M a n a g e m e n t o f O ro a n t r a l
Communications
Natasha Bhalla, DDS, Feiyi Sun, DDS, Harry Dym, DDS*
KEYWORDS
 Oroantral communication  Oroantral fistula  Maxillary sinusitis  Oral and maxillofacial surgery
KEY POINTS
 Clinical diagnosis of oral antral communication.
 Xenografts also make important role in the treatment of chronic oral antral communications.
INTRODUCTION
One of the most encountered complications by
oral and maxillofacial surgeons is oroantral com-
munications (OACs). OAC is an unnatural opening
between the maxillary sinus and the oral cavity.
These complications occur most frequently
following odontectomy of maxillary premolars
and molars due to the close proximity of the roots
within the maxillary sinus. Other common causes
include tuberosity fracture following maxillary pos-
terior teeth extractions, implant dislodgement,
dehiscence following implant failure, pathologic le-
sions within the maxillary sinus, maxillary tumor or
cyst enucleation, and a Caldwell-Luc procedure
complication.1 Procedures involving the posterior
maxilla with a pneumatized maxillary sinus, preex-
isting acute or chronic sinusitis, and traumatic ex-
tractions of teeth with large divergent roots can
impose a high risk leading to the development an
OAC. Existing literature reported a more frequent
occurrence of OAC in male populations than in fe-
male populations largely due to a higher frequency
of traumatic odontectomy in men.2
MAXILLARY SINUSES AND MAXILLARY
POSTERIOR TEETH
The maxillary sinus is a quadrangular pyramid with
its roof housing the floor of the orbit and floor
contributing to the alveolar process of posterior
maxilla. The volume can expand from 6 mL at birth
up to 15 mL during adulthood, and sinus
The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA
* Corresponding author.
E-mail address: hdym@tbh.org
Oral Maxillofacial Surg Clin N Am 33 (2021) 249–262
https://doi.org/10.1016/j.coms.2021.01.002
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pneumatization occurs with advancing age. The
maxillary sinus is innervated by the anterior supe-
rior, middle, and posterior superior alveolar
nerves, all of which are the terminal nerves of the
maxillary branch from the trigeminal nerve. It re-
ceives blood supplies from the anterior, middle,
and posterior superior alveolar arteries, all of
which are branches of the maxillary artery from
the external carotid artery.3,4 The maxillary sinus
is lined by a pseudostratified ciliated columnar
epithelium of 0.8 mm thickness called the schnei-
derian membrane. It is the inflammation of this
membrane that causes acute or chronic sinusitis,
which is a typical pathology that OAC is capable
of progressing to.
To better understand the etiology of OAC, it is
important to fully grasp the spatial relations of
maxillary posterior teeth apices to the maxillary si-
nus floor. The antral floor communicates with the
roots of the maxillary first and second M with an
incidence of 40%.5 The palatal roots of those teeth
are 50% closer to the sinus floor than they are to
the palate. The apex of the mesiobuccal root of
the maxillary second M was the closest to the
antral floor with a mean distance of 0.83 mm,
whereas the apex of the palatal root of the maxil-
lary first premolar remains the farthest away with
a mean distance of 7.05 mm (Table 1).6 The dis-
tance from the root apices from maxillary third mo-
oralmaxsurgery.theclinics.com
lars to the floor of the maxillary sinus is rather
difficult to determine due to various patterns of im-
pactions. Hasegawa and colleagues7 formulated
250 Bhalla et al

