Dentistry: Treatment of Oro-antral Fistula

Treatment of Early Cases (Iatrogenic Opening)

• Immediate primary closure by sliding buccal flap and acquiring enough soft tissue to cover the whole opening
• Supportive treatment with decongestants, mucolytics, antibiotics, and analgesics is recommended

Treatment Measures to Prolong Surgical Closure

• Gauge packed in medicaments like white head varnish is sutured and held in position till surgery
• Acrylic stent is placed in position till surgery

Treatment of Delayed Cases (Chronic Fistula)

• If patient comes within 24 hours, edge is cleaned and primary closure is achieved by sliding buccal flap technique
• If patient comes after 24 hours, treatment is postponed for 3-4 weeks until the gingiva has healed and is fit for surgical procedure
• If patient comes after gingival has healed (chronic fistula), surgical closure of the opening along with Caldwell Luc operation is done

Surgical Closure

• Done by advancing either buccal flap or palatal flap, or combination of both
• Caldwell-Luc operation may be done to retrieve root piece or drain out pus

Buccal Flap Advancement Procedure (Von Rehrmann Flap)

• Whole fistulous tract is excised along with some soft tissue margin
• Trapezoidal buccal flap is reflected to close the whole opening
• Sutures are placed over firm bone and post-operative care is taken

Caldwell-Luc Operation

• Done for treatment of chronic maxillary sinusitis, management of oroantral fistula, repair of fracture of orbital floor or zygoma, and management of hematomas of the sinus with active bleeding through the nose
• Procedures include:
  • Making an intraoral incision of 2.5 cm along the mucogingival sulcus in the canine fossa
  • Making a hole at the centre of the canine fossa of the size of index finger using a bone gauge and ronguer
  • Draining blood and pus from the sinus, removing foreign bodies, and removing only the diseased mucosa
  • Cleaning the cavity and replacing the soft tissue flap, which is sutured over the bone

Oro-antral Communications (Oro-antral Fistula)

• Unnatural communication between the oral cavity and maxillary sinus
• Etiology includes:
  • Pushing of tooth or root into the sinus while extracting it
  • Periapical abscess, leading to destruction of bony floor of sinus
  • Improper use of instruments leading to damage of sinus floor
  • Trauma to face
  • Surgical removal of cysts, polyp, or tumor of maxillary sinus
  • Osteomyelitis of sinus
  • Infected maxillary implant denture
  • Malignant diseases

Clinical Features

• Symptoms:
  • Nasal discharge from posterior region of nasopharynx into the mouth, leading to fowl taste
  • Epistaxis (unilateral bleeding from nose)
  • Change in voice due to enhanced column of air
  • Pain in the region
  • Popping out of an antral polyp in chronic cases
• Signs:
  • Tenderness over maxilla
  • Edema over cheek and infraorbital region
  • Otitis media (middle ear infection)
  • Fowl odour and halitosis
  • Nasal congestion

Diagnosis

• Clinically:
  • Part of bony floor of sinus seen along with extracted tooth apex
  • Close nose and blow inward, bubbling of air in the oral opening of fistula or the blowing of cotton kept in the area is seen
• Radiographic evaluation
• Rhinoscopy