Dentaltown August 2017 - 62

ECAUSE THE SIZE OF
THE ORAL/ANTRAL
COMMUNICATION WAS SO
LARGE, IT FAILED TO HEAL
AND CLOSE PRIMARILY,
ULTIMATELY RESULTING IN
A LONG-STANDING CHRONIC
ORAL/ANTRAL FISTULA."

Preoperative radiographs should be
critically evaluated to assess the risk factors for
oral/antral communication, which include:
* Pneumatized maxillary sinus.
* Little or no bone between the root
and the maxillary sinus.
* Widely divergent or dilacerated roots.
* Periapical pathology or abscess.
Preventing most sinus perforations in
difficult maxillary extractions is possible by
ensuring good visualization and lighting,
and opting for surgical extraction to trough
or section the roots for individual removal.
When elevating the tooth and roots, proper
surgical technique to avoid excessive apical
pressure is necessary. Referral to an oral and
maxillofacial surgeon is advised for these
complex, higher-risk extraction procedures.
If a sinus perforation does occur,
management is based on the size of the
communication. Sinus perforations 2
millimeters or smaller generally do not
require treatment. Perforations 2-6mm are
initially managed with attempts to promote
formation and maintenance of a blood clot
within the socket. Many surgeons prefer to
use an absorbable gelatin substance such as
gelfoam or a collagen plug secured with a
figure-of-eight suture. The patient is then
placed on sinus precautions: no sneezing
through nose; no nose-blowing; and avoid

AUGUST 2017 // dentaltown.com

straws, smoking and habits that would
cause differing pressures between the oral
cavity and paranasal sinus system, which
could potentially displace or dislodge a
blood clot. The patients are also placed on
antibiotics such as amoxicillin, cephalexin
or clindamycin, and a decongestant such as
pseudoephedrine, to decrease the potential
for developing a maxillary sinusitis.
Perforations 7mm or greater will usually
require surgical intervention for wound
closure in the form of a flap or combination of
multiple flaps (for example, palatal rotational
flap, buccal mucosal advancement flap,
buccal fat-pad advancement).
Timely referral to an oral and maxillofacial
surgeon for management of this complication
is important, especially to minimize the
development of sequelae such as sinusitis or
chronic oral/antral fistula formation.

Case study
A 63-year-old patient was referred to
the oral and maxillofacial surgery clinic by
his new general dentist (Fig. 1, p. 64). The
patient had undergone full-mouth extractions
at a facility in another state approximately
two years previously. His treatment had
been complicated by the development of an
oral/antral communication at the time #14
was extracted. He was placed on antibiotics

and given the sinus precaution instructions
mentioned above, but no initial attempts
at surgical repair were made at his original
facility. Soon afterward, he moved away
and was lost to follow-up.
Because the size of the communication
was so large, it failed to heal and close primarily, ultimately resulting in a long-standing
chronic oral/antral fistula. The patient
complained of constant food and liquid
trapping. He complained that no dentist
was willing to fabricate a denture for him
without first having this defect repaired.
Clinical examination revealed an
edentulous maxilla and mandible with
a large defect in the left posterior region
approximating the second molar region.
This defect measured 11mm by 13mm in
its greatest dimension (Figs. 2 and 3, p. 64).
The panoramic radiograph demonstrated
evidence of alveolar bone atrophy and
resorption, along with a visible defect in the
residual dental alveolus (Fig. 4, p. 64). Further
radiographic investigation with a CBCT
scan (Figs. 5 and 6, p. 64) demonstrated
a far greater defect beneath the mucosa,
measuring 15mm across (buccal/palatal) by
16mm (anterior/posterior), and 20mm from
alveolar crest superiorly along the lateral
maxillary wall/zygomatic buttress. The
CBCT scan also demonstrated a thickened
and reactive maxillary sinus mucosa with
several polyps. The maxillary sinus osteum,
which drains to the inferior nasal meatus,
was noted to be patent.

Buccal up: The treatment plan
During the preoperative consultation,
the patient was given a detailed informed
consent discussion and offered treatment
that included a sinusotomy/antrectomy
with debridement of the inflamed, infected
sinus mucosa and polyps, and a two-layered
closure using a buccal fat-pad advancement
flap and a mucosal advancement flap. The
patient elected to undergo the procedure
awake under local anesthesia, declining
treatment under IV sedation or intubated
general anesthesia.
Continued on p. 64

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