Table 1
risk of developing an oroantral fistula (OAF). An
Mean distance from maxillary posterior teeth OAF occurs as the migration of oral epithelium
root apex to antral floor into the defect, resulting in a permanent epithelial-
ized tract between the maxillary sinus and the oral
Root Distance (mm) SD cavity. The persistent communication allows aller-
Buccal 1st premolar 6.18 1.60
gens and bacteria to cause the inflammation of the
schneiderian membrane, leading to the obstruc-
Lingual 1st premolar 7.05 1.92
tion of the maxillary sinus ostia through which the
2nd premolar 2.86 0.60 fluid is drained into the middle meatus. The accu-
Mesiobuccal 1st molar 2.82 0.59 mulation of stagnant sinus secretions in a hypoxic
Palatal 1st molar 1.56 0.77 environment causes acute or chronic sinusitis. Iat-
Distalbuccal 1st molar 2.79 1.13 rogenic causes account for 55.97% of incidents of
Mesiobuccal 2nd molar 0.83 0.49 odontogenic maxillary sinusitis (OMS), whereas
Palatal 2nd molar 2.04 1.19 other possible etiologies include periodontitis
(40.38%) and odontogenic cysts (6.66%).8 The
Distalbuccal 2nd molar 1.97 1.21
leading cause for an iatrogenic OAF is extractions
From Eberhardt JA, Torabinejad M, Christiansen EL: A (47.56%), followed by extrusion of endodontic
computed tomographic study of the distances between obturation materials (22.27%), dressings or foreign
the maxillary sinus floor and the apices of the maxillary
posterior teeth. Oral Surg Oral Med Oral Pathol. bodies (19.72%), amalgam remains after apicoec-
1992;73(3):345; with permission. tomies (5.33%), maxillary sinus lift procedures
(4.17%), and poorly positioned dental implants
the 5 types of root-to-sinus (RS) classifications (4.17%).
(Fig. 1) and reported that the extraction of a Common clinical manifestations of maxillary
mesioangular maxillary third molar with a type 3 sinusitis include nasal congestion, nasal
RS classification imposes a higher risk of OAC. discharge, midface pressure, pain, and headache.
Acute maxillary sinusitis usually resolves within
2 weeks with an initial presentation of fever, mal-
MAXILLARY SINUSITIS aise, facial swelling, and pain when bending for-
When an OAC fails to spontaneously close and ward. Unlike the typical Streptococcus
persists for more than 48 hours, patients are at pneumoniae, Haemophilus influenzae, and

Fig. 1. The RS classification. Type 1 shows clear distinction between the root apices and the maxillary sinus floor,
whereas types 2 and 3 have different degrees of radiographic superimposition of the sinus floor across the roots.
Type 4 shows a close proximity of the sinus and the roots with a clear demarcation. Type 5 shows an indistinct
relationship between the roots and the sinus floor. (From Hasegawa T, Tachibana A, Takeda D, et al. Risk factors
associated with oroantral perforation during surgical removal of maxillary third molar teeth. Oral Maxillofac
Surg. 2016;20(4):369–75; with permission.)

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 Management of Oroantral Communications 251

Moraxella catarrhalis found in acute sinusitis of
nonodontogenic origin, the most common bacte-
rial pathogens in odontogenic acute sinusitis
include the aerobic S pneumoniae and Staphylo-
coccus aureus, as well as the anaerobic gram-
negative bacilli, Peptostreptococcus spp, and
Fusobacterium spp.9 Chronic maxillary sinusitis
usually lasts more than 4 weeks with symptoms
of postnasal drainage, halitosis, and diminished
sense of taste and smell. The predominant patho-
gens in odontogenic chronic maxillary sinusitis
involve a mixture of aerobic and anaerobic bacte-
ria similar to those found in odontogenic acute
sinusitis. When sinusitis is diagnosed following
an OAC or OAF, the empiric choice of antibiotics
should be Augmentin 875 mg twice daily, Clinda-
mycin 300 mg 4 times daily, or Moxifloxacin
400 mg once daily for at least 10 days, depending
on the resistance pattern.10 Culture and sensitive
tests should be performed if purulent discharge
is noticed. Patients also should be treated with
normal saline irrigation, nasal decongestant, anti-
histamines, and steroids to improve clinical symp-
toms. If medical attempts fail, surgical options
such as a functional endoscopic sinus surgery or
Caldwell-Luc antrostomy should be considered
to achieve proper drainage of the maxillary si-
nuses. Attempting an OAC closure without
addressing the chronic maxillary sinusitis is a futile
effort.
DIAGNOSIS
Clinical diagnosis of OAC is usually based on both
subjective and objective findings. Patients with an
OAC/OAF can be asymptomatic, but most
complain of altered nasal resonance, nasal regur-
gitation of liquid, foul intraoral smelling, whistling
sound while speaking, and symptoms associated
with sinusitis. A fistula at posterior maxilla can
easily be visualized (Fig. 2A). A Valsalva test can
be used by instructing the patient to gently expel
air against closed nostrils while remaining the

Fig. 2. OAC/OAF appearance on (A) intraoral examination, (B) panoramic radiograph, and (C) i-CAT scan. The red
circle is pointing to the area on the panoramic x-ray that is associating with oral antral communications seen in-
traorally. (Courtesy of H. Dym, DDS, Brooklyn, NY.)

