JowT~alof Cranio-Maxil#)facia[ Surgery (1998) 26, 267-271

1998European Association for Cranio-Maxillofacial Surgery

A clinical study on oroantral fistulae

Orhan Giiven

Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, University of Ankara, Ankara, Turkey
SUMMARY. The report presented is an analysis of 98 patients with an oroantral fistula (OAF). The tooth most
frequently involved was the upper second molar, followed by the first molar. The highest incidence was seen in the
fourth and third decades of life and the lowest incidence in the second decade. In this study, intercurrent sinusitis was
the most obvious cause of the chronic oroantral communication. The closure of OAF is one of the more challenging
problems in oral surgery. Long-term successful closure of OAF depends on the technique used, the size and location
of the defect, and on the presence or absence of sinus disease. Among the several techniques proposed for treatment
of OAFs, in the majority of cases, the buccal advancement flap technique was used in this study. The advantages and
Limitations of the technique are discussed.

INTRODUCTION
Oroantral communication and subsequent formation
of an oroantral fistula (OAF) is a common complication of dental extractions. Owing to its anatomical
location and intimate relationship with the teeth, the
maxillary sinus occupies an important place in oral
and maxillofacial surgery. From a small cavity at
birth, the maxillary sinus starts to enlarge during the
third month of foetal life and usually reaches maximum development around the eighteenth year. Its volume is approximately 20-25 ml in a normal adult. The
floor of the sinus consists of the alveolar process and
the hard palate. The roots of the maxillary premolar
and molar teeth are in close proximity to the sinus and
those of the second premolars and those of the first
molars may be observed within it. Schaeffer (1910)
and Mustain (1933) reported that the second upper
premolars have the most intimate relationship with
the maxillary sinus. The study of Von Bonsdorff(1925)
revealed that the second molars are in close proximity
to the base of the sinus. However Killey and Kay
(1967), Von Wowern (1971), Ehrl (1980) and
Punwutikorn et al. (1994) have shown that removal of
the first molars is the most common aetiological factor in OAE OAF is an abnormal communication
resulting most frequently from extraction of the upper
posterior teeth. The authors have seen a considerable
defect produced when premolars and molars together
with the surrounding bone were removed en bloc during an excessively traumatic extraction (McGovan et
al., 1993; Giiven, 1995) (Fig. 1).
Many techniques have been proposed for the
closure of OAF, including buccal or palatal alveolar
flaps and their modifications. The preferred technique
may vary from one clinic to another, depending upon
past experience. In addition to the above mentioned
techniques, the use of some alloplastic materials has
also been proposed Materials ranged from autogenous bone grafts (Proctor, 1969) to gold foil (Goldman
267

et al., 1969). With advancing technology, dura mater

and fascia lata, as examples of allotransplants, have
also been used for closing OAF (Criiven, 1995). In
recent years, the Use of a pedicled buccal fat pad in
closure of large oroantral openings has become popular (Hanazawa et al., 1995). Attempts to close larger
defects caused by severe trauma or tumours by local
flaps may lead to failure. Distant flaps from the
extremities or forehead (Edgerton and Zovickian,
1956) or tongue flaps (Guerro-Santos and Altamirano,
1966) have been described earlier. Successful closure
of OAF is dependent on the absence of pathology
within the sinus and a proper surgical technique. In
this study, the clinical course and treatment aspects of
OAF will be presented.

PATIENTS AND METHODS

The survey is based on 98 patients treated by the
author between 1983 and 1997. The factors considered were sex, age, cause of the OAF, incidence and

Fig.

1 - T e e t h a n d s u r r o u n d i n g b o n e r e m o v e d d u e to excessively
traumatic extraction.

Journalof Cranio-Maxillofacial Surgery

268

35

32.66g
>x<:x,~z<c.>:l

30

28.57%

25

N
~:.>?~:.zt.:c*:.x.:t
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:.:{.~z.~z.:c.zx~.:
::::::::::::::::::::::::::

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9.18%

41-50

51-60

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:""'=,~,c.-~c<+'~

0
11-20

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Fig. 3 - Age distribution o f O A E

Fig. 2

Sex distribution o f OAF.

i
v//
//

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i::::::::::::::::::::::::
:i~:ii:.~i:i'i~!'E:?:~

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71,43%
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/
/!

