbundant blood supply Satisfactory healingSatisfactory healing Don’t effect buccal vestibular heightDon’t effect buccal vestibular height

Advancement flapsAdvancement flaps

STRAIGHT ADVANCEMENT FLAPSTRAIGHT ADVANCEMENT FLAP Does not offer greater mobilityDoes not offer greater mobility Suitable for closure of minor palatal Suitable for closure of minor palatal

or alveolar defectsor alveolar defects

ROTATIONAL ADVANCEMENT FLAPROTATIONAL ADVANCEMENT FLAP Adequate mobilityAdequate mobility Adequate tissue bulkAdequate tissue bulk

Modified palatal flapModified palatal flap

ChoukasChoukas Parallel incisions to greater palatine Parallel incisions to greater palatine

vessel on either sidevessel on either side One on midline and other 5 mm One on midline and other 5 mm

away from free gingival marginaway from free gingival margin Flap raised, mobilized, incise around Flap raised, mobilized, incise around

fistulafistula Flap rotated buccaly underneath Flap rotated buccaly underneath

tissue bridgetissue bridge

Modified palatal flap (contd)Modified palatal flap (contd)

Suture palatal flap to circumferential Suture palatal flap to circumferential flapflap

AdvantagesAdvantages Maintains position of the flapMaintains position of the flap Surgical splints are not neededSurgical splints are not needed Adequate blood supplyAdequate blood supply Ease of surgical techniqueEase of surgical technique

Submucosal connective tissue Submucosal connective tissue flapflap

ITO & HARAITO & HARA abundant blood supply abundant blood supply Extremely elasticExtremely elastic Enable to rotate without tensionEnable to rotate without tension Epithelial layer of flap can attach to Epithelial layer of flap can attach to

donor sitedonor site Early healingEarly healing Minimal discomfortMinimal discomfort Dissection of submucosal connective Dissection of submucosal connective

tissue is often difficulttissue is often difficult

Palatal island flapPalatal island flap

Closure of larger fistulaClosure of larger fistula Excellent bulkExcellent bulk Abundant blood supplyAbundant blood supply Adequate mobilityAdequate mobility Closure of posterior fistulaClosure of posterior fistula Application is limited in anterior Application is limited in anterior

defectdefect

Modification of palatal island Modification of palatal island flap flap

Gullan & Arena Gullan & Arena Additional mobility for anterior Additional mobility for anterior

advancement flapadvancement flap Can obtain 1 cm extra length of flapCan obtain 1 cm extra length of flap Freeing of vessel at greater palatal Freeing of vessel at greater palatal

foremena.foremena.

Hinged or inversion flapHinged or inversion flap

Small to moderate size fistulasSmall to moderate size fistulas Mucoperiosteum surrounding palatal Mucoperiosteum surrounding palatal

defectsdefects Simple to performSimple to perform Minimum morbidityMinimum morbidity

Combined local flapsCombined local flaps

Can be used for larger defectsCan be used for larger defects Sufficient tissue bulkSufficient tissue bulk Combination of hinged & rotation Combination of hinged & rotation

advancement flapadvancement flap Double overlapping hinged flapDouble overlapping hinged flap Double island flaps and Double island flaps and

superimposition of reverse palatal superimposition of reverse palatal and buccal flapsand buccal flaps

Distant flapsDistant flaps

Tongue flapsTongue flaps Guerrero & AltamiranoGuerrero & Altamirano Palatal fistulasPalatal fistulas Anteriorly based tongue flap – Anteriorly based tongue flap –

tetheringtethering Posteriorly based – improves mouth Posteriorly based – improves mouth

functionfunction

Graft proceduresGraft procedures

BoneBone CockerilamCockerilam Used when conservative methods failsUsed when conservative methods fails Defect is to largeDefect is to large Autogenous cancellous boneAutogenous cancellous bone Ensures strengthEnsures strength Donor site – lateral wall of antrumDonor site – lateral wall of antrum Soft tissue coverage – palatal, buccal or Soft tissue coverage – palatal, buccal or

tongue flapstongue flaps

Alloplastic materialsAlloplastic materials

Simple procedureSimple procedure Does not require raising large amount Does not require raising large amount

of tissueof tissue Does not affect buccal vestibular Does not affect buccal vestibular

heightheight No raw area left behindNo raw area left behind Gold foil, tantalum plate, soft Gold foil, tantalum plate, soft

polymethylmethacrylate, lyophilized polymethylmethacrylate, lyophilized collagencollagen

