MAXILLARY SINUS (PART 2)

DIAGNOSIS OF OAC/OAF

DIAGNOSIS OF OAC/OAF

RADIOGRAPHIC EXAMINATION

Presence of an OAC & especially an OAF can be visible in a radiograph since there is a break in the floor of the maxillary sinus

DURATION

If OAC is present for > 72 hours → then it is considered to be an OAF

DURATION

Is an acute OAF lasts for > 15 days → then it is considered to be an OAF

DURATION

*Acute (treatment: non-surgical approach)

*Chronic (treatment: surgical intervention)

CLINICAL INSPECTION AND/OR INTRAORAL EXAMINATION

Refers to the use of some tests in order to confirm the presence of an OAC or OAF

CLINICAL INSPECTION AND/OR INTRAORAL EXAMINATION

Involves identifying the size (diameter) of the OAC / OAF to determine the course of treatment

CLINICAL INSPECTION AND/OR INTRAORAL EXAMINATION

A large fistula can be easily seen upon inspection

CLINICAL INSPECTION AND/OR INTRAORAL EXAMINATION

An OAF may also be blocked by a polyp

1. NOSE BLOWING TEST

2. COTTON WISP TEST

3. MOUTH MIRROR FOGGING TEST

4. VALSALVA’S TEST or VALSALVA MANEUVER

TESTS

NOSE BLOWING TEST

Presence of bubbles in the tooth socket upon expiration or exhalation

COTTON WISP TEST

Placing thin threads of cotton near the orifice for signs of movement

MOUTH MIRROR FOGGING TEST

Mouth mirror is placed opposite the fistula to check if fogging will result upon expiration or exhalation

VALSALVA’S TEST or VALSALVA MANEUVER

Moderate forceful exhalation with mouth closed and pinching the nose (like blowing air into a balloon)

VALSALVA’S TEST or VALSALVA MANEUVER

Exhalation with great pressure indicates the presence of an OAC

DIAMETER: < 2 mm

• no surgical treatment is required (spontaneous healing can occur)

• Antibiotic therapy may be beneficial

• Postoperative instructions must be followed

DIAMETER: 2-4 mm

• no surgical treatment

• Careful monitoring of the patient & recall for check-up in 1-2 weeks

• Antibiotic therapy is prescribed

• Postoperative instructions should be followed

DIAMETER: ≥ 5 mm

• surgical intervention is required

• Indicative of a chronic condition

*According to Hawazawe

Some consider an OAF size of 3-5 mm under non-surgical treatment, wherein it is expected to heal spontaneously in the absence of infection

Some mandate that surgical treatment of OAF is necessary _______

regardless of size

TREATMENT OF OAF

• based on both duration & size, treatment may either be a non-surgical approach or surgical intervention

  • DURATION

    • Acute (non-surgical approach)

    • Chronic (surgical intervention)

  • SIZE

    • < 5 mm (non-surgical approach)

    • ≥ 5 mm (Surgical intervention)

EFFECTS / RESULTS OF UNTREATED OAF

• an untreated OAC (oroantral communication) → OAF (oroantral fistula)

• untreated OAF will result to the following:

  • acute sinusitis or chronic sinusitis,

  • pansinusitis (infeciton of all the paranasal sinuses),

  • osteomyelitis (inflammation or infection of the bone),

  • infection or inflammation of the surrounding tissues or structures

DURING ENDODONTIC TREATMENT

• Infected canal: antibiotic therapy & closure of the OAC

• Non-infected canal: no treatment (decreased risk of sinusitis); but if sinusitis has occurred then drainage is done through the canal

DURING TOOTH EXTRACTION

• < 5 mm: non-surgical approach

• > 5 mm: surgical intervention

DURING DENTOALVEOLAR SURGERY

• < 5 mm: non-surgical approach

• > 5 mm: surgical intervention

• Extremely large openings: use of flaps and/or grafts

1. do not probe the defect

2. promote good blood clotting

3. copious irrigation with normal saline solution (NSS)

4. establish good gingival approximation

5. physical agents may be placed in the socket to stop excess bleeding (e.g., hemostatic agents)

6. simple suturing of the socket or closure by simple reduction of the buccal & palatal socket walls (l.e., immediate closure technique)