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252 Bhalla et al
mouth open. The passage of air or blood at the
postoperative site usually indicates the presence
of an OAC/OAF. Fogging of a mouth mirror placed
at the orifice can also confirm the clinical diag-
nosis. The formation of an antral polyp can be visu-
alized through the defect at a later stage. A
panoramic radiograph and a computed tomogra-
phy scan can determine the exact location and
size of the defect as well as the degree of sinus
involvement (Fig. 2B, C). Depending on the loca-
tion of the communication at the maxillary alveolar
ridge, OAF/OAC can be further divided into
alveolo-sinusal, palatal-sinusal, and vestibulo-
sinusal.1,11
TREATMENT OPTIONS FOR AN OROANTRAL
COMMUNICATION/OROANTRAL FISTULA
Decisions on how to treat an OAC/OAF are based
on the size of the defect, the time of diagnosis, the
presence of sinus infection, the amount and condi-
tion of tissue available for repair, as well as the
future restorative treatment plan at the site of
defect.10 It is suggested in the literature that an
OAC should be closed within 24 hours, as the
longer the communication persists, the more likely
one is to sustain an OMS.2 Maxillary sinusitis
should be treated either medically or surgically first
before the communication is repaired to avoid
impaired drainage. Most OACs are able to close
spontaneously if the diameter is less than 2 mm
in patients with healthy maxillary sinuses. When
the diameter of the defect is between 2 and
5 mm, a gel foam can be placed and secured
with figure-of-8 sutures within the defect. Regular
follow-ups are recommended to ensure that the
communication does not persist. Surgical repair
of OACs/OAFs are indicated when the diameter
of opening is more than 5 mm, as a defect of this
Fig. 3. Overview of treatment modalities for OACs. (From Visscher S, von Minnen B, Bos RR, et al. Closure of or-
oantral communications: a review of the literature. J Oral Maxillofac Surg. 2010;68(6):1385; with permission.)
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size does not tend to close spontaneously. Multi-
ple closure techniques have been described
throughout the years. According to the classifica-
tion of Visscher and colleagues,12 treatment mo-
dalities of OAC/OAF have been categorized into
autogenous soft tissue grafts, autogenous bone
grafts, allogeneic materials, xenografts, synthetic
closure, and other techniques (Figs. 3–10).2,11,12
An important point to remember based on the
opinion from the most senior author (Dr Harry
Dym) of this article is to remove all the granulation
tissues from the OAC before attempting any defin-
itive closure technique.
SOFT TISSUE FLAPS
Buccal Advancement Flap
The oldest and likely the most common surgical
method to close an OAC is the buccal advance-
ment flap, which is also known as the Rehrmann
technique.2,10,13,14 This flap has been known to
be successful in the closure of small to moderately
sized OACs. It is developed as a trapezoidal
mucoperiosteal flap with a wide base.
First, the epithelized margins of the flaps are
excised.2,10,13,14 This is to permit successful
wound healing. Next, 2 vertical divergent incisions
are made extending from the extraction site to the
buccal vestibule. The flap should be made 50%
wider than the side of the opening to be closed.
It is beneficial to score the periosteum high in the
vestibule, as this helps with passive closure of
the flap over the defect. The broad base of the
flap results in a reliable blood supply to the flap.
In a study conducted by Killey and Kay,13 a 93%
success rate was reported in 362 cases. Falci
and dos Santos15 also introduced a modified
buccal advancement flap in which the buccal
 Management of Oroantral Communications 253

Fig. 4. (A) Two vertical divergent incisions are made extending from the extraction site to the buccal vestibule. (B)
Scoring of the periosteum to achieve tension-free closure. (C) Advancement of the flap. (D) Cross section of the
closure of the oroantral communication. (From Schow SR. Odontogenic diseases of the maxillary sinus. In: Peter-
son LJ, Ellis E, Hupp JR, et al, editors. Contemporary oral and maxillofacial surgery. 2nd edition. St Louis (MO): CV
Mosby; 1993. p. 477; with permission.)

flap was tucked underneath a raised palatal flap to
enhance tissue survivability.
The disadvantage to the buccal advancement
flap is the shortening of the buccal vestibule
following the procedure.2,10,13,14 This has the po-
tential to make the use of a dental prosthesis chal-
lenging in the future. Von Wowern and
colleagues16 conducted a prospective study
demonstrating that the reduction in vestibule was
permanent in 50% of the cases following the
buccal advancement flap. An alternative is the
use of an implant retained prostheses. Last, pa-
tients can expect to feel pain and swelling after
the procedure for several days.
Buccal Fat Pad
Closure of an OAC using a buccal fat pad (BFP)
was first introduced in 1977 by Egyedi.3,10,17,18,19
This technique is also used to close an oral nasal
communication. The BFP functions as a pedicle
flap meaning that the buccal fat pad remains
attached to its original site via a band of tissue.
This ensures blood supply to the area of recon-
struction. The BFP has several advantages,
including but not limited to a rich blood supply,
resistance to contraction, and its close proximity
to the potential defect. Based on the volume of
the BFP, the recommendation is to close defects
of 5  4 cm.
Buccal fat pad anatomy
The BFP lies between the buccinator and
masseter muscle and is surrounded by a thin
fascial envelope.3,10,17,18 It is composed of a cen-
tral body and 4 extensions: buccal, pterygoid,
pterygomandibular, and temporal. The pterygoid,
pterygomandibular, and temporal extensions are