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Toot Extraction

Fig. 4

Infection,cysts

Tumour

Trauma

///

,1
'.,..,,

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AetiologicaI distribution o f the cases with OAF.

Fig. g

mode of treatment. The ;(2 test was used to establish

the correlation of OAFs in each group to tooth, aetiology, and site of 98 patients in the study, 52 (53.06%)
were female and 46 (46.94%) male (Fig. 2). The age
distribution of the patients is shown in Fig. 3. The
majority were found in the 31-40 age group
(P<0.001). The distribution of the cases according to
aetiology was highest in those involving tooth extraction (78.60%) (Fig. 4). The most notable feature in the
study group was the presence of pathology (hypertrophic, oedematous mucosa or polyps) within the
sinus, detected by radiography (P<0.001) (Fig. 5).
Thirty-five patients under our care had been previously treated elsewhere by other techniques and the
remaining 63 had had no previous treatment. The
highest incidence of OAF was found after extraction
of a second premolar (28.57%) (P<0.001), followed
respectively by the first molar (26.53%) and first premolar (22.45%) (Fig. 6).

Percentage o f pathology detected in the maxillary sinus.

RESULTS
In our study, we treated most of the cases (90.82%)
using Rehrmann's buccal advancement flap technique
(BAr) (Fig. 7). In addition, five (5.10%) were treated
using a palatal flap (PF) (Fig. 8) and four (4.08%) by a
sliding bridge flap (SBF) (Fig. 9). Figure 10 shows the
distribution of the techniques used in the study.
In two of the patients (2.04%), anaesthesia of the
infraorbital nerve was observed postoperatively and
disappeared in time. In six cases (6.12%), the diminution of vestibular sulcus height was permanent while
the others were temporary and it disappeared in the
following weeks. Three out of 98 cases (3.06%) needed
resuturing due to the the failure of the original
sutures. In two cases, granulation tissue developed in
the suture line and it was treated by local debridement
and resuturing. In three cases, neighbouring teeth

A clinical study on oroantral fistulae 269

28.57N

30

...=..=....=.

26.53%
25

22.45g

N!N

i!~!~;iN;ksJ

!!!~!!N

i!%::{~::!i{~

20

15

N!]

i!!iii?;s,
iiiii!:ii

::gg:N:i:~::gt
;:i:gi:~g:~JN:~

iiii2a~

NN

i:~i!~:%-i;i
2:~:292::::g:?

14.29~

:Sg/:NxN"~
10

=.=..,...,...:
e:':e:.~:.~:.'zls,

....

= .. . . . . .

6.12%
"i::Si:(-:!:~i.!:>]

;i~;;:,;,,;

iN

First
premolor

Second
premolar

2.04%

%%
%

::x~q~:~:

Conine

First rnolar Second molar Third molar

Fig. 6 Incidence of OAFs related to tooth extraction.

@
Fig. 7 - Rehrmann'sbuccal advancementflap.

Fig. 8 - Palatal flap.

were extracted during the operation and before

closure of the OAF due to weak support of the alveolar bone (Fig. 11).

DISCUSSION
Review of the literature as well as our findings demonstrates that O A F usually occurs after the third decade
of life; this is in close agreement with the reports of
other investigators (Lin et al., 1991; Punwutikorn et al.,
1994). Elderly patients with few maxillary teeth appear
to have larger sinuses than younger individuals. In our
series, the highest incidence was found in the 3 1 4 0

Fig. 9 Slidingbridge flap.

years age group. However, there was no statistically

significant difference in the other age groups. The risk
of occurrence of OAF in children is reduced because
of the relatively small sinus cavity. N o n e of the
patients in this study was younger than 11 years old.
The frequency o f occurrence of O A F was nearly
the same in both sexes, which correlates with the findings o f (Von V/owern, 1971; Skoglund et al., 1983;
Punwutikorn et al., 1994). However, according to (Lin
et al., 1991), females exhibit larger sinuses than males
and should, therefore, be at greater risk o f OAF.