7. a well-fitting denture base with or without a flange extension may be constructed to cover the opening denture as obturator

8. antibiotic therapy (e.g., amoxicillin or doxycycline)

9. nasal decongestants (e.g., ephedrine nasal drops or oxymetazoline) for 1 - 2 weeks

10. steam inhalation (with menthol & eucalyptus)

11. antiseptic mouthwash

12. antral lavage

13. postoperative instructions should be followed

NON-SURGICAL TREATMENT OF OAC/OAF

ANTRAL LAVAGE

• needle or tube is fed through the cannula into the sinus to allow repeated flushing with normal saline solution (NSS)

ANTRAL LAVAGE

approach may either be: transnasal (via the medial wall of the maxilla) or sublabial (via the anterior wall of the maxilla)

ANTRAL LAVAGE

• done in conjunction with other treatments, otherwise the normal saline solution (NSS) left within the sinus can lead to reinfection

  
  

ANTRAL LAVAGE

• also called PROOF PUNCTURE since it can prove or disprove that the maxillary sinus contains infected material

SURGICAL TREATMENT OF OAC/OAF

• successful closure of the OAC or OAF must be preceded by the complete elimination of any sinus pathology, fistulous tract, sinus infection, degenerated mucosa, & diseased bone

TWO BASIC PRINCIPLES should be considered while operating to close a OAC or OAF:

1. sinus must be free of any type of infection with adequate nasal drainage

2. flap closures must be tension free and consist of a broad based, well-vascularized soft tissue flap

FACTORS THAT DETERMINE SURGICAL TECHNIQUE OR FLAP SELECTION

1. size of the communication (OAC) or fistula (OAF)

2. location of the communication or fistula

3. timeline of diagnosis (if it is a new communication or a fistula)

4. presence of infection

5. anatomical relationship between the defect & the adjacent teeth

6. height of the alveolar ridge

7. duration of sinus exposure

8. presence or absence of sinusitis

9. persistent oroantral communication (OAC)

10. general health of the patient

SURGICAL TREATMENT OPTIONS FOR THE CLOSURE OF AN OAC/OAF

I. USE OF LOCAL FLAPS

II. USE OF DISTANT FLAPS

III. SYNTHETIC MATERIALS

IV. ALLOGENOUS MATERIAL

V. BONE GRAFTS

VI. XENOGRAFTS

VII. THIRD MOLAR

USE OF LOCAL FLAPS

• uses the tissue that is adjacent to the open wound in need of closure

• examples: buccal flaps & palatal flaps

USE OF DISTANT FLAPS

• tissue is brought from an area that is away from the open wound

• examples: tongue flap, buccal fat pad & temporalis flap

SYNTHETIC MATERIALS

• refers to the use of certain metal or minerals

• examples: gold, aluminum, tantalum, hydroxyapatite, polymethylmethacrylate (acrylic)

ALLOGENOUS MATERIALS

• tissue from genetically different individuals of the same species

• examples: fibrin glue & dura

BONE GRAFTS

• provides a rigid contour for support of the prosthesis

• examples: sourced from the chin, zygoma, retromolar area, or iliac crest

XENOGRAFTS

• graft taken from one species is used for a different species

• examples: collagen, gelatin film, & Bio-Oss / Bio-Gide (Geistlich biomaterials)

THIRD MOLAR

involves autotransplantation (rarely performed but it has been done)

autogenous or autografts

refer to the use of a tissue from one part of the body to another (e.g., local flap, distant flap, bone graft, & auricular cartilage)

IMMEDIATE CLOSURE (excluded from this list)

refers to the simplest method that requires minimum time, surgical skill, and adequate facilities

IMMEDIATE CLOSURE (excluded from this list)

• utilizes mucoperiosteal flaps (obtained by reducing the height of the bony socket) tha is loosely sutured over the defect

