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MANAGEMENT OF ORAL-ANTRAL FISTULAS: STATE OF THE ART TREATMENT

Harry Papadopoulos, DDS, MD; Sandeep Samant, MD; Neil Curtis, DDS INTRODUCTION Oral and maxillofacial surgeons and otolaryngologists frequently manage problems in overlapping areas within the head and neck. One particular area of overlap is the maxillary sinus. Oral and maxillofacial surgeons frequently perform surgery in and around the maxillary sinus when it is i nvolved in midfacial traumatic injuries, maxillary orthognathic surgery, and dentoalveolar surgery; including the placement of dental implants. Fortunately, clinical symptoms of sinus disease are uncommon after both fractures of the midface and maxillary osteotomies.1 However, approximately 20 million Americans have chronic rhinosinusitis.2 relationship of the maxillary sinus with the roots The etiology of sinusitis is multifactorial, of the posterior maxillary teeth, this should not involving local factors, systemic factors or both. be surprising. Local factors involve mainly the impairment of flow of secretions in the area of the osteomeatal complex, either because of a mechanical obstruction, ciliary dysmotility or thickened secretions. These abnormalities lead to mucostasis, bacterial colonization and finally sinusitis. Anatomic factors (e.g., turbinate pneumatization [concha bullosa], turbinate hypertrophy, nasal septal deviation, adenoid hypertrophy, tumors, polyps, or accessory ostia) can also contribute to or exacerbate the problem. Sinusitis of odontogenic origin may be acute or chronic. Some cases are associated with dental caries, usually in a maxillary molar, that can lead to pulpitis and abscess. Pulpitis can also occur secondarily from advanced periodontal disease. The infection can then have a direct extension into the maxillary sinus, especially if the bone separating the roots from the sinus is thin or the Schneidarian membrane is the only barrier. Fortunately, this is infrequent because the floor of the sinus is made up of dense cortical bone that acts as an effective barrier, rarely allowing direct penetration of odontogenic infections into the sinus.5 Certain dental procedures (e.g., root canal therapy6 ) may inadvertently violate the maxillary sinus, introducing foreign bodies or bacterial contaminants. Oral and maxillofacial

Systemic factors include the presence of a viral upper respiratory tract infection, atopic conditions (including asthma), and hereditary diseases such as cystic fibrosis. Other factors that increase the incidence of sinusitis include, allergic rhinitis and odontogenic causes. In fact, sinusitis of odontogenic origin is thought to comprise approximately 10% to 12% of all cases of maxillary sinusitis.3,4 Given the intimate SROMS

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surgeons are keenly aware of the possibility of a root or even a whole tooth being displaced into the maxillary sinus during exodontia. The maxillary first molar is by far the tooth whose roots (the palatal roots in particular) are most commonly displaced.7,8 This can lead to or exacerbate a pre-existing maxillary sinusitis. When the barrier separating the maxillary sinus from the oral cavity is violated, an oralantral fistula may form. Oral-antral fistulas that persist might not only cause a maxillary sinusitis,9 but can also exacerbate a pre-existing one. Conversely, chronic sinus disease, as well as other factors that will be discussed in this rticle, can lead to a persistent oral-antral fistula. a This article will review the concurrent management of chronic sinus disease and persistent oral- antral fistulas. We begin with a review of the anatomy and physiology of the maxillary sinus, followed by a discussion of the diagnostic clinical examination and appropriate imaging. ANATOMY AND PHYSIOLOGY OF THE MAXILLARY SINUS A series of paranasal pneumatic cavities, commonly referred to as the paranasal sinuses, consists of the frontal, sphenoid, ethmoid, and maxillary sinuses. The maxillary sinus, also known as the antrum, is the largest sinus. The primary location of the maxillary sinus is within the maxilla, but it can also extend into the zygomatic and palatine bones.10 The exact function of the maxillary sinus remains a matter of speculation. Several suggestions include humidifying and warming inspired air, giving resonance to the voice, lightening the skulls weight and act-

ing as a shock absorber to facial trauma. Multiple studies with slightly different results have assessed the average size of this sinus in a normally developed adult.11-13 A study using computed tomography of 107 subjects resulted in average measurements of the sinus in three different planes.11 The mediolateral, anteroposterior, and superoinferior dimensions averaged 27.0 mm, 35.6 mm, and 37.0 mm respectively,11 resulting in a calculated average dry volume of 35.6 cm3. Axial CTs of 115 patients, in a different study, were used to estimate the volume of the

There is wide variation in the shape of the maxillary sinus.

maxillary sinus in patients over age 20.12 They reported a mean volume of 14.7 cm3 with a range of 4.6 cm3 to 35.2 cm3. The differences in volume of the sinus were independent of sex and side. Another study used Waters view radiographs to compare the dimensions of the maxillary sinus in 30 dentate and 30 edentulous p atients.13 They reported a significant difference in sinus height but not width between the two groups. There is wide variation in the shape of the maxillary sinus. A study using impressions and casts of 60 dry skulls resulted in a fourfold classification of maxillary sinus shapes: cone-shaped (8% of specimens), semi-ellipsoid (15%), p araboloid (30%), and hyperparabolic (47%).14 Others refer to the sinus as a horizontal pyramid with an apex, a base and either three or four sides.15 The apex is normally found at the union of the maxilla and zygomatic bone with possible extension of larger antrums into the zygoma.

