Oro-antral fistula

Oro-antral fistula An analysis

of 100 cases

J. E. d.e B. Norman, M.B., CH.B., Y.D.S., F.D.S.R.C.S., F.A.C.D.S.,* and Geofirey Craig, B.D.S., L.D.S.R.C.S.,** Shefield, England In a series of 100 cases of oro-antral fist&, twenty fistulas were associated with fracture of the maxillary tuberosity and have been dealt with separately. The remaining eighty fistulas resulted from an attempt at the extraction of a single tooth; of these, one or more roots dislocated into the maxillary antrum in thirtythree cases. Other less common causes of oro-antral fistula were not encountered in this series (Fig. 1). There b no doubt that the existence of the m&l&y Gnu8 wa.s &ready kmown before Highmore. The celebrated anatomists, Ve8a&S, Ingsas&, Eust&ahti and Fallopbs have q&en of it very clearly. Only through ignorance of the history of anatomy has it been affirmed by many that this cavity was discovered by Highmore, to whom is only dzle the merit of having described the tillary W, by him called a&rum, most aoourately, and of having vnade known the possibil$ty of a communication between it and the mculcth. -V. Guerini.14

I

t is clear from the above quotation that the relationship of the teeth and the maxillary sinus was recognized by earlier writers. Although Nathaniel Highmorel’ (Figs. 2 and 3) described the antrum maxillaris superioris or antrum genae, and it is his name which is usually linked with this sinus, both Vesaliussl and Fallopiuss had written previously on the subject. In 1707 Drakes made reference to one of Highmore’s cases,and that report is of special interest: The lower Surface of this Cavity makes a thin covering to all the Roots of the Dent@ Molares, as well as the Dens Caninus of the fame fide, and is very thin, and frequently upon drawing any tooth, to which it fticks, taken along with it, whereby this Cavity is open’d into the Alveolus, and confequently into the Mouth. An inftance of this is mentioned by Dr. Highmore in a Gentlewoman who had the Dens Caninus drawn upon the account of pain, proceeding from an Inveterate Defluction of Fharp Humours that had deftroy’d most *Senior Registrar in Oral, Plastic, and Jaw Surgery, United Sheffield Hospitals. **Senior House Ofilcer in Oral Surgery, United Sheffleld Hospitals.

734

Volume 31 Number 6

Kg.

1. Established

Oro-antral

oro-antral

fistula

through

which large

Fig. 2. Nathaniel Highmore (1613-1685) Portrait Blooteling. (Courtesy of “The Wellcome Trustees.7’)

from

antral

line

polyp

fistula

735

is presenting.

engraving

by

Abraham

who upon thrufting a Silver Bodkin into the Alveolus, was exceedingly of her Teeth; frightened to find it pafs, as it did, almoft to her eyes. And upon further trial with a small feather Ftript of its Plume, which fhe thruft up a Hands breadth or more, was fo terrify’d at it as to confult the Doctor and others about it, imagining nothing lefs than that it had gone to her Brain: But they confidering the Cireumftances of the matter, found that the Feather had doubled only in this Cavity and gave the Lady full fat&faction in that point. The Doctor has given us a Figure of it tho’ no very exact one. Of this I have met with frequent Inftances where the Patients have all done very well again and the Aperture itfelf clofed after Injecting a proper Medicine to cleanfe the Antrum from any offenfive Humour.

736

Norman

and Craig

Fig. 9. Drawing from The Hague, 1651, 8. Broun.

Oral Surg. June, 1971

Nathaniel

Highmore:

Corporis

humani

disquisitio

anatomica,

It is not surprising that the roots of maxillary posterior teeth are occasionally dislodged into the maxillary antrum during an attempt at forceps extraction. An examination of the floor of the maxillary antrum shows the close relationship between 6he root apices and the antrum. Mustian, in an extensive anatomic study, found that the first and second maxillary molars came into closest relationship with the floor of the antrum. He also considered that the second molar roots occupied a position in the antral wall more frequently than any other tooth and that the second molar roots most frequently projected into the antrum.

Volume 31 Number 6

Oro-antral fitula

737

It is possible that the floor of the maxillary antrum is penetrated by the intact root during preliminary movements of the tooth with dental forceps but that this goes unrecognized by the dental surgeon. The resultant communication undergoes a spontaneous closure in most cases following the organization of the healthy blood clot filling the socket, Should the blood clot fail to form or be lost as a result of infection, the communication remains patent and becomes the established oroantral fistula. Spontaneous closure may still occur, and in this series of 100 casestwo fistulas closed spontaneously. In the first instance, a small fistula in the maxillary first molar region of 9 weeks’ duration closed after it was covered by an extension to the patient’s upper denture. A second fistula, present for 29 months in the maxillary second molar region, closed spontaneously after two antral washouts. Broadly complished

