Exodontia.Info
Closure of Oro-Antral Communications
This is a common complication, which may occur during an attempt to extract the upper back teeth
or roots (
premolars & molars).

The mouth-sinus communication (oro-antral communication) may  be confirmed by observing the passage of air or
bubbling of blood from the post-extraction socket  when the patient tries to exhale gently through their nose while their
nostrils are pinched (
Valsalva test). If the patient exhales through their nose with great pressure, there is a risk of
causing
oro-antral communication, even though communication may not have occurred initially, such as when only the
lining (
mucosa) of the maxillary sinus is present between the tooth socket and the sinus.

Mouth-Sinus communications (
oro-antral communications) may be the result of:


  • Closeness of the root tips to the floor of the sinus (maxillary antrum). The bony portion above the root tips is often
    very thin or may even be absent, whereupon oro-antral communication is inevitable during extraction of the tooth,
    especially if the socket is 'cleaned' unnecessarily.



  • Extensive bone removal for extraction of an impacted tooth / root.


  • Plunging an elevator through the bony floor during root tip removal


  • Perforation during incorrect curettage

  • HIV-associated periodontitis complicated by necrotising stomatitis & the development of an oro-antral fistula

  • Enucleating dental maxillary cysts where the partition twixt cyst & antral lining has become blurred


As a very broad generalisation, the following may be thought to indicate an OAC-likely situation:

  • Proximity of the Maxillary Sinus / Antrum

  • Hyper-cementosis / Ankylosis

  • Peri-apical infections / Long-standing Caries (decay)

  • Marked Periodontitis (gum disease)


  • Lone-standing / End of Arch

  • Previous history of OAC’s
Buccal Flaps

Palatal Flaps


  • Palatal Rotational Advancement Flap most common (see diagram below).
  • Others include Palatal Pedicle Island Flap (Henderson),
  • V-shaped Palatal Flap (Krueger) &
  • Split-Thickness Palatal Flap (Ito & Hara).
Post-op Régime

Last Updated 28th March 2020
Not all possible complications or risks can be foreseen in any medical or surgical treatment, and this is the case for
the closure of
OAC / OAF’s.  There may be other unusual risks that have not been listed here.  Please ask your Oral
Surgeon if you have any general or specific concerns.


Common Surgical Consequences:

Pain.  As it is a surgical procedure, there will be soreness after the operation.  This can last for several days.  Painkillers
such as
Ibuprofen, Paracetamol, Solpadeine or Nurofen Plus are very effective.  Obviously, the painkiller you use is
dependent on your medical history & the ease with which the operation was carried out.

Swelling.  There will be swelling afterwards.  This can last up to a week.  Use of an icepack or a bag of frozen peas
pressed against the cheek adjacent to the operation site will help to lessen the swelling.  Avoidance in the first few hours
post-op, of alcohol, exercise or hot foods / drinks will decrease the degree of swelling as well.

Bruising.  Some people are prone to bruise.  Older people, people on aspirin or steroids will also bruise that much more
easily.  The bruising can look quite florid; this will eventually resolve but can take several weeks (in the worst cases).

Stitches.  The operation site will be closed with stitches.  These are dissolve and ‘fall out’ within 10 – 14 days.

Mouth Opening.  Often the chewing muscles and the jaw joints are sore after the procedure so that mouth opening can
be limited for the next few days.  If you are unlucky enough to develop an infection afterwards in the socket, this can
make the limited mouth opening worse and last for longer (up to a week).

Post-op Infection.  You may develop an infection in the operation site.  This tends to occur 2 – 4 days later and is
characterised by a deep-seated throbbing pain, bad breath and an unpleasant taste in the mouth.  This infection is more
likely to occur if you are a smoker, are on the
Contraceptive Pill, on drugs such as steroids and if bone has to be
removed to facilitate the closure of the
oro-antral communication.  If antibiotics are given, they are likely to react with
alcohol and / or the
Contraceptive Pill (that is, the ‘Pill’ will not be providing protection).

BIPP Pack / Coe-Pack Dressing.  When a palatal flap is used, the bone in the roof of the mouth can be exposed.  This
is sore and can be slow to heal.  With this in mind, a dressing (
Coe-Pack) or gauze soaked in an antiseptic (BIPP Pack)
is sewn over the bare bone to facilitate healing.  This is removed 7 - 14 days after the op.

Flattening of Vestibulum (Sulcus).  If the tissue used to close the mouth-sinus hole is drawn from the cheek, then the
space between the cheek / lips and the teeth (
sulcus) is lessened (temporarily).  This tends to slacken off with time but
may necessitate a further op to restore the
sulcus.


Less Common Surgical Consequences:

Bleeding into Cheeks.  Swelling that does not resolve within a few days may be due to bleeding into the cheek.  The
cheek swelling will feel quite firm.  Coupled with this, there may be limitation to mouth opening and bruising.  Both the
swelling, bruising and mouth opening will resolve with time.