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The base, or lateral wall of the nasal cavity, is found, on average, a distance of 25 mm from the apex.10 The superior wall forms both the roof of the sinus and the floor of the orbit. The facial portion of the maxillary bone comprises the anterior wall while the posterior and lateral walls blend together to make the posterolateral wall lying directly adjacent to the i nfratemporal fossa. There is some disagreement whether the floor of the sinus should be considered a wall. Some consider it a fossa formed by the junction of the anterior and medial walls,16 while others refer to it as the inferior wall of the sinus, formed by the alveolar and palatal processes of the maxilla. The anterior wall of the maxillary sinus extends mediolaterally from the pyriform rim to the union of the maxilla and zygoma and spans the area from the infraorbital rim down to the alveolar process and maxillary teeth. The anterior wall is convex towards the sinus and ranges in thickness from 2 mm to 5 mm. The wall is thinnest directly in the center of the canine fossa becoming thicker peripherally. Important struc-

the maxillary posterior teeth. These canals sometimes protrude into the sinus forming ridges, similar to canals of the anterior superior nerve branches in the superior wall. Dehiscence of a canal permits direct exposure of the nerves to the sinus mucosa. The clinical implication is that referred odontogenic pain could very likely accompany acute sinusitis.18 Surgical removal of this wall allows access to important structures that lie directly posterior to it, such as the maxillary nerve, maxillary artery, sphenopalatine ganglion, and nerve of the pterygoid canal.19 The inferior nasal conchae, the palatine bone, the ethmoid bone, and the lacrimal bone all contribute to the vertical lateral nasal wall, which also forms the medial wall of the maxillary sinus.15 The pars membranacea refers to an absence of bone in this wall, leaving only a double layer of mucous membrane. Similar to the anterior wall, the shape of the medial wall tends to be convex toward the sinus. Important structures within the medial or nasal side of this wall include the sinus ostium, hiatus semilunaris, ethmoidal bulla, uncinate process, and the infundibulum.20 The sinus ostium, sometimes considered a canal of 3 mm to 5 mm length, is a direct communication between the sinus and nasal cavity. The ostium is normally found halfway between the anterior and posterior aspects of the medial wall lying, in its superior portion approximately 4 cm above the floor of the sinus.21 The nasal opening of the ostium is within the middle meatus, directly beneath the middle turbinate.

tures found in this wall include the infraorbital foramen (with its exit approximately 1.5 cm above the apices of the first and second premolars) and middle superior alveolar nerves that supply of the canines, premolars, and m olars.17

Dehiscence of a canal permits direct exposure of the nerves to the sinus mucosa.

The union of the zygomatic and greater wing of the sphenoid bones comprises the posterior wall, separating the maxillary sinus from the infratemporal and pterygopalatine fossae. A posteriorly bulging convex shape is typical, with thick lateral walls that tend to thin out medially. The posterior alveolar nerves, within their respective canals, pierce this wall to innervate

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The middle meatus is also the site of drainage for the anterior ethmoid and frontal sinuses. The bony opening usually measures 4 mm x 10 mm, but the mucous membrane covering is taken into account, the functional size averages 2.4 mm.22 The ostium develops at the first site of invagination of the nasal mucosa. This invagination continues as the floor of the sinus descends into the maxilla until completion of development, and the sinus floor is usually found inferior to the floor of the nose.

The floor of the sinus holds great clinical significance regardless of whether or not it is in fact a true wall. The anterior and medial sinus walls unite to form the floor of the sinus. One study showed that in the adult, the floor of the sinus is found approximately 1.0 cm to 1.25 cm below the level of the floor of the nasal cavity.18 16 Bony septa are often found on the floor dividing the alveolar recess of the sinus into multiple chambers. These septa occur in up to 31.7% of specimens studied, normally between the second

Paresthesia of these teeth is a common finding among trauma victims with mid-face fractures
The superior wall of the sinus is also known as the roof of the sinus or the floor of the orbit. This wall is typically very thin and fragile, making it the most vulnerable of the sinus walls to trauma of the orbit and maxilla. The infraorbital canal along with its associated neurovascular bundle passes in an anteroposterior direction within this wall. Posteriorly the neurovascular bundle lies in the infraorbital groove on the orbital side of the wall, and the groove gradually deepens to become a canal as it moves anteriorly, ultimately terminating as the infraorbital foramen. The roof of the sinus is very thin on both sides of the canal, but the lateral side is the thinner side. A dehiscence of the inferior aspect of this canal allows direct contact of the neurovascular bundle with the sinus mucosa. The nerve supply of the anterior maxillary teeth also courses through this wall in the form of the anterior superior alveolar nerve branches. Paresthesia of these teeth is a common finding among trauma victims with mid-face fractures, which often occur at points of weakness i.e. the thin walls of the infraorbital canal. premolar and first molar.23 Root-apex proximity to the sinus, in order of closest to furthest, begins with the second molar (specifically its mesiobuccal root) and continues in descending order to first molar, third molar, second premolar, and first premolar.24 The distance from the root tips of the maxillary teeth to the floor of the sinus also varies among individuals, being determined by the amount of bone between them. Eberhardt et al. found that the mean distance from the maxillary posterior teeth to the maxillary sinus floor was 1.97 mm.24 Younger children, with a less developed sinus, will have much more intervening bone than an adult with a fully developed sinus. In adult sinuses with significant pneumatization, alveolar bone resorption or both, this tooth to floor distance ranges from only a few millimeters to a complete absence of bone, with only sinus mucosa draped over root apices. Therefore, creation of an oral-antral fistula is much more likely to occur in an adult than a child.