speaking, the closure of the established oroantral fistula may be acby the use of a buccal advancement or a palatal transposition

flap. 1l I3128A nasolabial (Easer) flap may be indicated in a few cases.34Although there are situations in which palatal flaps are of use, that is, large palatally placed oro-antral

or oro-nasal fistulas, the subsequent retent.ion of a full denture

may be difficult following operation. CLOSURE OF THE ORO-ANTRAL Local anesthesia

FISTULA

Following excision of the fistula, closure by a buccal advancement flap (“sliding flap”) according to the principle of periosteal release advocated by Berge? provides a satisfactory and simple means of closure without tension. Vertical mattress sutures are used to obtain a broad adaptation of the raw mucosal surfaces. Care should be taken to avoid angulation of the flap over a bony crest or margin. This method is particularly suitable in those fistulas of immediate or recent origin where there is no evidence of antral infection, provided that a root has not been displaced so far into the antrum that it cannot reasonably be removed by way of the fistula. General

anesthesia

Should it be decided that closure of an oro-antral fistula is to be combined with a Caldwell-Luc operation21 endotracheal anesthesia is desirable. As a preliminary, in addition to a thorough cocainization of the nose, the area above the fistula and forward to the canine fossa is infiltrated with local anesthetic solution to aid hemostasis. When the patient is draped with towels the nostril and eye on the ipsilateral side should be exposed. Following excision of the margins of the fistula, the flap is incised to the periosteum. The anterior limb of the flap is carried forward to the region of the pyriform aperture to give adequate access to the canine fossa. The mucoperiosteal flap is raised and retracted, the infraorhital neurovascular bundle is exposed, and suitable retractors

are placed on either side of it as it emerges

from the infraorbital foramen in a small fibrous tube. The operation, as described by Williams,36 is carried out. To achieve tensionless closure of the fistula, the periosteum is incised with a clean blade at the base of the flap. Care is

738

Norman

Oral surg.

and Craig

June, 1971

taken not to carry the periosteal incision too far forward, thus avoiding damage to the infraorbital nerve and vessels. The flap must be freely mobilized, and it is sometimes necessary to undermine it with scissors to obtain further advancement. The wound is closed with interrupted vertical mattress sutures. H the fistula is in the region of the maxillary tuberosity, a separate incision is made for the Caldwell-Luc operation. The necessity of a nasal antrostomy as a routine procedure is in some doubt, and only five patients in the present series underwent nasal antrostomy, although WilliamsZ5 routinely performed this operation. If a pack has been placed in the antrum to check bleeding, it can be removed 1 hour postoperatively. If a grossly diseased and infected lining has been removed, then a pack suitably dusted with penicillin and sulfonamide powder is left in situ for 24 hours. Post operative treatment is minimal, and no irrigations of the sinus are carried out. Steam inhalations, analgesics, and an antibiotic are prescribed. The sutures are removed on the tenth postoperative day. In the past, management of t,he established oro-antral fistula has been facilitated by the use of gold plate,7, llr 27 tant,alum foiJz2 or tantalum plate3$ 4 to cover the bony defect prior to mucosal closure. In the present series it has been found that closure of the defect by local tissue in the form of an advancement or transposition flap has given such consistent,ly good results that it has not been necessary to use metal implants. Following closure of the fistula, there appears to be no reason other than support of the surgeon’s morale for the use of an acrylic dental plate to cover the operation site. Indeed, the use of such a plate may disrupt the suture line by a pumping movement during mastication. A tie-over dressing of bismuth iodoform paraffin paste or Whitehead’s varnish and ribbon gauze has never been used, as it was thought that there was a potential risk of compromising the circulation in the flap. Fractured

maxillary

tuberosity

A large oro-antral communication may follow fracture of the maxillary tuberosity, and twenty such cases (Fig. 4) are included in this analysis. Provided the defect is immediately repaired following surgical removal of the tuberosity, wound breakdown is exceptional. Norman and Cannon,24 in discussing the problem, concluded that an extension of the maxillary sinus into the tuberosity was the most important causal factor, although wide divergence of the roots of the maxilla.ry third molar was also significant. This confirmed the findings of Tomes and Tomes,2Q Tomes and NewelJ30 Gerrie,12 Rounds,26 Cohen,$ and Burla.nd.5 An abnormal number of roots is considered to be of less significance in the causation of such a fracture. The isolated maxillary molar tooth should always be treated with caut,ion. The tooth

root

and

the

maxillary

antrum

Management of the displaced tooth root or apex has been considered by numerous authoqz5 and conflicting opinions are given. Wakefield3*l 33 advocates immediate removal of the roots via a Caldwell-Luc operation and closure of the fistula. Fickling’O recommends the removal of roots from the antrum via

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31 6

Fig. 4. Fractured maxillary showing extent of bone loss.