COMMONLY USED SURGICAL TREATMENT OPTIONS FOR OAC/OAF CLOSURE

I. LOCAL FLAPS

II. DISTANT FLAPS

III. OTHER FLAPS

IV. SYNTHETIC MATERIALS

V. ALLOGENOUS MATERIALS

LOCAL FLAPS

1. BUCCAL FLAPS

2. PALATAL FLAPS

3. COMBINATION OF BUCCAL FLAPS & PALATAL FLAPS

4. BRIDGE FLAPS

BUCCAL FLAPS

• used for small defects by buccal mucoperiosteal flaps

• best closure for an OAF located in the anterion region

TWO MAIN TYPES OF BUCCAL FLAPS:

1. ADVANCEMENT FLAPS (linear movement)

2. SLIDING FLAPS (shifting movement)

MODIFICATIONS OF BUCCAL FLAPS

A) REHRMANN'S FLAP

B) BERGER'S FLAP

C) MOCZAIN'S FLAP

REHRMANN’S FLAP

• most common buccal advancement flap used for an OAF

REHRMANN’S FLAP

• flap is raised & stretched over the defect

REHRMANN’S FLAP

• broad base with good blood supplv. but it is associated with the reduction of the buccal vestibule

REHRMANN’S FLAP

• can be done with the Caldwell-Luc procedure

BERGER'S FLAP

most popular flap used for an OAF closure

BERGER’S FLAP

full thickness mucoperiosteal flap

BERGER’S FLAP

• an advancement flap based of Rhermann's flap so it is also referred to as the MODIFIED REHRMANN'S FLAP

MOCZAIN'S FLAP

trapezoidal buccal sliding flap

MOCZAIN’S FLAP

suitable for edentulous patients

MOCZAIN’S FLAP

with minimal change to the depth of the buccal vestibule

MOCZAIN’S FLAP

• distal shifting of the flap covers the OAF, but it leaves a gap (raw area medially on the buccal alveolus that will heal with granulation tissue

PALATAL FLAPS

best for closure of an OAF located in the premolar region

FOUR MAIN TYPES OF PALATAL FLAPS

• STRAIGHT ADVANCEMENT FLAP

• ROTATIONAL ADVANCEMENT FLAP

• PALATAL SUBMUCOSAL CONNECTIVE TISSUE FLAP

• HINGED & ISLAND PALATAL FLAP

• STRAIGHT ADVANCEMENT FLAP

limited usage since palatal tissue reduces lateral mobilization

• ROTATIONAL ADVANCEMENT FLAP

based on the greater palatine artery

PALATAL SUBMUCOSAL CONNECTIVE TISSUE FLAP

after flap elevation, submucosal connective tissue with periosteum & arteries is used to close the OAF

PALATAL SUBMUCOSAL CONNECTIVE TISSUE FLAP

• eliminates the donor site defect, but dissection of the submucosal flap is difficult

HINGED & ISLAND PALATAL FLAP

• based on the greater palatine vessels

HINGED FLAP

• utilized for small openings on the palatal side of the alveolar ridge

ISLAND PALATAL FLAP

used for large openings on the anterior aspect of the palate

*Note: Both hinged flap & island palatal flap _________________

will leave a raw area that would heal with granulation tissue.

MODIFICATIONS OF PALATAL FLAPS

A) ASHLEY'S FLAP / ASHLEY'S PALATAL PEDICLE FLAP

B) KRUGER'S MODIFICATION /V-SHAPED FLAP

C) SCHUCHARDT'S TRANSVERSE FLAP

A) ASHLEY'S FLAP / ASHLEY'S PALATAL PEDICLE FLAP

• most commonly used palatal flap

• used when the OAF is near the palatal side of the ridge and the use of a buccal procedure has failed

• can be used to close contralateral OAC or OAF located posterior to the second molars

• only limited rotation is allowed without twisting the palatal artery

• this is a palatal rotational advancement flap that was originally described by Dunning

B) KRUGER'S MODIFICATION /V-SHAPED FLAP

• modified from Ashley's flap, but with a v-shaped excision of tissues on the lesser curvature to minimize flap folding

• care must be taken to avoid injury to the vessels

C) SCHUCHARDT'S TRANSVERSE FLAP

• mucoperiosteum on an edentulous ridge near the OAF is used as a transverse flap so the buccal vestibule height is not affected

• dissection is difficult

COMBINATION OF BUCCAL FLAPS & PALATAL FLAPS

• done when a re-repair is required so the thick covering provides more strength & reduces shrinkage