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The maxillary sinus is lined with a single layer of ciliated pseudostratified columnar ciliated epithelium. Beneath the epithelium is a thin connective tissue layer, the lamina propria, which overlies the periosteum. Interspersed in the epithelium are numerous goblet cells that are the major source of mucus secretion in the sinus. As one gets closer to the ostium, there is an increase in density of goblet cells. The lamina propria contains mucous, seromucous, and serous glands, however it is the goblet cells that contribute the most mucous in the sinus. The mucous forms a blanket that is propelled toward the ostium by the cilia, which beat approximately 1000 times per minute.25

premolar or canine) being the most common cause. Other causes include surgical treatment of a periapical or dentigerous cyst, placement of a dental implant,27 root canal therapy,6 maxillofacial trauma, gunshot wound, neoplasm or invasive fungal disease.28 Any previous attempts at surgical repair of the fistula could not only affect the choice of subsequent surgical technique (see p. 12) but might also point toward the presence of pre-existing factors that could adversely affect the healing process. Conditions that impair healing must be specifically looked for during the clinical evaluation so that necessary steps may be taken to correct reversible abnormalities. Treatment of uncontrolled diabetes mellitus and autoimmune diseases, such as systemic lupus or rheumatoid arthritis, prior to surgery will result in an improved likelihood of success in patients suffering from these conditions. Presence of other generalized debilitating illnesses, such as congestive cardiac failure, will require that such conditions be adequately treated medically prior to undertaking surgical repair of the fistula. Every attempt must be made to convince the patient to stop smoking at least four weeks prior to surgery and to maintain cessation for at least a month postoperatively.29 It may be prudent to refer the patient to a smoking cessation program. In patients with a history of radiation to the area, hyperbaric oxygen may be indicated to enhance the likelihood of achieving successful repair. Freedom from acute or chronic inflammatory disease within the paranasal sinuses (the maxillary sinus in particular) is of paramount importance for ensuring optimal conditions for

Creation of an oral-antral fistula is much more likely to occur in an adult than a child.
CLINICAL EXAMINATION When assessing a patient with an oral- antral fistula, attention must be paid to elements in history and physical examination that might influence not only the treatment plan but also the prospects for success of therapy. Regurgitation of ingested fluids through the nose and drainage of odd or foul-tasting fluid material through an opening in the alveolar ridge are common complaints in patients with an oral-antral fistula. Patients who have a history of chronic sinusitis may report nasal obstruction, nasal congestion, discharge, fatigue, headache, facial pain or pressure over the sinus, and dysosmia.26 In addition, they may also report of pain in the adjacent teeth. It is important to note the duration of symptoms because fistulas of recent onset may close spontaneously while long-standing ones are unlikely to do so without intervention. History of the inciting event is usually readily available, with extraction of an upper molar (or rarely, a

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surgical correction of the fistula. Other than the aforementioned symptoms of sinusitis, complaints related to allergic rhinitis, asthma and hay fever must be elicited. Presence of such conditions may perpetuate inflammation within the sinuses making them more susceptible to infection.30 The severity and frequency of symptoms of sinusitis and allergic rhinitis, as well as prior attempts at medical or surgical therapy, must be assessed. Such history may help determine the type of therapy for nasal and sinus disease that must be undertaken prior to, or simultaneously with, the treatment of the fistula. Presence of symptoms of sinusitis since the development of fistula without a significant past history of sinus disease suggests odontogenic origin of sinusitis secondary to reflux of contaminated microbe-rich material from the oral cavity into the maxillary sinus.31 In such cases, the definitive treatment of sinusitis will require surgical closure of the oral-antral communication. The physical examination must ascertain the location and size of the fistula as well as appearance of the mucosa at its margins. Edema,

mucosal lining and to look for any pre-existing scars or tori. A biopsy of the mucosal margins of the fistula may be indicated when a neoplasm or invasive fungal disease is suspected. Finally, an anterior rhinoscopy and, if indicated, an endoscopic visualization of the nasal cavity and the region of the osteomeatal complex in the middle meatus should be performed by an otolaryngologist to look for purulent secretions, mucosal inflammation, nasal polyps, septal deviation, and any other anatomic abnormality that may predispose the patient to sinus infections. A swab must be obtained from either the middle meatus under endoscopic guidance or through the oral-antral fistula from the maxillary sinus for microbial culture and sensitivity testing to test for infection with a particularly resistant organism, an occurrence not uncommon in cases with chronic sinusitis.32 DIAGNOSTIC IMAGING Imaging studies are indicated in patients with oral-antral fistula to look for a foreign body within the maxillary sinus, detect any pathology such as cyst remnants, abscess cavity or tumor in the bone around the fistula, to determine the height of the bone between the tooth roots and maxillary sinus floor and to detect evidence of infection in the maxillary as well as other paranasal sinuses. A panoramic radiograph helps evaluate the relationship of the maxillary teeth to the sinus and detect displaced tooth roots, pseudocysts and foreign bodies in the sinus. A dental radiograph can better detect pathology in the bone surrounding the tooth roots and assess bone

The physical examination must ascertain the location and size of the fistula

erythema or necrosis of the mucosal margins may suggest infection, while presence of abundant healthy granulation tissue may indicate a more favorable likelihood for spontaneous healing or less of a need for extensive repair. Tenderness in the neighboring gingival bone or teeth may suggest osteitis that would warrant further assessment of the health of the adjacent dentition and treatment with a rather prolonged course of antibiotics. The alveolar ridge, buccal cavity and the hard and soft palate must be inspected to assess the health of the

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height. Although many radiographic studies have been done to determine risk factors for inferior a lveolar nerve injury, few have truly assessed the risk of oral-antral communication.33 Computed tomography has now replaced Waters and Caldwells view radiographs for evaluation of sinusitis34,35 and of anatomic abnormalities that predispose to its development. Opacification of the sinus, mucosal thickening, and bone remodeling and thickening indicating osteitis are all radiologic correlates of sinusitis. Acute collections of fluid tend to have lower attenuation coefficient in the range of 10-25 Hounsfield units (HU) while more long-standing collections that are thickened tend to be more opaque (30-60 HU).

