OAF Part-1.pdf

Oral and Maxillofacial Surgery - II Oro-Antral Fistula Asst. Prof. Canseda AVAĞ School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] OROANTRAL COMMUNICATION Abnormal connection between the oral and antral cavities When OAC is left open, epithelial tissue...

Oral and Maxillofacial Surgery - II Oro-Antral Fistula Asst. Prof. Canseda AVAĞ School of Dental Medicine Department of Oral and Maxillofacial Surgery [email protected] OROANTRAL COMMUNICATION Abnormal connection between the oral and antral cavities When OAC is left open, epithelial tissue may develop in its track - OAF Oroantral Fistula - Part 1 01.12.2023 Oral and Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY • Extraction of maxillary posterior teeth (most common) • Tumour • Cyst • Trauma Oroantral Fistula - Part 1 01.12.2023 Oral and Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY 1. Aberrant anatomy causing the sinus floor to dip down between the roots of premolars and molars/decreased thickness of sinus floor. 2. Unusually long roots, which lie in close proximity to the sinus floor/Schneiderian membrane. 3. Dense alveolar bone causing difficult extractions. Oroantral Fistula - Part 1 01.12.2023 Oral and Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY 4. Removal of root canal-treated maxillary molars is usually difficult due to the brittle nature of the tooth. 5. Improper use of dental elevators when attempting to remove root tip can cause undue vertical forces, which may push the roots into the sinus Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY 6. Progressive pneumatization of the sinus as age advances, especially around lone standing molars 7. Progressive pneumatization is also a cause for OAC during removal of maxillary third molars especially when associated with tuberosity fractures. Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY 8. Teeth, which have periapical pathologies, cause bone loss/erosion at the sinus floor and are at a higher chance of causing OAC after extractions. It is imperative that such cases are identified pre-operatively, adequate radiographic examinations are done, the patients are pre-warned and necessary measures are to be taken to close the OAC, if they occur during the procedure Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY 9. Occasionally, odontogenic infections/abscess may spread to the sinus, which may manifest “Fluid levels” in the sinus on paranasal sinus X-rays. Extraction of such teeth involves a greater chance of having OAC. 10. Teeth, which have aberrant root anatomies, dilacerations, hypercementosis and ankylosis, are all at risk of developing OAC Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION ETIOLOGY 11. Lack of adherence to basic principles of dentoalveolar surgery or overzealous/aggressive attempts to remove or retrieve fractured root tips of maxillary posterior teeth may cause OAC. Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION SIGNS AND SYMPTOMS • Unpleasant tasting discharge and odor • Reflux of fluids and foods into the nose from the mouth (nasal regurgitation) • Leakage of air • Difficulty in tobocco smoking • Some patients are asymptomatic Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION CLINICAL EXAMINATION • Inspection after hemostasis • Gentle suctioning of the socket produce a hollow sound • Leakage of air while blowing against closed nostrils (valsalva maneuver) • Radiograph is usually used for confirmation and to determine extent of the defect • Probing is generally not recommended, could cause perforation Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION PATIENTS AT HIGH RISK • Extraction of maxillary 2nd molar • Periapical infection • Approximation of the maxillary sinus floor from the teeth apices Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION RADIOLOGICAL FEATURES OF OAC • There may not be radiological evidence of a small OAC on a routine IOPA, unless there is sizeable loss of antral floor or breach in antral floor, which will manifest as a direct communication between the sinus and socket. • It is not advisable to insert a probe or radiopaque marker into the socket and take an x-ray as it may enlarge the OAC Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT 1. Inform the patient about the anticipated treatment plan and the sequel. Patient has to be aware of the condition as post-operative compliance form of the patient is of paramount importance in order to prevent any dehiscence or clot break down at the OAC closure Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT 2. Openings less than 3–5 mm in size may be left without any intervention hoping for spontaneous healing, or a primary closure may be attempted depending upon individual case scenarios. If left for spontaneous healing, patients are specifically instructed to avoid any manoeuvres, which may increase the intra-sinus pressure. Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT • • • A routine suturing across the socket in maxillary premolar/ molar extraction sites may not suffice in suspected cases of OAC, as the buccal and palatal gingivae may not approximate primarily and healing may be secondary in nature. Suturing in such cases just plays a role in supporting the clot. If aiming at primary closure to treat OAC, the buccal and palatal gingivae may be approximated by the following additional measures: Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT a) Reduce the height of the buccal/palatal alveolar bone in order for the sutures to approximate. b) As it is the palatal mucoperiosteum that is more adherent, a semilunar relaxing incision may be placed about 5 mm away from the palatal gingival edge and the flap is advanced buccally to meet the buccal gingivae Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT • Beyond these two steps, any attempt at closing the OAC would mean that the surgeon is using techniques that are common with established techniques of closing an OAF. If primary closure is not obtained by (a) or (b), the next logical step would be to raise a buccal full thickness three-sided (trapezoidal/rectangular/4 cornered) flap and advancing it to the palatal side. At this stage, if adequate relaxation is not present for the flap, the mucoperiosteum may have to be scored and the details of this are given in OAF surgical closure section of this lecture. Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNICATION MANAGEMENT • If the sinus is healthy, the best chance of closing an OAC is at the time of occurrence and the surgeon may use any of the techniques in his armamentarium, and these decisions are taken on a case-by-case basis. Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ OROANTRAL COMMUNİCATİONS MANAGEMENT (Summary) • Communication • During dentoalveolar surgery • Small – noninvasive wound closure • Large – rotational flaps • Extremely large – distant flaps (e.g. tongue flap) & grafts • Fistula • Surgical closure is mandatory regardless of the defect size Oroantral Fistula - Part 1 01.12.2023 Oral and Maxillofacial Surgery-II © Asst. Prof. Canseda Avağ