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254 Bhalla et al
Fig. 5. The BFP. (From Diamante M. Buccal fat pad
flap. In: Kademani D, Tiwana PS, editors. Atlas of
oral and maxillofacial surgery. St. Louis, MO: Elsevier.
p. 1134–7; with permission.)
deeply situated, whereas the buccal extension is
the most anterior and superficial, contributing to
the fullness of one cheek. It is the main body of
the BFP and its buccal extension that are used in
OAC closure. Rich blood supply to the BFP is pro-
vided via several vessels: branches of the
Fig. 6. BFP with its central body and 4 processes.
(From Arce K. Buccal fat pad in maxillary reconstruc-
tion. Atlas Oral Maxillofac Surg Clin North Am.
2007;15:23–32; with permission.)
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maxillary artery, superficial temporal artery, and
facial artery.
Surgical technique
Reconstruction with a BFP can be conducted un-
der local anesthesia. If the situation warrants it, it
can be performed under general anesthesia. An
incision is made in the mucosa posterior to the
zygomatic buttress. Next, an incision is made
through the periosteum and the envelope sur-
rounding the BFP. Metzenbaum scissors are
used to bluntly dissect and expose the BFP. The
yellow-colored BFP is gently advanced to cover
the defect and sutured to the mucosal edges.
The goal is to preserve a wide base and avoid me-
chanical suction on exposure of the BFP.
COMPLICATIONS
A review of the literature demonstrates a low fail-
ure rate of the BFP reconstruction.3,10,17,18 The
most common cause of failure is necrosis resulting
in a recurrent OAC. A depression in the cheek
following reconstruction also has been noted.
Tideman and associates20 reported a case of
reconstruction with BFP in which they did not
cover the BFP with gingival mucosa.3,10,17,18
They reported complete epithelialization in
2 weeks. To achieve this, they ensured that the
defect was covered with the BFP in its entirety,
the patient followed a complete liquid diet during
the healing process, and that the BFP was not su-
tured under tension. Last, trismus is usually re-
ported after reconstruction using the BFP. To
mitigate this, Dean and associates18 recommend
mouth opening exercises starting day 5
postoperatively.
Palatal Flap
A palatal rotational flap has been used for OAC
reconstruction when the defect is large or a previ-
ous repair has failed.3,21 Advantages to this flap is
a robust blood supply, preservation of the buccal
vestibule, and keratinized mucosa for the recon-
struction. The palatal flap is also thicker than the
buccal mucosa and hence less prone to ruptures
and tears.
ANATOMY
The blood supply to a palatal flap arises from the
greater palatine artery.3,21 The greater palatine ar-
tery anastomoses with several other arteries;
hence providing a potentially robust blood supply
to a palatal flap. Anteriorly, it anastomoses with
the nasopalatine artery, the right and the left
greater palatine artery anastomose, and
 Management of Oroantral Communications 255

Fig. 7. (A) Incision followed by elevation of full-thickness mucoperiosteal flap to expose the OAC. BFP accessed.
(B) BFP harvested and sutured to the palatal tissue. (C) Closure of mucoperiosteum. (From Arce K. Buccal fat pad
in maxillary reconstruction. Atlas Oral Maxillofac Surg Clin North Am. 2007;15:23–32; with permission.)

posteriorly it anastomoses with the ascending
pharyngeal artery. Studies have shown that if the
greater palatine artery were ligated, a palatal flap
would still have a robust vascular supply.
INDICATIONS
Aforementioned, the palatal flap is recommended
for the closure of large defects.3,21 Specifically, it
has been recommended for defects larger than
10 mm. Lee and associates22 reported a 76%
success rate of palatal flaps. They reported that
an appropriate length-width ratio was the most
important determinant of success of a palatal flap.
CONTRAINDICATIONS AND LIMITATIONS
A previous palatoplasty or traumatic injury to the
palate are contraindications to the use of a palatal
flap.3,21 If a patient may have difficulty following
home care instructions, this flap may be contrain-
dicated. The use of a continuous positive airway

Fig. 8. (A, B) Development of a full-thickness palatal flap with inclusion of the greater palatine artery. (C) Rota-
tion of the palatal flap into the defect. (From Schow SR. Odontogenic diseases of the maxillary sinus. In: Peterson
LJ, Ellis E, Hupp JR, et al, editors. Contemporary oral and maxillofacial surgery. 2nd edition. St Louis (MO): CV
Mosby; 1993. p. 477; with permission.)