atal complex, frontal sinus outflow tract and the ethmoid sinuses.36 This requires scanning in the prone position with significant head extension, which may be difficult in certain situations (e.g., the elderly). More modern, multi-slice scanners can circumvent this difficulty by allowing multiplanar reconstruction with high resolution. Magnetic resonance imaging should be reserved for cases of malignancy or invasive fungal disease where it is important to determine the boundaries of soft tissue extension of the lesion as well as any perineural invasion or orbital or dural extension of the pathology.37 For evaluating an oral-antral fistula, the panoramic radiograph will be the first, and most of the time, only imaging needed. Visualization of a foreign body, such as a tooth root, will

An oral-antral fistula with recalcitrant sinusitis may require surgery


Because both maxillary and frontal sinuses open in the osteomeatal complex within the anterior ethmoid region, any obstructing pathology such as polyps, fungal debris or a neoplasm in this location can lead to failure of medical therapy. Anatomic variations such as a prominent bulla ethmoidalis, a medially or laterally dislocated uncinate process, a prominent Haller cell near the maxillary ostium, septal deviation with secondary impingement of the middle turbinate, or paradoxical curvature of the middle turbinate can all lead to impairment of maxillary sinus outflow leading to repeated acute or chronic infection. An oral-antral fistula with recalcitrant sinusitis may require surgery to address one or more of these entities and to facilitate healing. Coronal images with a slice thickness of 3 mm are optimal for evaluation of the osteome nfluence the treatment plan. However, if the i patient reports symptoms or a history of chronic sinusitis, the senior author sends the patient for a preoperative CT prior. If the CT shows any of the signs of chronic sinusitis, the patient is sent to an otolaryngologist for consultation prior to surgery. CAUSES OF ORAL-ANTRAL FISTULAS Because of the close relationship of the posterior maxillary teeth with the maxillary sinus, inadvertent opening into the sinus can occur during extraction. Fortunately, these openings are frequently small enough (2 mm or less) to heal spontaneously without additional intervention. Some surgeons take additional steps to ensure stabilization of the blood clot within the socket in order to minimize fistula formation, especially with openings 3 mm to 5mm.37 Usually,

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an absorbable gelatin sponge like Gelfoam is placed in the socket and secured with a suture. Patients are then placed on sinus precaution measures for approximately one week, including instructions for the patient to avoid nose blowing, to sneeze with their mouth open, and to avoid vigorous mouth rinsing. In addition, systemic (oral) decongestants such as pseudoephedrine are prescribed. The alpha adrenergic vasoconstriction of this drug helps decrease tissue edema and facilitates proper sinus drainage. Topical decongestants may also be useful; however, they become less effective after 3-5 days, and may even be detrimental.39 Because of the growing problem of antibiotic resistance by bacteria, antibiotics are usually not prescribed. However, if the patient reports a history of sinus disease, antibiotics should be strongly considered. An acute sinusitis can be treated empirically with amoxicillin (500

Unfortunately some oral-antral openings persist, forming oral-antral fistulas that require surgical intervention to close. The question then arises which are likely to persist? After an extraction an oral-antral communication of 2 mm or less is likely to close spontaneously. For openings of 3 mm to 5mm stabilize the blood clot in the socket as described above. For openings greater than 5 mm consider immediate primary closure with one of the techniques described below. Although a communication greater than 5 mm diameter is frequently described in the literature,8,37 frequently, the soft tissue opening is smaller than the underlying bony opening. In addition, certain factors will increase the likelihood of a fistula forming, regardless of the size of the initial communication. Some of these factors are unavoidable while others can be managed to increase the likelihood of proper healing after surgical closure. When a root, or less commonly a whole tooth is accidentally displaced into the maxillary

Antibiotic coverage for patients with a history of chronic sinus disease is more difficult.
mg po tid), or trimethoprim-sulfamethoxazole (double strength tablets, one po bid) if the patient is allergic to penicillin, for 10-14 days. These antibiotics are directed mainly against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Antibiotic coverage for patients with a history of chronic sinus disease is more difficult. This is because coverage is needed not only for the above-mentioned common sinus pathogens, but also Staphylococcus aureus and anaerobes. In these patients clindamycin, amoxicillinclavulanate or trimethoprim-sulfamethoxazole would be appropriate.

sinus during extraction, certain direct and indirect actions can be taken to successfully r emove it. If the root is not removed, it can act like a foreign body or form a nidus of infection within the sinus, initiating an acute sinusitis, especially if the tooth was carious. If chronic sinusitis already exists, the root tip can exacerbate the problem or cause acute sinusitis. This can also cause the oral-antral communication to become a fistula. Therefore it needs to be removed. The wait and see approach is not recommended unless the patient is not able to tolerate any further procedures.3 Assuming the roots location has been confirmed in the sinus by panoramic or periapical

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radiographs, measures can be taken to remove it. Simple but indirect measures include suctioning of the socket, followed by sterile irrigation of the sinus in the hope of bringing the root closer to the opening.

More complex measures include creating a large enough bony window into the sinus to directly access the sinus and displaced root. This is usually accomplished by a Caldwell-Luc procedure, where an opening is created in the canine fossa, into the maxillary sinus. (Fig. 1A-C) 8 Alternatively, a sinus lift approach can be used, however the visualization obtained from a Caldwell-Luc is superior. An endoscope can also be used to etrieve foreign bodies in difficult situar tions as well.40,41

Oral-antral communications can also occur in dentoalveolar surgery when the tuberosity is fractured during removal of a maxillary second or third molar. Fracturing can be prevented by adequate elevation of the tooth prior to forceps extraction. However if it occurs, the tooth should be separated from the fractured bone, without separating the fractured bone segment from its attached soft tissue pedicle. As long as the bone remains attached to the soft tissue pedicle it has a reasonable chance of healing. If the soft tissue attachment is violated, the fractured bone should be removed, and the area primarily closed to prevent formation of an oral-antral fistula. Besides root tips or teeth, any other foreign body has the potential to cause or exacerbate sinusitis. Certain foreign bodies like endodontic paste or cement can be irritating, leading to

After closure of the Caldwell-Luc, primary closure of the oral-antral opening via the socket must be accomplished.