Oro-antral

tuberosity.

Specimens

of

fractured

maxillary

fistula

739

tuberosity

the site of the fistula whenever possible. Killey and KayI advise immediate removal of roots, whereas Harrison16 considers that they can be left and observed. Leezo advocates the immediate removal of root fragments by the transalveolar approach above the site of the fist&a. Occasions may arise when it is possible, with a minimal intrasocket or transalveolar operation, to remove a root displaced into the maxillary antrum. As a general rule, however, if this fails, the root should be removed via the canine fossa. After a number of unsuccessful attempts to flush out roots by irrigation through the tooth socket, this method has been discarded. Usually the bony defect in the antral floor is small, and the tooth root or apex lying on its side is not likely to be delivered by this route. Displaced roots may give rise to acute or chronic infection of the maxillary

740

Norman and Craig

Fig. 5. Occipitomental

radiograph.

Oral Surg. June, 1971

Tooth root shown in opaque right maxillary

sinus.

antrum, although equally certain uninfected roots may lie for years in the antrum without causing symptoms. Of the thirty-three cases seen, only six were associated with gross infection of the antrum. The tooth root or apex contains pulp tissue which may be infected; it would therefore seem advisable to remove it as soon as possible and achieve mucosal cover of the fistula. Whether the tooth root is lying outside the mucosa of the maxillary antrum or within the antrum is of little practical importance. In this series, thirty-one of the thirty-three roots were in the antrum and two roots were between the mucosa and the bony walls. The possible extrusion of a root apex through the via naturalis is mentioned by Killey and Kaylo and Jones and Steel.18 DIAGNOSIS

The referring dental surgeon is occasionally in doubt as to whether or not a root has been displaced into the maxillary antrum, but usually intraoral radiographs (Fig. 4) will clearly confirm its presence and position. Reliance should not be placed on the occipitomental radiograph (Fig. 5) alone for confirmation of the presence or absence of the tooth root or apex, since a small root lying in the floor of the antrum will be “lost” in this film. The intraoral radiograph, with its better definition, clearly reveals the root and its position if it is lying in the floor of the sinus. The topographic occlusal film of the maxilla is also valuable. It is noted that a large number of oro-antral fistulas occurred on the left side, and it was considered that this may have been due to the position of the operator on the right-hand side of the chair during extraction of the teeth. The visibility of the left maxilla from the right-hand side is poor, and it was considered that this factor, combined tiith the dental surgeon leaning across the patient and working in a position of discomfort, might account for the discrepancy between the two sides.18

Volume Number

Table

Oro-antral

31 6

fistula

741

I. Age incidence No. of oro-antrd

4% fw@ oto

9

$stulas

0

10 19 20 to 29

2:

30 to 49 39 40 50 to 59

:; 7

60 70 to f 69

0” ii

Table

II. Site of occurrence Teeth

No.

of ore-antral

Canine First premolar Second premolar First molar Second molar Third molar Total

fistulm

Per

cent

4 3 2 31 32 8

5 3.75 2.5 38.75 40 10

80

I;;;;

RESULTS Side

Forty-four of the oro-antral fistulas six were found on the right side. Age

occurred

on the left side, and thirty-

incidence

Table I shows the age incidence of oro-antral fistulas, with the greatest number of fistulas occurring in the decade from 30 to 39 years.

The various sites at which oro-antral fistulas occurred are shown in Table II. In this series is was noted that the first and second maxillary molars were about equally involved and, in fact, accounted for 79 per cent of all fistulas. Sex Sixty-three (79 per cent) of the fistulas studied occurred in male patients, and seventeen (21 per cent) occurred in females. In this series the ratio of males to females with fistulas was 3.7 to 1, which was in approximate agreement with the attendance ratio of the sexes (3 to 1) in the minor oral surgery department. Roots

in the

maxillary

antrum

If fistulas resulting from fracture of the maxillary tuberosity were excluded in this series of eighty cases, thirty-three (41 per cent) presented with one or more roots in the antrum (Table III). The ratio of males to females was 25 to 8. Roots were found in the left maxillary antrum on nineteen occasions and in the right antrum on fourteen occasions.

742

Norman

Fig. Definition

Table

and Craig

6. Intraoral and detail

Oral h-g. June, 1971

radiographs showing presence of tooth roots are superior to those obtainable in occipitomental

III. Teeth involved Tooth

No.

Ca.Ri.ll.3 First premolar Second premolar First molar Second molar Third molar

IV. Duration

of causes 1 4 1: 14 3

ii

Total

Table

in maxillary radiograph.

of root in antrum

Duration

I

No. of mz*es

1 day

14

1 day monthto to 1 month 1 year 1 year to 7 years Total

1; 2 ii-

~~

sinus.