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256 Bhalla et al

Fig. 9. (A) Development of the defect. (B) Development of the dorsal tongue flap. (C) Elevation of the tongue
flap. (From Smith TS, Siegfried JS, Collins JT, et al. Repair of a palatal defect using a dorsal pedicle tongue
flap. J Oral Maxillofac Surg. 1982;40:670–3; with permission.)

pressure, bilevel positive airway pressure, smok-
ing history, and coagulopathy can compromise
the healing process.
Tongue Flap
A tongue flap also can be used to reconstruct
OACs.3,12,23,24 This flap has been used in cases
in which the buccal and palatal flaps have failed
and the defect is larger than 15 mm. Advantages
to the tongue flap include rich vascularity and
pliability; however, flap failure can be greater due
to the mobility of the tongue during speech and
swallow. To mitigate this risk, several investigators
have recommended placing patients in maxilla-
mandibular fixation (MMF) postoperatively.
Tongue flaps can be developed as anterior-
based or posterior-based flaps. Anterior-based
flaps are used to treat defects in the hard palate
and anterior-based buccal mucosa.3,12,23,24
Posterior-based flaps are used to treat defects in
the soft palate and posterior buccal mucosa.
Lateral tongue flaps can also be used in OAC
repairment. The flap design is dictated by the loca-
tion and extent of the defect. The thickness of the
flap usually ranges from 3 to 5 mm. The flap may
extend anteriorly to within 1 cm of the tip of the
tongue and posteriorly to within 1 cm of the
circumvallate papilla. The tongue flap is then
secured to margins of the defect by sutures for
14 to 21 days to permit healing, after which the
pedicle is severed and the tongue tissue is rein-
serted. Sometimes, a third procedure might be
needed to debulk the recipient site within 3 months
of the pedicle separation.
Patient tolerance can be a limitation to this
procedure.3,12,23,24 Relative contraindications
include tobacco use and medical comorbidities,
like anxiety disorder, seizures, severe malnutri-
tion, and diabetes. Other concerns with this