Figure 1. A. Panoramic radiograph showing the root from the left maxillary first molar in the maxillary sinus. B. Surgical opening into the left maxillary sinus (Caldwell-Luc). C. Root retrieved from the maxillary sinus.

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inflammation.6 Another mechanism for causing sinusitis is interference with the proper drainage of the maxillary sinus via the osteo-meatal complex. An oral-antral communication after extraction in a patient with a history of chronic sinusitis should raise the concern of the possible fistula formation. If secretion flow is impaired within the sinus, secretions will follow the natural course of gravity downward and outward through the communication created via the tooth socket. Any closure, regardless of technique, will run

An oral-antral communication after extraction in a patient with a history of chronic sinusitis should raise the concern of the possible fistula formation.
the risk of dehiscence and fistula reformation if the sinus is disease-ridden. show this is true.

Although the maxilla has a rich blood supply, conditions that impair the local blood supply can interfere with wound healing and lead to fistula formation. An example is radiation to the head and neck. Depending on the dosage and location received, these patients may require hyperbaric oxygen therapy (HBO) prior to extraction of any teeth. HBO is well known to decrease the risk of osteoradionecrosis42 by increasing the oxygen tension in the hypovas cularized soft tissues, leading to neovascularization. This improves wound healing and theoretically may decrease the risk of fistula formation. However there are no studies in the literature to

Performing a nasal antrostomy with the hope of alleviating this problem runs counter to the functional anatomy of the maxillary sinus, because the sinus is below the nasal floor. The maxillary sinus depends on the mucociliary sweep of the sinus to clear secretions in an upward direction. Therefore, in such cases, it is prudent to seek consultation with an otolaryngologist, to address the underlying chronic sinusitis prior to fistula closure. This may require a team approach in the operating room: an otolaryngologist performs functional endoscopic sinus surgery and addresses the presence of s inus disease; and closure of the fistula by the oral and maxillofacial surgeon immediately follows. Large neoplasms can also interfere with the proper function of the maxillary sinus. Invasive neoplasms can directly open fistulas by eroding into the oral cavity.

Another category of high-risk patients is smokers. The vasoconstrictive effects of nicotine, the relative hypoxia produced by carbon monoxide, as well as the increase in platelet aggregation and blood viscosity can all have deleterious effects on wound healing.43 The best way to optimize wound healing in these patients is permanent cessation of smoking; however this is too difficult for many patients. In addition to the physiological effects of smoking, the negative pressure created when taking a puff can dislodge a blood clot formed within the extraction socket. This can be problematic if the blood clot is the only barrier between the sinus and oral cavity. A good mnemonic to remember the predisposing factors for a fistula is FRIENDS. This mnemonic, without the S, has been applied in general surgery to enterocutaneous fistulas,44 but easily applies to oral-antral fistulas as well: Foreign body (e.g. root tip)

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Radiation

Infection (e.g. sinusitis) or Iatrogenic Epithelialization Neoplasm

Distal obstruction (e.g. obstruction of the osteo-meatal complex) MANAGEMENT OF ASSOCIATED SINUS DISEASE It is important to determine whether the accompanying sinusitis is odontogenic or if the patient has pre-existing chronic sinus disease. Features pointing toward an odontogenic origin include onset dating back to the development of fistula, unilateral sinusitis on the side of the fistula, and predominance of maxillary rather than ethmoid sinus involvement.3,5 While a definitive cure of odontogenic sinusitis requires repair of the fistula, pre-existing sinus disease may or may not require surgical treatment based upon symptom severity, frequency of exacerbations and responsiveness to medical therapy. In general, a more aggressive approach to the management of sinus disease might be indicated prior to undertaking surgical fistula repair. Medical management of acute and chronic sinusitis 39,45 includes antimicrobial and antifungal therapy, topical and oral steroids, antihistamines, and leukotriene modifiers.39,45 In addition, topical and systemic decongestants, mucolytic agents and nasal saline irrigation can facilitate recovery. It is important to remember that a shotgun approach with all or many of these agents must be avoided and treatment tailored to the individual patient. For instance, the use of antihistamines, leukotriene modifiers and topical nasal steroids is only known to be beneficial in Smoking

patients with history of atopic rhinitis. Systemic steroids, however, have been empirically used with success in recalcitrant rhinosinusitis to reduce inflammatory edema of the nasal and sinus mucosal lining in concert with antimicrobial therapy. Similarly, antifungal therapy should be reserved for cases with documented fungal infections. The choice of antimicrobial therapy should preferably be culture-directed. Swabs obtained from the middle meatus or through the oroantral fistula should be sent for identification of the offending pathogens and for testing of drug sensitivity. Whereas Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are seen in uncomplicated acute sinusitis, polymicrobial infections are common in cases of chronic rhinosinusitis. Mixed aerobic-anaerobic infection is present in a majority of patients with chronic sinusitis of both non- odontogenic and 32,39 odontogenic origin. Aerobic organisms commonly identified include Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia while the common anaerobes include Peptostreptococcus subspecies, Fusobacterium subspecies, anaerobic gram-negative bacilli, and Propionibacterium acnes.32 Beta-lactamase producing isolates are common. Although amoxicillin or trimethoprim/ sulfamethoxazole are commonly employed in cases of uncomplicated acute sinusitis, amoxicillin-clavulanic acid, clindamycin, cefoxitin, a carbapenem and metronidazole are the drugs most commonly employed in cases of chronic disease.32,39,45 In addition, acute sinusitis is generally treated for 10 to14 days, whereas antibiotic therapy for chronic cases may last anywhere from 3 to 6 weeks. Sinusitis of odontogenic

