Management of Oroantral Fistulae and Communications: Our Recommendations for Routine Practice

Oroantral communication (OAC) is one of the main complications of extracting antral or sinus teeth. OAC is a gap between the maxillary sinus and the oral cavity. When left untreated, it causes maxillary sinusitis and dramatically impairs the patient’s quality of life. Numerous surgical treatment techniques have been described, from mucosal techniques to using bone substitutes or very conservative alternative means. Many cases of recurrence after treatment have been reported, and the choice of the method adapted to the clinical situation remains challenging. Therefore, it is necessary to establish a correct diagnosis and choose the surgical technique best adapted to the case. This work is aimed at reviewing several techniques for the treatment of OAC and at describing our recommendations for use in daily practice for each of them through four clinical cases.

Combined Endoscopic and Intraoral Approach or Intraoral Alone in Surgical Management of Odontogenic Sinusitis

The physiological behavior of paranasal sinuses depends on the potency of the ostiomeatal complex and on normal mucociliary function. The interruption of this delicate equilibrium can lead to pathological conditions such as sinusitis. Anywhere between 10% and over 25% of cases of maxillary sinusitis have an odontogenic origin, such as: dental infection; alveolar dental trauma; or iatrogenic causes, such as extractions, endodontic therapies, maxillary osteotomies or placement of endosseous implants. The resolution of sinus pathology is related to the resolution of odontogenic pathology. Aim: to evaluate the therapeutic efficacy of a combined oral and endoscopic approach in the treatment of chronic odontogenic sinusitis vs. oral dental management through a case control study. Materials and Methods: all patients showing signs and symptoms of odontogenic sinusitis with obliteration (appreciable radiopacity in CT) of unilateral maxillary sinus between January 2018 and September 2019 at Padua University Hospital were enrolled in this retrospective study. The exclusion criteria were: maxillary sinusitis without odontogenic origin, or resolution with a systemic antibiotic therapy; and presence of anatomical abnormalities that promote the onset of rhinosinusitis. The patients were divided into two groups: one group was treated with a combined surgical approach under general anesthesia (Functional Endoscopic Sinus Surgery-FESS and simultaneous closure of oroantral communication with Bichat’s fat pad advancement); while the other group was treated only with an intraoral approach under local anesthesia and conscious sedation (closure of oroantral communication with Bichat’s fat pad advancement). The variable “success of the surgical procedure” in the two groups was compared by a Student test (with p < 0.05). Results: among the patients enrolled, 10 patients (aged between 42 and 70) made up the case group and the other 10 patients (aged between 51 and 74) constituted the control group. There was no statistically significant difference in success between the two groups (p < 0.025). Conclusions: according to this case study, an exclusive annotation invasive intraoral approach seemed to be comparable to the transoral endoscopic combined method. However, during diagnosis it is necessary and fundamental to distinguish between odontogenic and rhinogenic sinusitis in order for the resolution of odontogenic sinusitis to be achieved.

Conduta Clínica Frente a Comunicação Oro-Antral: Uma Revisão de Literatura / Clinical Conduct Facing Oroantral Communication: A Literature Review

Resumo: Inúmeras complicações podem ocorrer durante procedimentos cirúrgicos odontológicos, sendo a comunicação oro-antral uma das mais abordadas na literatura. Esta condição é resultante, principalmente, em exodontias de elementos dentários superiores posteriores, visto sua proximidade com o seio maxilar. O seu diagnóstico é feito basicamente por meio da manobra de Valsalva e análise do fragmento, contudo exames complementares podem evidenciar essa condição. A literatura considera, também, que a conduta de tratamento pode ser bastante diversificada. Objetivo: Apresentar por meio de uma revisão narrativa da literatura, as possibilidades técnicas de condutas clínicas para casos de comunicação oro-antral. Metodologia: A pesquisa bibliográfica foi online, com inclusão de artigos em português, inglês e espanhol, publicados nos últimos 10 anos, exceto àqueles fundamentais a respeito do tema, com tempo maior de publicação. Foram excluídos, também, cartas ao editor e editoriais. Foi, então, confeccionada uma análise descritiva dos artigos e os dados foram organizados de forma a subsidiar os profissionais da odontologia a intervir de forma segura diante desta complicação. Considerações finais: A comunicação oro-antral é uma realidade que pode ocorrer no consultório odontológico. Suas consequências são bastante variadas, cabendo ao Cirurgião-Dentista, além de evitar e diagnosticar, saber intervir quando necessário de forma eficaz. Haja vista que suas complicações podem limitar a qualidade de vida do paciente. Palavras-chave: Seio maxilar; Cirurgia bucal; Procedimentos Cirúrgicos Bucais. Abstract: Numerous complications can occur during dental surgical procedures, and oroantral communication is one of the most discussed in literature. That condition results mainly from extractions of posterior superior dental elements, given its proximity to the maxillary sinus. Its diagnosis is basically made through the Valsalva maneuver and analysis of fragment, however complementary exams can demonstrate that condition. The literature also considers the treatment approach can be quite diversified. Objective: Topresent, through a narrative review of literature, technical possibilities of clinical approaches for cases of oroantral communication. Methodology: The bibliographic research was online, including articles in Portuguese, English and Spanish, published in the last 10 years, except for those fundamental on the topic, with longer publication time. Letters to editor and editorials were also excluded. A descriptive analysis of articles was then carried out and the data were organized in order to support dentistry professionals to intervene safely in face of that complication. Final Considerations: Oroantral communication is a reality that can occur in the dental office. Its consequences are quite varied, and it is up to the dental surgeon, in addition to avoiding and diagnosing, to know how to intervene effectively when necessary, given that its complications may limit the patient's quality of life. Keywords: Maxillary sinus; Oral surgery; Oral Surgical Procedures.

