Int. J. Oral Surg.

1974: 3:124-132
(Key words: fistMa; oroamral communication; sbutsitis: attrgery, oral)

Treatment of oroantral communication

H A N S R. H A A N A E S AND KJELL NORMANN PEDERSEN

Department of Oral Surgery and Oral Medicine, Dental

Faculty, University o/ Oslo, Oslo, Norway

ABSTRACT One hundred and fourteen patients with oroantral com-

- -

munication were operated at the Department of' Oral Surgery and

Oral Medicine, Dental Faculty, University of Oslo, during the 4-
year period 1968-1972. The closure method used was the buccal
non.rotating flap technique as described by Mbcz~I~ in 1930. Five
cases (4.3 %) failed to heal primarily. Three of these healed spontane-
ously within 1 month postoperatively. Preoperative diagnostic proce-
dures are described as well as the Mbcz~m surgical approach and the
follow-up regime. Vestibular height was found to have normalized
in 88% of the patients examined. The g~ngival condition was examined
before and after surgery in 61 patients. In all these cases, pocket
depths were found to have been reestablished to preoperative values
within 3 months postoperatively. Requirements of the optimal sur-
gical procedure for closure of or communication are stressed,
and the most common errors causing failure or recurrence are listed.

(Received/or publication 22 January, accepted 4 February 1974)

The establishment of oroantral communica- distance of less than 0.5 m m in about 45 %