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 Management of Oroantral Communications
Fig. 10. Intraoperative photograph. Black arrow:
Caldwell-Luc followed by packing of maxillary antrum
with iodoform gauze. Blue arrow: Placement of bone
graft from Caldwell-Luc into the alveolar crest. Green
arrow: Harvest of BFP and advancement into defect.
(From Weinstock RJ, Nikoyan L, Dym H. Composite
three-layer closure of oral antral communication
with 10 months follow-up-a case study. J Oral Maxillo-
fac Surg. 2014;72(2):266.e3; with permission.)
procedure postoperatively include tongue
edema and consequent airway compromise.
Decadron postoperatively can help reduce
tongue edema. Wire cutters must be kept
bedside at all times if the patient is in MMF
with instructions on how and when to cut the
wires. If there is significant bleeding, the MMF
may need to be released. Last, a liquid diet is
recommended until the flap is divided.
LAYERED CLOSURE FOR OROANTRAL
COMMUNICATIONS
Buccal Fat in a 3-Layered Closure
The previously described techniques have recom-
mended soft tissue closure over an OAC/OAF.25
There can be some potential disadvantages to
this. The presence of a defect results in dead
space following the closure. Fluid can accumulate
into this space and cause tension to the wound
edges, eventually resulting in breakdown. These
fluids can also act as a nidus for infection.9 Place-
ment of a bone graft before initiating soft tissue
flaps has advantages. The presence of hard tissue
can act as a scaffold.25 Last, the presence of bone
could prevent the pneumatization of the sinus
membrane to the alveolar crest.25
Weinstock and associates25 described a 3-
layered closure of an OAC in 2014. They per-
formed this procedure 3 days after the formation
of the communication of 1 cm in diameter.25 A
sulcular incision was made from the maxillary
canine distal to the second M with vertical
releasing incisions.25 The OAC was curetted.
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257
Next, a Caldwell-Luc window was created in the
canine and premolar region apical to the OAC
with care to preserve the bony window. The bony
window was removed and placed over the defect.
A BFP was harvested and sutured in place.25 A
buccal advancement flap followed that.
Weinstock and colleagues25 reported a suc-
cessful 3-layered closure of an oral antral commu-
nication with no signs of sinusitis. The patient was
followed up to 10 months postoperatively.
The Use of Platelet-Rich Fibrin in a 3-Layered
Closure
Rosenfeld and colleagues26 reported a case of
successful layered closure using advanced
platelet-rich fibrin (A-PRF), a BFP, and buccal
advancement flap. A-PRF is a newly developed
technique that uses 10 mL of the patient’s blood
to be centrifuged at 208 gravities for 8 minutes.27
A-PRF is rich in platelets, leukocytes, transforming
growth factor b-1, vascular endothelial growth fac-
tor, and bone morphogenetic protein 2, which can
play a crucial role in wound healing, with its bone
formation and antibacterial properties (Fig. 11).
Two A-PRF membranes were derived in a stan-
dard fashion from 20 mL of the patient’s blood with
no additives (see Fig. 11).26 The A-PRF layer was
separated from the red blood cell clots and was
pressed in a PRF box for another 8 minutes,
Once the granulation tissue and irregular bony
margins were carefully removed, the A-PRF mem-
branes were placed to cover the defect. The BFP
was then extruded to completely seal the OAC.
Two vertical releasing incisions were made at the
buccal vestibule to allow full advancement of the
buccal periosteum for complete soft tissue
coverage. After being discharged with sinus pre-
caution instructions and Augmentin, the patient
exhibited no signs of sinusitis, wound infection, tis-
sue dehiscence, or localized pain in subsequent
follow-ups. The use of A-PRF membranes in this
technique not only added extra stability to the
Fig. 11. A-PRF membranes. (Courtesy of H. Dym, DDS,
Brooklyn, NY.)
258 Bhalla et al
layers of BFP and the buccal flap, but also accel-
erated wound healing with local antibacterial pro-
tection. Layered closure with A-PRF should
therefore be considered for patients exhibiting
poor wound healing or those who cannot afford
other expensive alternatives such as xenografts.
Review of the Literature on Soft Tissue
Closure for Oroantral Communications
As per a review by Visscher and colleagues,12 an
OAC is most often treated with a buccal advance-
ment flap.14,28–30 A success rate of 93% has been
reported for the procedure. The disadvantage to
this procedure is a reduction in the vestibule
depth. A subsequent study by von Wowern16
demonstrated that the reduction in the vestibule
is permanent in 50% of the cases. Many investiga-
tors have recommended the use of buccal flaps for
smaller defects. The perfusion through the buccal
flap is poor; the flap is not as thick as a palatal flap
and hence may not be recommended for larger
defects and recurrent fistulas.
Aforementioned, an alternative soft tissue
closure of the OAC is the use of a palatal
flap.12,14,28–30 It has been especially recommen-
ded for use in defects larger than 10 mm. A 76%
success rate of palatal flaps was reported in 21 pa-
tients by Lee and associates.22 Salins and Kish-
ore31 reported that the blood supply via the
greater palatine artery is advantageous to the suc-
cess of this flap. The palatal flap is also thicker
than the buccal flap and hence less prone to
rupture. A disadvantage to the palatal flap is the
area of exposed bone as a result of the rotation
of the flap. This area heals via secondary intention
and can be painful for the patient. Awang32 re-