270

Journalof Cranio-Maxillofacial Surgery

PF
5.1O"/o

SBF

,,~' i

4.08%
6
5
4
3

[ ] Infraorbital
anaesthesia
Limitation of the
vestibular sulcus
[ ] Suture dehiscence

2
Granulation tissue

BAF
90,82%

0
Fig. 11 - Distribution o f complications.

BAF

: Buccal advancement flap

PF

: Palatal flap

SBF

: Sliding bddge flap

Fig. lO Techniques used for closure of OAFs.

The results of the present study were similar to

those of previous studies by Killey and Kay (1967),
Von Wowern (1971), Punwutikorn et al. (1994) and
Hanazawa et al. (1995), who also reported that the
most frequent cause of the OAF was tooth extraction.
We found that dentoalveolar infections, cysts,
tumours and trauma were other frequent causes. In
this study, the highest incidence of OAF was found
after extraction of a second premolar followed by the
first molar. However, there was no significant difference in the incidence of OAF between the extraction
of premolars and first molars.
In a study of 104 oroantral communications, Von
Wowern (1971) concluded that the chance of spontaneous healing was small, and that therefore closure of
a perforation is frequently needed. In contrast to this
study, we have found that no such closure was needed
in cases where the sinus was healthy and the cavity
small. The aim was to provide support for the blood
clot in the socket so that it will organize, be replaced
by bone and epithelialize on its oral and antral surfaces. The clot in the cavity should be protected with a
gauze sponge dressing for 48 h. A figure-of-eight wire
or an acrylic splint may also be applied for additional
support to healing of the tissues. Furthermore, the
patient should be motivated to avoid intraoral negative pressure such as blowing the nose and to use
antibiotics for prophylaxis.
Our study revealed that the high incidence of
chronic sinusitis or antral polyps may be the most
commonly associated cause of OAF formation.
Otherwise, in a case with a healthy sinus wall and
mucosa, the opening of the sinus will repair spontaneously following injury caused by tooth extraction.
Also the length and width of the extraction socket is
of importance. Shorter and wider extraction sockets

are unfavourable to spontaneous closure. In the present study, the clinical diagnosis of chronic sinusitis
was always confirmed by radiographic examination.
The surgical treatment of cases with chronic sinusitis
involved a classical Caldwell-Luc procedure. Because
of its reliability and straightforward nature, the easy
surgical technique of buccal advancement flap (BAF)
was the most frequently used for the closure of OAF.
Other techniques were used much less frequently (Fig.
10). In our study a palatal flap (PF) was preferred in
the cases who had reduced depth of the buccal sulcus
due to an unsuccessful previous attempt at closure of
an OAF. A sliding bridge flap (SBF) was used in cases
which were totally edentulous and had a reduced sulcus depth due to alveolar resorption. Mucoperiostium
overlying an edentulous ridge in the vicinity of the fistula has been utilized in the form of a SBF. Buccal
vestibular sulcus height was not affected in those
cases. The BAF has been criticized by some authors,
for example, Von Wowern (1982) and Zide and Karas
(1992) because of the postoperative decrease in sulcus
depth. However, it has a broad base, which ensures an
adequate blood supply to the flap. The flap mobility is
improved by making a parallel incision in the
periostium at the base of the flap (Rehrmann, 1936)
(Fig. 7). Although there is an argument that this
method reduces the depth of the buccal vestibular sulcus, the studies of Rehrmann (1936), and Eneroth and
Martensson (1961) showed this to be a temporary
problem. These authors used study models from alginate impressions before and after surgery which
showed that the decrease in depth present at 2 weeks
had disappeared after about 8 weeks. All of the cases
in this study treated by BAF healed almost uneventfully and none needed vestibuloplasty later on.
Therefore, it can be concluded that BAF is a conventional, simple and well tolerated technique for
patients with an oroantral fistula, provided that any
type of chronic sinusitis has been properly treated.

A clinical study on oroantral fistulae

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Orhan Giiven
Ye~ilyurt Sokak, No: 24/15
06690 A~a~i Ayranc~
Ankara, Turkey
Tel: 90 312 4676832; 90 312 4278072
Fax: 90 312 4278072; 90 312 2123954

Paper received 15 December 1997

Accepted 22 May 1998