  
  

OTHER ADDITIONAL SUPPORT FOR REPAIR:

acrylic extension to a denture, denture base, shellac base plate, cotton wool roll impregnated with zinc oxide & eugenol paste (obtundent dressing)

BRIDGE FLAPS

• useful for cases of edentulous maxilla

• a local bridge of tissue located in an area adjacent to the OAF may be moved to cover the defect

DISTANT FLAPS

• TONGUE FLAP

• BUCCAL FAT PAD

TONGUE FLAP

• tongue is considered as an excellent donor site for oral soft tissue reconstruction due to its vascularity

TONGUE FLAP

used when the OAF cannot be closed with a buccal or palatal flap due to its size (done under general anesthesia)

TONGUE FLAP

• can be taken from the dorsum where ⅔ width of the tongue is utilized (DORSUM TONGUE FLAP) or from the lateral border (LATERAL TONGUE FLAP) which is ideal since it is a common location for most OAF

BUCCAL FAT PAD (BFP)

best for Closure of moderate to large OAF located in the posterior region

BUCCAL FAT PAD

Is eased out & sutured in place to cover the OAF or the BFP can be covered with a buccal flap, split skin graft, or lyophilized porcine dermis

BUCCAL FAT PAD

uncovered BFP will epithelialize in 2 - 3 weeks

BUCCAL FAT PAD

this is performed when all other methods or procedures have failed

BUCCAL FAT PAD

1st recognized by Bichat which is the reason it is also referred to as BUCCAL FAT PAD OF BICHAT or BICHAT'S FAT PAD

BUCCAL FAT PAD

• use of the BFP as a pedicle graft with a split skin graft cover was 1st described by Egyedi

*BUCCAL FAT PAD

*is a biconcave disc of specialized fatty tissue that is distinct from subcutaneous fat, lying behind the zygomatic arch between the mandibular ramus & the buccinator muscle, separating the masticatory muscles from each other, and surrounded by a fascial envelope.

OTHER FLAPS

• TURNOVER FLAP

• NASOLABIAL FLAP

TURNOVER FLAP

type of hinged flap that is turned usually 180° to receive a second flap due to the need & extent of the surgery

TURNOVER FLAP

• done for closure that was caused by a combination of defects that may include OAF, oronasal fistula (ONF), & cleft palate

NASOLABIAL FLAP

• best for anterior located defects due to the limited amount of tissue that can be used

NASOLABIAL FLAP

• utilized for reconstructing small defects with an overall cosmetic and functional outcome

SYNTHETIC MATERIALS

1. GOLD FOIL TECHNIQUE

2. POLYGLYCOLIC ACID MESH / VICRYL MESH

GOLD FOIL TECHNIQUE

• conservative measure with minimal surgical procedures

• used for very large OAF with failed flaps from other sites

• can only be done with a healthy maxillary sinus

• foil acts as a protective barrier for the overgrowing sinus mucosa

• an oblong / oval piece of foil is placed & burnished over the defect (with its edges over healthy bone) after the excision & curettage of the OAF

• foil is removed when healing progresses

• popularized by Crolius

*Tantalum, Teflon sheets, or aluminum foil (found in dental film packages)

may be used with a similar technique when using gold foil, but gold foil is commonly preferred by most operators.

POLYGLYCOLIC ACID MESH / VICRYL MESH

• absorbable mesh is used like the gold foil technique, but it is absorbed by the tissues

• sometimes used together with fibrin glue

ALLOGENOUS MATERIAL

FIBRIN GLUE

FIBRIN GLUE

• utilized in a similar fashion like gold foil technique, but the material is injected into the socket & will then be absorbed by the tissue

• sometimes used together with polyglycolic acid mesh / Vicryl mesh

POSTOPERATIVE CARE AFTER SURGICAL CLOSURE OF AN OAC / OAF

1. antibiotic therapy for infections

2. analgesics for pain management

3. careful & gentle cleansing of the mouth with normal saline solution (NSS) or antibacterial mouthwash

4. postoperative instructions must be followed

5. nasal drops (e.g., ephedrine) and inhalations (e.g., menthol or benzoin)

6. soft diet

7. adequate rest & relaxation