ported that surgeons prefer a palatal flap over a
buccal flap.
The BFP procedure has also been reported with
high success rates.12,14,28–30 Hanazawa and asso-
ciates33 reported success in 13 of 14 patients. As
per Neder, the proximity of the BFP to its surgical
site plays a large role in its success.34 The BFP
also has a very rich blood supply. However the
BFP procedure is very technique sensitive and
may not provide as much success in closing large
OACs. Attempted closure of large defects may
result in graft necrosis. It is recommended for
medium-size defects of 5  4 cm approximately.
Tongue flaps are also an option for the closure of
OACs.12,14,28–30 Their success can be attributed to
the rich blood supply to the tongue. Siegel and col-
leagues35 used a full-thickness pedicled flap from
the lateral border of the tongue to close a large
OAC. The OAC occurred after partial maxillec-
tomy. Healing was uneventful in this patient. Kim
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and colleagues36 also used a posteriorly based
full-thickness lateral tongue flap to close an OAC,
with success. The disadvantage to this procedure
may be patient discomfort and need for multiple
surgical procedures.
BONE GRAFTS
Bone grafts also can be used in the closure of an
OAC/OAF.2,10 The recommendation has been to
use bone grafts for larger defects or after failure
with soft tissue closure. The placement of a bone
graft may reduce the need for a sinus augmenta-
tion in the future. Bone grafts can be obtained
from anterior ramus, symphysis, maxillary tuber-
osity, and anterior iliac crest. The morbidity with
an anterior iliac crest involvement may be larger
but gives one access to a larger amount of bone.
Hass and colleagues37 described a technique to
use bone grafts whereby they standardized bone
defects of the sinus floor with use of a round
trephine bur.2,10 A bone graft of the same size
was then placed in the defect and miniplates
used to secure the graft material. Soft tissue
closure was achieved via a buccal flap. Last, mul-
tiple investigators have recommended a sinus lift
procedure simultaneously with the closure of the
communication and placement of bone graft
material.
XENOGRAFTS
Resorbable Collagen Membrane
Markovic and colleagues38 described the use of a
resorbable Bio-Gide collagen membrane that pro-
vides support to blood clots, allowing for cell orga-
nizations, reepithelization, and bone replacement.
The porcine collagen has a dense, porous surface
that permits the in-growth of osteoblasts while
preventing the formation of a fibrous tissue mem-
brane. After curettage of granulation tissue at the
fistula, a Bio-Gide membrane was placed and
secured with resorbable pins over the bony defect
without repositioning the buccal flap.39 The mem-
brane was left exposed postoperatively, and a
complete soft tissue closure was achieved in
2 weeks.38 The collagen membrane resolves
within 24 weeks. This technique offers an alterna-
tive for moderately large defects, missing neigh-
boring teeth, and lack of available soft tissue for
local grafts.
Sandwich Technique Using Collagen
Membrane and Bone Substitutes
Ogunsalu39 reported the combined use of the Bio-
Gide collagen membrane and the Bio-Oss bone
graft material. The bovine bone containing
 Management of Oroantral Communications
cancellous particles was sandwiched between 2
sheathes of the resorbable collagen membrane.
Three sides of the collagen membranes were su-
tured together using resorbable sutures before
the placement of the cancellous bone to prevent
leakage. After the insertion of the Bio-Oss bone
particles, the sandwich was entirely closed using
resorbable sutures and positioned into the
communication. Buccal and palatal flaps were
repositioned in primary closure. Subsequent
follow-ups showed formation of a bony floor with
sufficient bone height for dental implants. This
method offers both soft and hard tissue closure
without the need of donor site surgery, and it
shows a promising result to create an ideal bone
height when an endosseous implant is planned.
METAL FOILS AND PLATES
There have been reports of the use of metal plates
and foils for closure of OACs. The standard metals
for such techniques include tantalum, vitalium,
gold, and aluminum.40 This procedure entails
elevating a split-thickness mucoperiosteal flap,
leaving the inner layer of periosteum attached to
the bone. The intact inner layer allows for more
efficient healing, while a metal foil, which is placed
over the inner layer, serves as a bridge for the
overgrowing mucosa at the top (Fig. 12). The
buccal and palatal tissue should be sutured in a
tension-free fashion. The healing process typically
takes 4 to 6 weeks. The reparative tissue usually
displaces the metal from its initial position, making
it much easier for removal. The advantages of us-
ing metal plate or foil for OAC closure are the
simplicity of surgery, minimal postsurgical scar-
ring, and the preservation of intraoral anatomy.
Fig. 12. Placement of a metal foil over the inner layer
of periosteum to initiate soft tissue proliferation.
(From Steiner M, Gould Ar, Madion DC, et al. Metal
plates and foils for closure of oroantral fistulae. J
Oral Maxillofac Surg. 2008;66(7):1552; with
permission.)
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259
The main disadvantage is the time it takes for
soft tissue healing over the defect. An inexpensive,
alternative approach to the gold foil is an aluminum
plate to cover OAC. Steiner and colleagues40 re-
ported favorable outcomes of OAC closure with
no evidence of residual sinusitis or infection in
the 8 cases using aluminum foil.