REFERENCESREFERENCES H.C. KILLEY and L.W. KAY. The maxillary sinus H.C. KILLEY and L.W. KAY. The maxillary sinus

and its dental implications.and its dental implications. AXHAUSEN. Methodik des verschlusses van AXHAUSEN. Methodik des verschlusses van

Defekten in alveolar for Satzoberkiefer. Deutsche Defekten in alveolar for Satzoberkiefer. Deutsche manatschrift for zahnekam. 48: 193-196. 1930.manatschrift for zahnekam. 48: 193-196. 1930.

WOWERN. N.V. Treatment of oroantral fistula.. WOWERN. N.V. Treatment of oroantral fistula.. Arch otolaryngal. 96; 99-104, 1972.Arch otolaryngal. 96; 99-104, 1972.

MOCZAIR, L NUOVO. methodo operatiopela MOCZAIR, L NUOVO. methodo operatiopela chirsura dele fistole del seno mascellase di chirsura dele fistole del seno mascellase di origina oentale. Stomatol (Roma). 28. 1087-origina oentale. Stomatol (Roma). 28. 1087-1088, 1930.1088, 1930.

SCHUCMARDI.K. METHODIK DES VERSCHILUSSES SCHUCMARDI.K. METHODIK DES VERSCHILUSSES VON DEFEKTEE Alvealor forsate zahnlose VON DEFEKTEE Alvealor forsate zahnlose oberkiefer, Dtsch. zahn mund kieferheick 17: oberkiefer, Dtsch. zahn mund kieferheick 17: 366-369-1953 366-369-1953

EGYEDI. P. The bucket-handle flap for closure of EGYEDI. P. The bucket-handle flap for closure of fistulas around the premaxilla. J. Maxillofac. Surg. fistulas around the premaxilla. J. Maxillofac. Surg. 4: 212-210-1976.4: 212-210-1976.

WNITNEY.J.H.S HAMNER et al, The use of cancellous WNITNEY.J.H.S HAMNER et al, The use of cancellous bone for closure of oroantral fistula and oronasal bone for closure of oroantral fistula and oronasal defect. J. oral Surg. 38-679-681, 1980.defect. J. oral Surg. 38-679-681, 1980.

RINTALA. A couble overlapping hinged flap to close RINTALA. A couble overlapping hinged flap to close palatal fistula. Scand. J. Plast. Reconstr. Surg. 5, 91-palatal fistula. Scand. J. Plast. Reconstr. Surg. 5, 91-98-1971.98-1971.

QUAYLE.A. Double flap technique for closure of QUAYLE.A. Double flap technique for closure of oronasal and oroantral fistula. BJOMFS, 19-132-oronasal and oroantral fistula. BJOMFS, 19-132-137.1981137.1981

GUERERO-SANTOS, et al, The use of Lingual flaps in GUERERO-SANTOS, et al, The use of Lingual flaps in repaire of fistula of hard plate. Plast. Recrost. Surg repaire of fistula of hard plate. Plast. Recrost. Surg 38, 123-128, 1966 38, 123-128, 1966

AL – SIBAHI, A. & Al- BADR. Closure of oroantral AL – SIBAHI, A. & Al- BADR. Closure of oroantral fistula. J. oral maxillofac. Surg 40, 165-166,1982.fistula. J. oral maxillofac. Surg 40, 165-166,1982.

MOHD NOOR AWANG, Closure of oroantral fistula, Int. MOHD NOOR AWANG, Closure of oroantral fistula, Int. JOMFS, 17, 110-115. 1988.JOMFS, 17, 110-115. 1988.

CARLOS A. PEREZ, et al, Diagnostic radiology of CARLOS A. PEREZ, et al, Diagnostic radiology of maxillary sinus defects. J. oral surg oral med oral maxillary sinus defects. J. oral surg oral med oral pathol. 66,507-512-1988.pathol. 66,507-512-1988.

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EGYEDI P. Utilization of the buccal fat pad for closure EGYEDI P. Utilization of the buccal fat pad for closure of oro-antral/nasal communications. J. Maxillofac surg, of oro-antral/nasal communications. J. Maxillofac surg, 5: 241-244, 1977.5: 241-244, 1977.

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