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origin requires a prolonged antibiotic course targeting oral pathogens.5 Surgical treatment of sinusitis should be reserved for cases refractory to maximal medical therapy. An endoscopic approach is now the standard of care with its goal being to optimize the drainage and ventilation of the affected sinuses, and improve symptoms significantly.46,47 Since the most common site of compromise of outflow is the ostiomeatal complex in the anterior ethmoid sinuses, this area is the focal point of all attention during such operations. Removal of the uncinate process and portions of the bulla ethmoidalis behind are typically the first surgical steps in accomplishing this goal. A maxillary antrostomy is then created in the middle meatus close to the natural ostium in order to facilitate drainage of secretions assisted by the direction

done already have shown early indication of this.48,49 SURGICAL MANAGEMENT OF ORALANTRAL FISTULAS A simple and reliable test can confirm a suspected oral-antral communication. The patient blows air through their nose, with their nostrils occluded, while the clinician looks for the escape of air via the suspected area intraorally. If no air escape is seen, but a small communication is still strongly suspected, stabilizing the blood clot within the socket as described earlier can be undertaken. For a larger communication (i.e., greater than 5 mm), surgical closure with a flap is indicated.

An endoscopic approach is now the standard of care


Patients that are seen post-operatively or for the first time with an established fistulous tract have special considerations. Many of these patients will complain of nasal regurgitation of liquids when drinking. Some will feel the air escape via the oral-antral fistula, especially when blowing their nose. In instances when the fistula is not readily visible, the clinician can carefully probe for the tract. We have found a 20 gauge soft angiocatheter to be useful for this (Fig. 2). After performing a thorough history and physical, and obtaining the appropriate imaging, the clinician must determine why the fistula formed. Was it poor surgical technique during dentoalveolar surgery or some underlying cause? Any underlying cause must be addressed prior to closure of the fistula or the fistula will recur. In patients requiring endoscopic treatment for

of ciliary drive of the sinus lining. An anterior ethmoidectomy is also performed to reduce congestion and improve drainage of all the sinuses draining in this location. Additional opening of the frontal sinus outflow tract, posterior ethmoids or the sphenoid sinus is governed by the extent of inflammatory disease in these sinuses. Endoscopic dbridement and toilet of the operative cavity as well as saline nasal douches are of critical importance in the success of endoscopic sinus surgery. Continued medical management and general prophylaxis against nasal allergy should be employed as i ndicated in individual patients. In the future it will be interesting to see if there is a decrease in sinusitis cases with the introduction of the Hemophilus influenzae B and 7-valent pneumococcal vaccines. Some studies

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chronic sinusitis or a foreign body, many surgeons will close the fistula immediately after, in the same operating room setting.50,51 This not only is convenient, but the patient undergoes only one general anesthetic, as opposed to two. If there is no underlying cause closure can be undertaken as described below. Over the years, many procedures have been reported for closing oral-antral communications. These have ranged from simple local flaps to more complex distant flaps, and even closure with alloplastic materials. With the plethora of reliable soft tissue procedures available, the use of alloplastic materials such as gold foil,52 polymethylmethacrylate 53 and hydroxylapatite block 54 has fallen out favor, and wont be discussed here. If the patient has an established fistulous tract, regardless of the flap technique used, the first step is to de-epithelialize the opening of the fistulous tract. This is usually accomplished ____________________________________

with a scalpel by removing a rim of epithelium approximately 5 mm around the opening, leaving only connective tissue. The goal is to expose the bony defect, which is always larger than the soft tissue defect. First Choice Flaps Buccal Flaps Generally for small oral-antral fistulas, ocal flaps can be utilized successfully.37,56,57 l Perhaps the simplest technique and the first choice for closing an oral-antral communication is the buccal flap. There are three types of buccal flaps: the Rehrman buccal advancement flap, Moczair buccal sliding advancement flap, and the buccal transposition flap. The Rehrman buccal advancement flap 55 (Fig. 3) is the most commonly used. This is a trapezoidal full-thickness mucoperiosteal flap, with the buccal sulcus as its base. Scoring the periosteum with a blade can facilitate primary closure when difficulty is found closing the flap or there is a great deal of tension. The disadvantage of this flap is that it results in a significant reduction of vestibular depth.56 Therefore, if a removable prosthesis is planned, a vestibuloplasty will be r equired after healing. Unlike the Rehrman flap, the Moczair buccal sliding advancement flap57 (Fig. 4) does not obliterate the vestibule.58 Similarly, it is trapezoidal, sliding one tooth width distally to close the defect. The disadvantage of this flap is that it leaves an area of exposed bone that heals by secondary intention. If the patient is dentate this can lead to a periodontal problem.

Figure 2. A soft angiocatheter being used to probe and locate a small oral-antral fistula.

Unlike the other two buccal flaps, the buccal transposition flap is taken horizontally, parallel to the buccal sulcus, and pedicled either

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Figure 3: Rehrman buccal advancement flap for closure of an oral-antral fistula. (From Awang MN: Closure of oroantral fistula. Int J Oral Maxillofac Surg 17:110-115, 1988; with permission.)

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Figure 4: Moczair buccal sliding advancement flap for closure of an oral-antral fistula. (From Awang MN: Closure of oroantral fistula. Int J Oral Maxillofac Surg 17:110-115, 1988; with permission.)