HYDROXYLAPATITE BLOCK
Multiple cases of OAC closure using a nonporous
hydroxyapatite (HA) block with good outcomes
have also been reported.41 The technique requires
carving of the HA block to approximate the bony
margins from the defect. If the defect is large,
bur holes are placed in the bony margin of the
defect, and a 26-gauge wire is used to stabilize
the block over the fistula to prevent its dislodge-
ment into the maxillary sinus. Primary closure is
preferred without compromising the vestibular
height. The HA block serves as a scaffold for sur-
rounding tissues to grow over the defect. Once the
sinus has sealed, the block usually loosens and
exfoliates. The major advantage of this technique
is that the HA block is able to convert a relatively
large defect into a sealed, smaller area that facili-
tates spontaneous healing without a donor site
morbidity. However, trimming the HA block to
match the size of the defect is usually time-
consuming, and the options for various sizes of
prefabricated blocks are limited.
ALTERNATIVE APPROACHES TO OROANTRAL
COMMUNICATION CLOSURE
Third Molar Transplantation
Kitagawa and colleagues42 reported a unique
technique for OAC closure using transplanted third
molars with closed apices at the anticipated defect
site immediately following extractions. Both pa-
tients in the case study were in their 30s and
were planning to get dental implants after removal
of hopeless maxillary teeth that had periapical
infection into the maxillary sinus. Anticipated
OACs occurred following extractions, and third
molars were transplanted into the defect immedi-
ately. Mucoperiosteal flaps were not raised at the
recipient sites to preserve sufficient blood supply,
and the donor third molars were extracted with
minimal damage to root surfaces. The recipient
sockets were shaped to fit the transplanted third
molars. The transplanted teeth underwent end-
odontic treatment in 3 weeks and had prosthetic
work afterward. Both patients had no complica-
tions 2 years following the procedure. It is a chal-
lenging technique, as recipient site soft tissue
viability, alveolar bone heights of more than
260 Bhalla et al
5 mm, root integrity of the donor third molar, and
size of the recipient socket within the defect all
contribute to the viability of the transplanted tooth
as well as the overall success of OAC closure.
Laser Therapy
Low-level laser therapy has widely been used in
the field of oral and maxillofacial surgery, as it facil-
itates wound healing by stimulating angiogenesis
and collagen synthesis in a dose-dependent
manner.43 Grzesiak-Janas and Janas44 used a
biostimulative laser of 30-mW power and 830-nm
wavelength on 56 patients who sustained an
OAC larger than 8 mm; 3.5 minutes of contact irra-
diation of 4J was applied extraorally to the infraor-
bital region and intraorally to the floor of the sinus
as well as the alveolar process where the existing
defect is located. Complete closure of OACs was
observed in all patients after 4 days of consecutive
laser treatment, and those patients did not
complain of postoperative pain or discomfort.
The laser technique offers a superior result in erad-
icating temporary nasal discharge, rhinitis, head-
ache, and local pain always seen postoperatively
from other methods, but its main disadvantage is
its cost and the multiple visits the patients need
to commit.
Oroantral Communication Closure in
Immunocompromised Patients
Delayed wound healing is a common postextraction
complication in immunocompromised patients,
and there have been a few OAC cases reported
associated with patients with human immunodefi-
ciency virus. Because surgical approaches of
OACs in immunocompromised patients can poten-
tially prolong the healing process, Logan and
Coates45 reported the use of an acrylic splint as a
scaffold following removal of the epithelium tissue
from the communication. The patient was
instructed to rinse the splint with 0.02% chlorhexi-
dine gel between meals. A complete closure of the
OAC was noticed after 8 weeks, and the splint
was removed. However, for any OACs that are
larger than 5 mm in immunocompromised patients,
a surgical approach is still indicated.
SUMMARY
The practicing oral and maxillofacial surgeons must
be aware of the diagnosis and manifestations of
OAC/OAFs, as this is not at all an uncommon
occurrence during procedures involving the poste-
rior maxilla, especially during extractions, implant
placement, and cyst or tumor removal. It will be
referred to the office frequently. The article has
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reviewed the various approaches for closure of
OACs as well as their advantages and disadvan-
tages. It has also provided insight on the preferred
treatment modalities based on the size and location
of the defect, soft and hard tissue availability, time
of diagnosis, future restorative work, and presence
of sinus infection. It is critical to understand that a
successful closure of any OAC/OAFs occurs only
if the removal of the inflamed, diseased sinus tissue
is achieved before any surgical attempt at closure.
CLINICS CARE POINTS
 Maxillary sinuses must be cleared of exten-
sive granulation tissue prior to attempting
closure of existing oral antral communication.
 Active purulent discharge from the OAC and
active sinusitis must be treated prior to at-
tempting permanent closure of the OAC.
 The use of the buccal fat pad to close a long
standing OAC is very predictable and should
be familiar to practicing oral and maxillofacial
surgeons.
DISCLOSURE
The authors have nothing to disclose.
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