tion is a common complication during exo-
dontia and other operative procedures in the
maxilla. The greatest number of investiga-
tions dealing with the relationship of the
teeth to the maxillary sinus repm~ the sec-
ond molar roots to be closest to the antral
floor. BONSDORFF5 presented the following
ranking list of the teeth in the order of their
proximity: the second molar, the third mo-
lar, the first molar and the second premo-
lar. The canine and the first premolar were
found to exhibit the greatest distance to
the sinus. BONSDORF1~5 measured the dis-
tance between the floor of the sinus and
the apices of the molar teeth. He found a
of second molars and about 30~/o of first
molars. The close relationship of the mo-
lar roots to the maxillary sinus is empha-
sized in several reports14, 15, 20, 22, 27.
I n adults, the sinus volume is usually with-
in the range of 10 to 20 ml. Futhermore,
the maxillary sinus volumes are usually
nearly identical within an individual.% ~0
The lower part of the maxillary sinus
is often called the alveolar sinus. T h e an-
tral floor may be located 0.5 m m to 10 mm
lower than the nasal floorS0, while the max-
illary ostium is situated in the upper third
of the nasal wall. This anatomic topogra-
phy explains the drainage problems invol-
 0ROANTRAL COMMUNICATION
ved in sinus disease, and antrostomy is
usually performed below the inferior tur-
binate.
Approximately 50 % of oroantral perfo-
rations encountered during exodontia hap-
pen in conjunction with the removal of the
first molar, while - paradoxically - the ex-
traction of the second molar accounts for
only 25-30 %9, 25, 87.
It is estimated that about 15 % of max-
illary sinus disease is of dental origin, one-
third to one-half o.f these cases being se-
condary to oroantral communication.% 12, 2a,
so. However, there is reason to believe that
a great number of accidental perforations
are never diagnosed, since they may be
small and consequently heal without com-
plications.
Before exodontia and operative proce-
dures in the maxilla, good radiographs are
mandatory to evaluate the relationship of
the apices to the sinus floor. When roots are
curved and the sinus floor thin, forceps
extraction is likely to cause removal of the
delicate bone barrier and produce an oro-
antral commnnication. F o r these instances,
there is less chance of this happening if the
tooth is sectioned and the roots are remov-
ed separately. During the reflection of a
flap for the sectioning, the lines of incision
are placed in such a way as to facilitate
immediate surgical closure if the sinus is
entered. When only a solitary maxillary
molar remains, there is often marked ant-
ral pneumatization. A forceps extraction in
this instance can cause a tuberosity frac-
ture and a large oroantral opening.
An oroantral communication left untreat-
ed may rapidly cause acute sinus disease.
WASNMI.INDa5 found sinusitis in 60 % of the
cases on the fourth day after sinus expo-
sure, and E~,mRo~ & Mhta~_NSSON9 re-
ported a sinusitis frequency of about
50 % on the third day after oroantral com-
munication. Some reports indicate 24-48
hours as the time limit within which surgi-
125
cal closure is likely to have a good progno-
sis. This time limit should not be considered
absolute, as several other criteria are also
of importance. Early intervention with sur-
gical closure is the treatment of choice and
prevents the development of chronic and
irreversible changes of the sinus mucosa.
Small perforations through healthy tissue
will have a good prognosis forprimary heal-
ing, provided the socket is filled with a satis.
factory blood clot. Sutures for adaptation
of the gingival rims may facilitate healing,
but the insertion of a bite gauze sponge
between the jaws to protect a blood clot
is of greater importance. The patient should
not be dismissed until a blood clot has for-
med, and instructions designed to minimize
the chance of dislodging the clot should
be given. Antibiotic therapy should be star-
ted, and the first follow-up visit ought to
be scheduled the next day.
The insertion of gelfoam in the socket
is to be condemned16, as this material will
swell considerably and may penetrate the
defect into the sinus. When this occurs, it
is more difficult for the sinus injury to heal.
Antral epithelium and bone will not bridge
a disruption unless cell proliferation is al-
lowed on the basis of healthy connective
tissuelL
Large acute oroantral communications
and cases with acute dislocation of a root
or root fragments into the sinus require im-
mediate referral to an oral surgeon for
treatment. Before referral, antibiotic therapy
should be started and adaptation sutures
may be necessary. Orahesive| tape or a
flat gauze dressing covering the socket will
help to protect a blood clot. Packing of
gauze into the socket is to be condemned.
The flat gauze bandage over the extraetion
site should be saturated with antibiotic oint-
ment to prevent the dressing from turning
septiOs, _96,31 and may require sutures. On
referral of the patient, the extracted tooth
- especially when a root has been dislocated
126 I-IAANAES A N D P E D E R S E N
into the s i n u s - and all radiographs should
be sent with the patient. If the interval be-
tween the estabIishment of the oroantral
opening and the appointment with the oral
surgeon exceeds 48 hours, the referring
dentist should provide a m o r e solid dress-
ing (splint) to cover the extraction site. T h e
splint should be m a d e of a thermoplastic
material. Orahesive| tape is useful also in
some of these instances.
The optimal operative procedure to ac-
complish closure of oroantral c o m m u n i c a -
tion ought to fulfill the following require-
ments: (1) be applicable in most cases, (2)
have minimal incidence of failure when ade-
quately performed, (3) be relatively simple,
(4) not require removal of additional teeth
or bone, and (5) not leave raw surfaces.
The aim of this clinical study was to
evaluate the M6cz~R surgical m e t h o d for
closure of oroantral communication. A treat-
ment was considered successful when pri-
m a r y healing had occurred at the time of
suture removal.
Material and methods
TERMINOLOGY
The term oroantral communication comprises
two pathologic conditions. One is the acute
oroantral perforation and the other is the chro-
nic communication (fistula). Szano~4 found
7-8 days to be the average time for an oro-
antral perforation to epithelialize and become
a chronic fistulous tract.
MATERIAL
At the Department of Oral Surgery and Oral
Medicine, Dental Faculty, University of OsIo,
114 patients (47 women, 67 men) were treated
for oroantral communication by the M6cz/,an
method of surgical closure during the period
1968-1972. One of the patients had two ope-
rations, one on each side, thus resulting in 115
operations. Fourteen of the cases were com-
plicated by root dislocation to the sinus. The
causes of oroantral communications are shown
in Table 1, while the age distribution is de-
monstrated in Fig. 1. Table 2 shows time inter-
vals elapsed between the establishment of the
communication and closure. The distribution of
the cases on the two sides was nearly 1:1. In
26 cases there were adjacent teeth on both
sides of the communication site, while 69 pa-
tients had a neighboring tooth on one side
only. In the remaining 20 cases there were no
teeth adjacent to the sinus exposure. In two
cases, a partial Caldwell-Luc procedure was
performed prior to the closure.
PREOPERATIVE DIAGNOSTIC METHODS
The nose blowing test - The examiner closes
the patient's nostrils with his fingertips, while
the patient is asked to blow through the nose.
A positive intra-antral pressure is thereby cre-
ated, provided the Valsalva method with
closed glottis is avoided. A negative intra-
antral pressure is obtained by having the pa-
tient suck air instead of blowing. Intra-antral
polyps or blood clots may act as a valve and
prevent the escape of antral air during the
blowing test.
Sinus probing - A sinus probe may be safe-
ly used to diagnose an oroantral fistula. The