Implants displaced into the maxillary sinus, an endoscopic approach - a report of two cases

Accidental implant displacement into the maxillary sinuses and accompanying complications are well documented in the literature. Two surgical approaches have been suggested to remove the displaced implants and to handle the related complications: an intraoral approach and the nasal endoscopy. The intraoral approach is preferred in cases of absence of local infection, ostium obstruction, and oroantral communication needing to be closed. The nasal approach, besides retrieval of displaced implants, allows the treatment of any associated pathology and reestablishment of the mucociliary clearance as well as the natural ventilation through the ostium. This article reports two clinical cases of implant displacement in the maxillary sinus treated with a nasal endoscopy through the middle meatal meatotomy. This article reports two clinical cases of implant displacement in the maxillary sinus treated with a nasal endoscopy through the middle meatal meatotomy. Implants accidentally displaced can be avoided by a proper exploration of the preoperative x-ray, selecting an appropriate treatment plan, and esteeming the surgical skills. The most appropriate approach to handle these complications is close cooperation between oral surgeons and otolaryngologists.

Facial Emphysema following Closure of Oroantral Fistulae

Subcutaneous emphysema (SE) is a swelling which develops due to air entrapped underneath the subcutaneous tissue and facial planes causing distention of the overlying skin. SE can develop due to trauma, surgery, or infection. The diagnosis of SE is mostly based on clinical findings of crepitation upon palpation of the swelling. Once diagnosed, SE is usually managed by close observation and in some cases may require surgical decompression and antibiotic prophylaxis. We report a rare case of SE of the left malar which developed following closure of oroantral communication using the buccal fat pad.

Implant Placement after Closure of Oroantral Communication by Sinus Bone Graft Using a Collagen Barrier Membrane in the Shape of a Pouch: A Case Report and Review of the Literature

Oro-antral communication (OAC) acts as a pathway for bacteria between the maxillary sinus and oral cavity, and is a common complication after the removal of a dental implant or extraction of a tooth from the maxillary posterior area. In the case of an untreated OAC, oro-antral fistula develops and becomes epithelialized. We aimed to introduce a treatment for OAC closure via a sinus bone grafting procedure using bone tacks and a collagen membrane with an allograft. The procedure was performed by applying an absorbable membrane made in pouch form. This membrane acted as a barrier for closing the large sinus membrane perforation. Bone tacks were used to fix the membranes. Subsequently, the maxillary sinus was filled with the allograft, and the absorbable membrane was reapplied. Primary closure was achieved by performing a periosteum-releasing incision for a tension-free suture. After 6 months, sufficient bone dimensions were gained without any occurrence of maxillary sinusitis or recurrence of OAC. Additional bone grafts and implantation could be performed to rehabilitate the maxillary posterior area. We conclude that this technique might be a useful treatment for reconstructing the maxillary posterior area with simultaneous sinus bone graft and OAC closure.

Intra-sinus complex odontoma management simultaneously to oroantral communication closure: Why remove it?

The oroantral communication is considered one of the most frequent complications in oral surgery, especially in extractions of posterior teeth in the maxilla, treatment of cystic lesions, neoplasms, osteomyelitis and trauma in the region of the maxillary sinus, forming fistulas. However, ectopic third molar and lesions such as odontomas are rarely found simultaneously in the maxillary sinus. This report shows a successful treatment performed in a specific case of oroantral communication, associated to an underdiagnosed complex odontoma and an impacted ectopic third molar into the maxillary sinus and discuss the requirement of intervention. The treatment strategy involved clinical and surgical management through the oroantral communication, avoiding additional bone access to the maxillary sinus. This proposal presented a satisfactory result, and at six months after surgery, the patient has an excellent evolution, proving to be a successful strategy.

Detachable Lip and Cheek Plumper for Rehabilitation of Facial Disfigurement

Background. Hemimaxillectomy of acquired palatal defects may predispose the patient to hypernasal speech, leakage of fluids into the nasal cavity, impaired masticatory function, and swallowing difficulties leading to a detrimental impact on the quality of life. Sequentially, it can also affect individual character and trust in social life, leading to social phobia and anxiety. This article presents prosthodontic management of a young male patient with deformation of the entire right half of the face due to surgical removal of odontogenic myxoma. It describes a method where the clinician utilized a simple, noninvasive, and cost-effective technique to cut the weight of the obturator and to attain aesthetics, utilizing a detachable lip and cheek plumper. Case Presentation. A 19-year-old male attended the Prosthodontic Clinics at Faculty of Dentistry, the University of Khartoum, eight months after the surgical removal of a tumor. The chief complaint was difficulty eating or drinking. Furthermore, he dropped out of school because of his facial deformity and his indistinct voice. Medical and dental history revealed surgical resection of the entire right half of the maxillary alveolar bone due to myxoma. Intraoral examination revealed a well-healed surgical defect in the maxillary right buccal vestibule creating an oroantral communication. A treatment plan was formulated, keeping the patient’s demand in mind. The decision was made to treat the patient with a maxillary obturator that would gain its support from the remaining teeth and tissues with a detachable cheek and lip plumper. The use of dental magnets as a means of attachment was elected. Conclusion. This article has described a simple, noninvasive, and cost-effective method to improve facial appearance in patients with hollow faces. The plumper prosthesis successfully improved the patient’s appearance to the extent that comfort and function would permit and encourage self-esteem.