Oral-Antral Communication: thoughts?
This case involves a 55 yr old white female. No significant medical history. Gross decay “J” [maxillary left primary second molar], poor prognosis, indicated for extraction only. Extraction of “J” resulted in an approximate 1cm exposure to maxillary sinus. Placed NuOss XC socket expandable bone grafting composite ( Ace Surgical ) loosely, followed by HeliTape ( Miltex ), absorbable collagen membrane. A perio pack was placed over site and extended one tooth adjacent to area. Created good bleeding to soak bone and membrane. Prescribed amoxicillin 875mg BID for 10 days, and Claritin 10mg one tab per day for 14 days. Patient to return for post-op check in 1 wk. Patient leaving for two weeks and patient instructed to return thereafter for suture removal ( 3 wks total ). Patient understands the significance and importance of this exposure, and the probable intervention in the future. OK what I did? Should I have done more? Have I attempted something an OS should have intervened upon? (I have successfully closed up smaller oral-antral exposure in past, yet were in sockets, this was not).
12 Comments on Oral-Antral Communication: thoughts?
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CRS
4/1/2016
I would have placed a cross linked collagen membrane at base with stabilization then placed a prgf and bone allograft similar to repair of a sinus lift perf case. Trying to get some kind of bone base. But the most important part is primary closure with an advanced buccal flap. The tissue will have far to travel on this and the perio pack will not help. It will keep the area clean and protected from food. Not sure where the blood supply will come from for the Nuoss and what will keep it from entering the sinus. The advanced flap provides periosteum and blood supply with primary closure. Then you can go back and do a sinus lift to get more bone.
Please post how this heals and any sequela. Another thing could be laying a strip of cortical bone over the defect and advancing the flap. The flap is the most important thing in any case with a defect and etiology of this type.
DrH
4/5/2016
CRS,
This might be a referral to an Periodontist/ OS specialist to complete, yet if I were to advance this buccal flap would it be extended from the posterior or anterior of the site? Split thickness?
DrDave
4/5/2016
Can't say much else besides what CRS stated. Spot on. However, that being said I've unfortunately followed a few from other offices and have seen them heal primarily with no issues.
K oms
4/5/2016
Best treatment is buccal fat pad advancement into the site. Patients own tissue , no foreign body , no increased cost, excellent results.
DrG
4/5/2016
When you say oral-antral communication what exactly did you see? Did you try a Val Salvo to see if there is a perforation of the schniderian membrane?
CRS is spot on. It's a full/split thickness flap from the buccal. Internal mattress sutures, preferably Teflon so they can stay in for 2 weeks or more. Then remember you will need to reposition the flap back to the buccal in 3+ months or else the patient won't have a vestibule and oral hygiene becomes difficult in the area.
Dennis Flanagan DDS MSc
4/5/2016
Yes I agree, the facial flap, undermine the sinus lining a bit and slip a collagen barrier under and put a layer of particulate graft material with CaSO4 (80:20) then another barrier atop that on the osseous ridge. Primarily close with 4-0 silk horizontal mattress so there are no gaps, water tight (meaningless term but about right). Instruct: no nose blowing, achoo sneezing is OK, Afrin for any nasal congestion. Rx Augmentin or Z-Pak and CHX (for one week only) , return every week for follow-up.
Dennis Flanagan DDS MSc
CRS
4/6/2016
You can get burned on these deciduous teeth since the alveolus does not develop without a permanent tooth eruption. My post op instructions are no nose blowing, sneeze with mouth open, wipe any secretions. Amoxicillin, Sudafed, Afrin to affected side X 5 days. Skip the second membrane on the periosteal side for blood supply. Skip the CHX until the flap heals primarily keep the silks in 10-14 days. Most important no smoking! Next time refer best for the patient in experienced hands. These are not east and need to be followed. They can open up around six weeks post op with a fistula. Spent years fixing these for dentists. Please post the result and thanks for sharing, diagnosis is key.
omsjaw
4/7/2016
Buccal fat pad flap - no loss of vestibular depth.
pascal valentini
4/8/2016
actually the sinus was infected and the ostium was blocked and therefore sinus drainage was only possible trough the alveolar socket. The only way to solve the problem will be an antrostomy in order to open the ostium and then to close the pro astral communication with the cheek fat past or a pedicule from the palate
CRS
4/10/2016
Actually if that was the case then a caudwell luc open procedure with a nasal antrostomy or a closed fiber optic procedure needs to be coordinated with the extraction. If this was known ahead of time. Extracting the tooth and not closing the site primarily is not how this should have been managed. I am not sure how this would be known based on what was posted. Is there a CT scan?
DrH
4/11/2016
A referral will be recommended. By the read on these multiple solutions, I will not pursue any Tx in trying to correct this defect. Last question though, a Periodontist or OS specialist.
Thank you in advance to all that have commented on this issue.
Dr H
CRS
4/12/2016
Oral surgeon this is covered in our training and the buck stops there period. OMFS are on hospital staff and interface with ENT. Be careful since your initial treatment is suspect make sure you know the surgeon and consult with him/her.Wonderful opportunity to learn we have your back! 😉