use of a probe to. verify suspicion of an acute
opening into the maxillary sinus may be con-
traindicated. Where there is no perforation,
probing of the thin barrier may easily produce
one.
The vestibular sulcus o n the affected side
was estimated preoperatively and compared
to the other side.
The gingival pocket depths of the teeth on
the injured side were measured with a perio-
dontal probe graded in 2 mm steps.
OPERATIVE TECHNIQUE
The surgical method used for closure of oro-
antral communications in our material was
the buccal nonrotating flap technique (Fig. 2
A-D) described in 1930 by MSczLrd, 23,31.
With this approach, a marginal incision is made
along the teeth from the tuberosity to the me-
sial of the canine o r - depending on the c a s e -
to the mesial of the first premolar. Here a
relaxing incision is carried obliquely upwards
Table i. Causes of oroantral communications
Tooth extractions 89
Surgical removal of impacted teeth 17
Cystectomies 8
Removal of foreign body 1
 0ROANTRAL COMMUNICATION
39,5 %
20,2~
6J %
5-19 20-29 30-39
Fig. 1. Age distribution of 114 patients with oroantral communications
and mesially in the vestibule. The buceal flap
is reflected subperiosteally, and a relieving pa-
rallel incision is made in the periosteum to
aid in the mobilization of the flap. Next, the
palatal gingiva is loosened and slightly ele-
vated so as to expose the palatal cortical bone
of the socket rim. Necessary trimming of
bony edges is performed. The buccal flap is
then positioned with its gingival part moved
one width of a tooth to the distal, resulting
in the transposition of the mesial papilla to
the distal of the teeth to which they belong.
This technique gives the operator an ample
flap for the approximation of the buccal mu-
coperiosteum towards the palatal soft tissue
without creating undesirable tension of the
flap. Vertical mattress sutures in the socket
area are used to secure the firm position of
the flap, and interrupted sutures are inserted
to approximate the incision lines.
In the two cases where a partial Caldwell-
Luc procedure was found necessary, gauze
packing of the sinus was done without nasal
antrostomy, carrying the end of the drain
through the vestibular vertical incision in the
canine area, through which opening the pack
was removed 4-5 days postoperatively.
Table 2. Time interval between establishment
of the oroantral communication and closure
Same > 14
day 1-2 days 3-7 days 8-13 days days
84 14 5 4 8 days postoperatively. However, these three
127
14,o% 11.4
4,4 ~o 4~
40-49 50-59 60-69 70-79
Results
CLINICAL OBSERVATIONS
Of the 115 oroantral communications clos-
ed using the M6cz,i~ method, five patients
failed to heal primarily. One of these was
reoperated with a Caldwell-Luc procedure
in combination with closure of the fistula.
The patient, a 31-year-old woman who was
7 months pregnant, presented with a sinus-
itis secondary to an oroantral fistula o~ 2
weeks' duration. She was an out-of-town re-
sident, and special conditions made imme-
diate closure desirable. An antral irriga-
tion procedure was performed immediate-
ly prior to the operation. Under normal
circumstances, surgical closure would have
been postponed and additional preoperative
irrigations undertaken. The other case was
left untreated because of the patient's men-
tal condition (a 71-year-old demented wom-
an with no ability to cooperate). She actual-
ly removed the sutures herself on the first
or second day postoperatively. At the 3-
month follow-up visit she still had an oro-
antral fistula, but revealed no signs or symp-
toms of sinus disease. No further follow-up
has been possible in this particular case.
I n three patients, relapse was diagnosed
at follow-up visits varying from 7 to 14
128 HAANAES AND PEDERSEN
A
Fig. 2. A-D, the M6cz~-a method.
cases healed within 3 to 4 weeks without
necessitating a reoperation.
An initial lowering of the vestibular sul-
cus secondary to the M6czXR method was
found. Follow-up examination of 75 out of
114 patients demonstrated remodeling of
preoperatively registered vestibular height
in 66 cases at observations 3 months post-
C
t)
operatively or later. The gingival condition
was examined in 61 patients. In all cases,
pocket depths were found to be reestablished
within 3 months compared to preoperative
measurements. In four patients, gingival
pocket depths had been reduced at an aver-
age of 1 m m at the 3-months follow-up vis-
its, compared to the preoperative findings.
 OROANTRAL COMMUNICATION
Discussion
The advantages of the M6czAR method
are: (1) ample mucoperiosteal flap with
adequate blood supply, (2) minimal tension
of the soft tissue during suturing, and (3)
only minor bone removal and trimming.
The placing of the incision lines and the
size of the flap offer good vision into the
field of operation and enable the surgeon
to perform additional sinus surgery simul-
taneously (e.g. removal of dislocated roots
and/or curettage of the antral mucosal lin-
ing). These factors probably at least partly
explain the good results obtained in this
study (95.7 % successful). Of great impor-
tance is also the fact that 98 of our pa-
tients were operated within 48 hours after
the establishment of oroantral communica-
tion.
Regarding the two cases with permanent
relapse, both these patients had been refer-
red with oroantral fistulas. Closures were
performed, in one case 7 days and in the
other 14 days after the sinus exposure. The
additional three patients in the failure group
had relapse diagnosed within 14 days post-
operatively, and all of these healed spon-
taneously within 1 month after the opera-
tion.
In earlier publications9, 10, t9, ~s, 88, ope-
rations ad modum REHRMANN have been
reported successful in up to 90 %.
The BERGER ~ SA~/'qDER86 or R~ftRMAN'J'q~8
buccal approach is likely to create too much
tension of the flap. Wown~,Nss found a
reduction of vestibular height in 40 % of
her material operated according to this
method. Other studies10 with the R~HR-
MANN method indicate reduction of sulcus
height to occur in up to 50 %. BOCHS &
I.~trr~maca0 experienced a lowering of the
sulcus in 12 % of their cases. Others report
that vestibular anatomy will always be re-
stored in 4 to 8 weeks after this operative
technique 9, ~9, ~s, 83.
129
Concerning the question of lowering of
the vestibule, normalization of vestibular
anatomy in this study was found in 88 %
of the examined cases after 3 months.
Our method of merely preoperative clin-
ical estimation of vestibular height is a
rough and inaccurate one, but still informa-
tive.
The gingival pocket measurements using
a periodontal probe are also less accurate,
giving information of clinical pocket depth
in the range of only + 1 mm.
During the postoperative follow-up visits,
attention should be directed towards signs
and symptoms of acute sinus infection. Ele-
vated temperature, excessive pain, purulent
secretion from the nostrils and massive nasal
stenosis are signs and symptoms of antral
empyema.
Radiographs immediately after closure
will in most cases reveal some opacification
of the sinus (Fig. 3A). Such findings are
secondary to hemorrhage, postoperative
edema and/or temporary swelling of the
antral mucosa. In patients with normal
sinus condition preoperatively, these chang-
es will usually disappear after 3-5 weeks
(Fig. 3B).
The most common errors causing failure
after oroantral closure are:
1. Failure to provide satisfactory preope-
rative irrigation and antibiotic therapy for
existing sinus disease.
2. Excessive tension of the flap with im-
pairment of the blood supply. This is usual-
ly the result of inadequate flap reflection
and insufficient periosteal incision for mo-
bilization.
3. Insufficient trimming of excessively trau-
matized soft tissue and bony edges during
the operation.
4. Inadequate approximation of soft tissue
margins. The buccal and palatal soft tissue
may be sutured in two different ways:
(a) with everted wound edges to create
broad contact surfaces (Fig. 4A).
130 HAANAES AND PEDERSEN