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mesially or distally.8 After the flap is rotated 90 to close the defect, the donor site is closed by mobilizing the adjacent unattached mucosa. This technique is infrequently used because it not only obliterates the vestibule but causes loss of attached keratinized tissue. Buccal Fat Pad Graft Use of the pedicled buccal fat pad graft37 for oral-antral fistulas was first described by Egyedi,59 and has subsequently been used for other intraoral defects as large as 50 mm x 60mm and a thickness of 6 mm. After the tract is de-epithelialized, a trapezoidal buccal mucoperiosteal flap is reflected.

The buccal flap is sutured into its original position. (Fig. 5)

This is a technique is easy, does not obliterate the vestibule, and has a high degree of success. It should be the first choice technique for closure of an oral-antral fistula or the second choice after failure of a buccal flap. (Fig. 6) Palatal Flaps Unlike the buccal flaps whose pattern of blood supply is random, palatal flaps have an axial blood supply based on the greater palatine artery. They can provide approximately 10 cm of tissue. The rotational advancement palatal flap (Fig. 7) is a full-thickness mucoperiosteal flap that preserves its neurovascular bundle. After the flap is elevated, it is rotated 90 and sutured over the defect. (Fig. 8) The area of exposed bone on the palate is left to granulate,

The exposed fat will epithelialize in 2 to 4 weeks.37

A 1 cm vertical incision is then made through the periosteum posterior to the zygomatic buttress to expose the buccal fat pad.

The buccal fat pad is then advanced over the defect and sutured into place.

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Figure 5: Buccal fat pad used for closure of an oral-antral fistula. A. Outline of incision. B. Full thickness mucoperiosteal flap reflected on buccal. Dotted line depicts small incision made through posterior aspect of flap to gain access to buccal flap. C. Buccal fat pad sutured over oral-antral opening. D. Mucoperiosteal flap replaced into position. (From Hanazawa Y, et al. Closure of oro-antral communications using a pedicled buccal fat pad graft. J Oral Maxillofac Surg 53:771-775, 1995; with permission)

________________________________________________________________________________ which may take 2 to 3 months. (Fig. 8)

The palatal island flap provides a pedicle graft of palatal mucosa,60,61 or submucosa 62,63 (Fig. 9). Although more tedious, this technique results in less patient discomfort because part of the flap is returned to cover most of the donor site. In the hinged or inversion flap, 64 a fullthickness incision is made around the defect. The tissues are then released on both sides, sutured, then inverted into the sinus. The area of exposed

bone that is left heals secondarily. This flap is frequently used in conjunction with a rotational advancement palatal flap to provide a two-layer closure. Finally, the straight advancement palatal flap (Fig. 7) has very little usefulness because of the inelasticity of the palatal mucosa, and it is not recommended for closure of oral-antral fistulas.8 Palatal flaps are also technically easy, but they do require a bit more surgical skill than the buccal grafts. They do not obliterate the vestibule, and enjoy a high degree of success. Hence, they may be considered a first choice for closure of oral-

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antral fistulas, or a second choice after failure of a buccal flap or pedicled buccal fat pad graft. Second Choice Flaps The following flaps are not first choice flaps for closure of oral-antral fistulas. Because of their complexity and need for a second surgery for pedicle release they are difficult to do in an office setting and they should be considered only after all previously described flaps have failed. In cases where the size of the fistula is too large to be closed by any of the above, these flaps may certainly be used as first line procedures. Tongue Flaps Tongue flaps are local flaps that have been extensively used for various intraoral defects, especially oral-nasal fistulas. The rich blood supply of the tongue makes it suitable for areas that have a compromised blood supply. These _____________________________________

Figure 6: A. Full thickness mucoperiosteal flap reflected on buccal aspect of an oral-antral fistula. B. Buccal fat teased from zygoma region and brought over the oral-antral opening. C. Buccal fat pad graft and flap sutured into place. Note area of exposed fat which will later epithelialize.

Figure 7: Straight advancement palatal flap (A) and rotational advancement palatal flap (B) used for closure of an oral-antral fistula. (From Awang MN: Closure of oroantral fistula. Int J Oral Maxillofac Surg 17:110-115, 1988; with permission.)

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Figure 9: Submucosal connective tissue flap (A) and palatal island flap based (B) on the greater palatine artery. (From Awang MN: Closure of oro-antral fistula. Int J Oral Maxillofac Surg 17:110-115, 1988; with permission.)

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the dorsalis lingual artery for posteriorly based flaps, and the deep lingual artery for anteriorly based flaps.65 In general, defects posterior to the junction of the hard and soft palates are more easily treated with a posteriorly-based dorsal tongue flap.66 Conversely, defects anterior to the junction of the hard and soft palates are more easily treated with an anteriorly-based dorsal tongue flap.67 (Fig. 10) Because of their greater mobility and location, anteriorly-based dorsal tongue flaps are the better candidate of the two for closing oral-antral fistulas, especially along the alveolar ridge. Lateral posteriorly-based tongue flaps (Fig. 11) are also excellent for treating oral- antral fistulas.68 Regardless of flap chosen, it should follow basic flap principles such, as being long enough to close without tension and having a wide enough base. In addition, the width of

Figure 8: A. Oral-antral fistula after de-epithelialization, and reflection of full thickness mucoperiosteal flap off hard palate (greater palatine flap). B. Greater palatine flap sutured into place over oral-antral opening. C. Surgical site approximately 4 weeks post- operatively. Note area of denuded bone still healing by secondary healing.