Breakdown of the Flap & Recurrence of the OAC / OAF.  The flap used to close the mouth-sinus hole can breakdown
for a number of reasons.  If this happens, then, depending on the size of the mouth-sinus hole, the procedure will need to
be done again.
Radiographs illustrating potential Oro-Antral Communication situations
Useful Articles:

BJOMS 1986.  Oro-Antral Fistulae - A Study of Clinical, Radiological & Treatment Aspects

Acta Stomat Croat 2002.  Treatment of Oro-Antral Fistula

Austral Dent J 2003.  Non-Surgical Management of an Oro-Antral Fistula in a Patient with HIV Infection

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003.  Use of third molar transplantation for closure of the oroantral
communication after tooth extraction.  A report of 2 cases

Swiss Med Wkly 2003.  The reconstruction of oral defects with buccal fat pad

Dental Update 2004.  The Buccal Fat Pad in the Closure of Oro-Antral Communications: An Illustrated Guide

Turk J Med Sci 2004.  Buccal Corticotomy for Closure of Oro-Antral Openings - Case Report

JOMS 2005. Bony Press-Fit Closure of Oro-Antral Fistulas - A Technique for Pre-Sinus Lift Repair and Secondary
Closure

W Ind Med J 2005.  A New Surgical Management for Oro-Antral Communication.  The Resorbable Guided Tissue
Regeneration Memebrane - Bone Substitute Sandwich Technique

Intl J Oral Maxillofac Surg 2006.  Evaluation of different treatments for oroantral & oronasal communications -
experience of 112 cases

Med Oral Patol Oral Cir Bucal 2006.  Incidence of oral sinus communications in 389 upper 3rd molar extraction.

BJOMS 2007.  Incidence & predictive factors for perforation of the maxillary antrum in operations to remove upper
wisdom teeth. Prospective multi-centre study

JOMS 2009.  Closure of Oroantral Communications with Bichat’s Buccal Fat Pad

JSCR 2010.  Oro-Antral Fistula from Bisphosphonates-Induced Osteonecrosis of the Jaw

J Int Oral Health 2010.  Treatment of Oro-Antral Fistula using Palatal Flap.  A Case Report & Technical Note

J Oral Maxillofac Surg 2010.  Closure of Oroantral Communications - A Review of the Literature

JOMS 2010.  Closure of Oroantral Communications Using Biodegradable Polyurethane Foam - A Feasibility Study

Med Oral Patol Oral Cir Bucal. 2010.  Oroantral Communications.  A Retrospective Analysis

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010.  Buccal Pad of Fat & its Applications in Oral & Maxillofacial
Surgery - A Review of Published Literature 2004 to 2009

Pakistan Oral & Dent J 2010.  Treatment of Oroantral Fistula – A Study

BDJ 2011.  Oro-Antral Fistulae & Fractured Tuberosities

BJOMS 2011. Technical Note.  Closure of Oro-Antral Fistula using Auricular Cartilage. A New Method to Repair an Oro-
Antral Fistula

Eur Soc Radiology 2011.  Oroantral Fistulas.  CT Evaluation with Dentascan software

Int J Dent Clinics 2011.  Use of Palatal Rotation Flap in the Closure of Oroantral Communication

J Maxillofac Oral Surg 2012.  Surgical Management of Oro-Antral Communications Using Resorbable GTR Membrane
and FDMB Sandwich Technique - A Clinical Study

JUMDC 2012.  Case Report.  Use of Buccal Fat Pad Oro-Antral Fistula Repair

Open Dent J 2012.  Surgical Options In Oroantral Fistula Treatment

Otolaryngology 2012.  Reliability of 2 Surgical Methods for Oro-Antral Communication Closure.  A Clinical Study of 20
Patients

JOMS 2013.  Treatment of Oro-Antral Fistulas using Bony Press-Fit Technique

J Clin Exp Dent 2015.  Alternative Surgical Management of Oroantral Fistula using Auricular Cartilage

Acta Otorrinolaringol Esp 2016.  Case Study.  Odontogenic Sinusitis, Oro-antral Fistula & Surgical Repair by Bichat’s Fat
Pad - Literature Review

Annals of Otolaryngology & Rhinology 2016.  Etiology & Management of Oro-Antral Fistula

Cochrane Database of Systematic Reviews 2016.  Interventions for Treating Oro-Antral Communications & Fistulae due
to Dental Procedures (Review)

Intech 2016.  Management of the Oroantral Fistula

Intl J Adv Res 2016.  Double layered flap for closure of recurrent oroantral fistula using buccal fat pad & palatal pedicled
flap – a case report

Int J Sci Study 2017.  Closure of Oroantral Communication Using Buccal Advancement Flap - A Case Report

World J Plast Surg 2017.  Management of Oro-antral Communication & Fistula - Various Surgical Options



PowerPoint Presentation on OAC's
The medico-legal landscape of consent has been shaped by a number of cases, such as Chester v Afshar [2004],
Montgomery v Lanarkshire Health Board [2015], Duce v Worcestershire Acute Hospitals NHS Trust [2018] amongst
others, so that it is more patient-centred.

Many of the legal claims in surgical (& medical) cases occur as a result of “failure to warn”, i.e. lack of adequately
documented and appropriate consent.

A pre-requisite for obtaining consent for a surgical (medical / dental) procedure from a patient, is a full exchange of
information regarding any risks, drawbacks and limitations of the proposed treatment and any alternatives to it (even
non-treatment).

The clinicians should provide the patient with as much information as is appropriate and relevant, that it should be in
terms the patient understands & the risks should be personalised for that individual patient.  Also, there should be
enough time for the patient to understand the information given and get a second opinion if needs be.