Fig. 3. A, sinograph demonstrates clouding of the right ma~xillary sinus 6 days after an imme-
diate closure of an oroantral communication B, radiographic examination of the same patient
4 weeks postoperatively showing complete clearing up of the affected sinus.

A 13

v.,

Fig,. 4. A - B , approximation of wound edges.

1
 OROANTRAL COMMUNICATION
(b) with buccal flap overlapping the pala-
tal tissue. When using this technique, de-
epithelialization of the palatal mucosa is
mandatory (Fig. 4B).
5. Inadequate instructions to the patient as
to postoperative precautions, or patient's
negligence in following instructions. Fre-
quent follow-up visits are necessary for 10-
14 days postoperatively. Recurrences are
not likely to occur at a later date, but the
patient should be seen several weeks or
months later to verify absence of sinus
disease.
The postoperative morbidity with the
M6CZ~R method is moderate. There is some
swelling and pain, which is easily control-
led by ice packs mad oral analgesics. In-
structions to the patient are very important
and should include:
1. Advice against blowing the nose. In-
struction to open the mouth when coughing
or sneezing to avoid excessive intra-antral
pressure.
2. Soft diet regime to avoid trauma to the
operated area.
3. Advice against the use of straws for
drinking.
4. Advice against excessive suction while
smoking.
5. Advice against strenuous physical effort
after the operation. I n special situations
(systemic disease, larger oroantral openings),
bed rest for a day or two is advisable.
Prescribing decongestant nose drops is
indicated to shrink the nasal mucosa and
keep the antral ostium open for drainage.
Pathologic changes of the ostium have been
found by DRSTT~,m.R7 in conditions of nasal
or paranasal disease s.
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