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the flap should be 20% greater than the size of the defect, and at least 5 mm to 7 mm thick to include muscle for protecting the submucosal vascular plexus.69 Achieving a two-layer closure at the recipient site with a hinged or inversion flap underneath the tongue flap will maximize success.58 The flap may be divided, with the pedicle returned to the donor site after 2 to 3 weeks. Although controversial, it is the experience of one of us (HP) that placing patients in intermaxillary fixation for 2 to 3 weeks of immobilization, increases the likelihood of success. Temporalis Flap The temporalis muscle flap is a regional flap that has been used successfully to reconstruct a variety of maxillofacial defects because of its close proximity, good vascularity, and adequate bulk.70-72 It can be used as a myofascial, myo-osseous or myo-osseocutaneous flap. When used for closure of intraoral defects, including oral-antral fistulas, the myofascial flap is usually used. The muscles blood supply is mainly from three sources in descending order: the posterior deep temporal artery, middle temporal artery, and the anterior deep temporal artery.73-75 The anterior and posterior deep temporal arteries are derived from the second portion of the maxillary artery. The middle temporal artery is the main blood supply to the temporalis fascia and is derived from the superficial temporal artery. The flap is usually accessed via a hemicoronal approach, and frequently divided into anterior and posterior segments. (Fig. 12) The anterior portion of the muscle is then r otated intraorally to close the defect. This usually necessitates an osteotomy of the zygomatic arch in order to facilitate the arc of rotation, and tunFigure 10: Anteriorly based, partial thickness, dorsal tongue flap used to close an oral-antral fistula. (From Awang MN: Closure of oro-antral fistula. Int J Oral Maxillofac Surg 17:110-115, 1988; with permission.) ____________________________________

Figure 11: Posteriorly based, full thickness, lateral tongue flap used to close an oral-antral fistula. (From Awang MN: Closure of oro-antral fistula. Int J Oral Maxillofac Surg 17:110-115, 1988; with permission.)

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neling from the temporal fossa into the mouth. If the flap is to cover a palatal defect, bone from the posterior-lateral wall of the maxilla needs to be removed as well. The osteotomized segment of the zygomatic arch is placed back and fixated with a miniplate. The temporalis flap is preferred over tongue flaps in many instances. Unlike the tongue flaps it does not require a secondary procedure to divide the pedicle. Nor does it require a period of intermaxillary fixation. Epithelialization of the flap occurs in 4 to 6 weeks. Although the flap failure rate is low,60 a cosmetic defect can occur in the temporal r egion if not addressed during surgery. Advancing the posterior muscle segment anteriorly or placing an alloplastic material in the temporal fossa can prevent the temporal hollowing effect sometimes seen after these flaps. In addition, there is the risk of temporary or permanent injury to the frontal branch of the facial nerve during the dissection.70 Besides the temporalis muscle, the overlying temporoparietal fascia has been used successfully for closure of oral-antral fistulas.76 This axial flap derives its blood supply from the superficial temporal artery. The surgical technique and complications are similar to the temporalis flap. Other Flaps Other flaps, which can be considered for closure of larger oral-antral fistulas include the buccinator myomucosal island flap 77 and facial artery musculomucosal flap.78 Both consist mainly of mucosa and some underlying buccinator muscle, and the antomy of both has been studied extensively.79-81 The buccinator myomucosal flap can be based posteriorly on the buccal branch of the maxillary artery, infe-

Figure 12: Anterior and posterior segments of a temporalis flap.

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riorly on the facial artery, or anteriorly on the angular artery. The facial artery musculomucosal flap can be based superiorly or inferiorly.82 The superiorly-based flap obtains retrograde flow from the facial artery and is used for defects in the anterior hard palate. For oral-antral fistulas, in the posterior hard palate and soft palate, the inferiorly-based flap is indicated, with its orthograde flow from the facial artery. Many other regional flaps have been mentioned in the literature for closure of various palatomaxillary defects. However, because of limitations of pedicle length, arc of rotation and vascular supply they will not be discussed here. Free Flaps Lastly, a variety of free flaps have been reported for closure of more complex palatal defects.83-85 Free flaps are rarely indicated for isolated oral-antral fistulas and would be the last choice, after all of the above have failed. Obviously with each attempt to close a fistula surgically, the amount of scar tissue increases, and the blood supply lessens. Thus, free flaps,

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with their inherent blood supply, become a viable alternative. Although it is beyond the scope of this article to discuss free flaps, suffice it to say, they are not without their own set of complications, including donor site morbidity. CONCLUSIONS Oral and maxillofacial surgeons will ncounter oral-antral fistulas during the course e of their career. Fortunately, most are managed with little difficulty. However with the large number of patients who have chronic rhinosinusitis,2 recalcitrant fistulas will be encountered. Even the most experienced surgeons may require multiple attempts at surgical closure.28 Oral and maxillofacial surgeons working, closely with their otolaryngology counterparts, can manage these patients satisfactorily, utilizing the information provided in this article.

Sandeep Samant, MD, is chief of the division of head and neck surgery and skull base surgery and an associate professor in the Department of Otolaryngology-Head and Neck Surgery at the University of Tennessee Health Sciences Center in Memphis, Tennessee. He attended medical school and completed his otolaryngology residency at the All-India Institute of Medical Sciences, New Delhi, India. He received his fellowship training in head and neck and reconstructive surgery at the University of Miami and in head and neck oncology and skull base surgery at the University of Tennessee. His clinical interests include management of upper aerodigestive tract malignancies, thyroid and parathyroid tumors and endoscopic skull base surgery. Neal Curtis, DDS , received his DDS from the University of Iowa, and is currently a second year resident in the Department of Oral and Maxillofacial Surgery at the University of Tennessee Health Science Center in Memphis.

_____________________________________ ____________ Harry Papadopoulos, DDS, MD, received his DDS from New York University and his MD from New York Medical College. He completed his OMS residency training at Lincoln Medical Center in New York, and a fellowship in craniofacial surgery at the University of Pittsburgh. He is currently an associate professor and the residency program director, in the Department of Oral and Maxillofacial Surgery, at Indiana University Medical Center. His clinical and r esearch interests include cleft and craniofacial surgery, orthognathic surgery and pediatric facial trauma.

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78.

79.

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