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31 6

Oro-antral fistda

743

Sixteen roots were removed within one week, under local anesthesia, by the transalveolar route, with a buccal advancement flap for closure. Seventeen roots were removed under general anesthesia. Table IV shows the findings with respect to the duration of roots in the antrum. Although the numbers are small, the figures indicate that, in this series, the maxillary second molar is the tooth more often involved if a root is displaced into the antrum. This tends to support the anatomic findings of Mustian. Jones and Xteell* consider that the increased incidence of first molar involvement was due to the frequency of extraction of this tooth and the divergence of its roots. No firm conclusions have been made regarding the necessity of carrying out intranasal antrostomy. In the case of established infection, it would appear prudent to perform a nasal antrostomy for drainage purposes since, unless proof puncture has been carried out, the surgeon will not know whether the ostium is patent. We have made a practice of performing this procedure via the antral route if a Caldwell-Luc operation has been performed. All fistulas were closed by means of the buccal advancement flap technique, although in some instances periosteal release was supplemented by minimal reduction of bone in order to preserve alveolar ridge height for future denture construction. We wish to thank Mr. R. C. W. Dinsdale, Mr. M. D. Beetham, and Mr. R. Rastall for granting us access to their records and Mr. R. Cousins for his invaluable help with the illustrations. We are grateful to the librarian of The Wellcome Institute of the History of Medicine, London, for his assistance. The illustrations taken from originals in the Welleome Library are published by courtesy of the Trustees. A grateful acknowledgment is made to Mr. Richard Williams, T.D., F.R.C.S., who taught the writer the refinements of sinus surgery.

REFERENCES

of Oral Surgery, ed. 2, Philadelphia, 1956, W. B. Saunders 1. Archer, H.: A Manual Company. 2. Berger, A.: Arch. Otolaryng. 30: 400-410, 1939. 3. Budge, C. T.: Dent. Survey 27: 953, 1951. 4. Budge, C. T.: J. Oral Burg. 10: 32, 1952. 5. Burland, J. G.: Dent. Pratt. 12: 313.321, 1962. 6. Cohen,L.: ORAL SURG.~~: 409-411,196O. 7. Crolius,W. E.: ORAL SURG.9: 836,1956. 8. Drake, James: Anthropologica Nova, London, 1707, S. Smith and B. Walford, vol. 2. 9. Fallopius, Gabrielis: Observationes Anatomicae, Venice, 15d2. 10. Fickling, B. W.: Brit. Dent. J. 103: 199-214, 1957. 11. Fredrics, H. J., and others: J. Oral Surg. 23: 650-654, 1965. 12. Gerrie, J. W.: J. Amer. Dent. Ass. 22: 731-748, 1935. 13. Grabb, W. C., and Smith, J. W.: Plastic Surgery, ed. 1, London, 1968, J. & A Churchill, Ltd. 14. Guerini, V.: History of Dentistry, Philadelphia, 1909. (Quoted by Gysel.15) 15. Gysel, C.: Janus 54: 262-269, 1967. 16. Harrison, D. F. N.: Brit. J. Clin. Pratt. 16: 169, 1961. 17. Highmore, N.: Corporis humani disquisitio anatomica, The Hague, 1651, S. Broun. 18. Jones, E. H., and Steel, J. S.: Aust. Dent. J. 14: S-11, 1969. 19. Killey, H. G., and Kay, L. W.: Brit. Dent. J. 116: 73-77, 1964. 20. Lee, F. M. 8.: Oral Burg. 29: 491, 1970. 21. Mubeth, Ronald: Arch. Otolaryng. 87: 630-636, 1968. 22. M&lung, E. J., and Chipps, J. E.: U. S. Armed Forces Med. J. 2: 1183, 1951.

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and Craig

Oral Surg. June, 1971

23. Mustian, W. F.: J. Amer. Dent. Ass. 20: 21752187, 1933. 24. Norman, J. E., and Cannon, P. D.: ORAL SURB. 24: 459-467, 1967. 25. Reading, P., Harrison, D. F. N., and Dinsdale, R. C. W.: Brit. Dent. J. 100: 233-238, 1956. 26. Rounds, F. W.: ORAL SURG. 3: 148-156, 1355-136’5, 1950. 27. Steiner. M.: J. Oral Sure: 18: 514-516. 1960. 28. Thoma, Kurt: Oral Su;gery, Ed. 2, ‘St. Louis, 1952, The C. V. Mosby Company. 29. Tomes, J., and Tomes, C. S.: A System of dental Surgery, ed. 4, London, 1897, J. & A. Churchill. Ltd. 30. Tomes, d. S., and Newell, W. 5.: A System of Dental Surgery, ed. 5, London, 1906, J. & A Churchill, Ltd. 31. Vesalius. Andreas: De Humani cornoris fabrica. Basle. 1543. J. Ouorinus. 32. Wakefieid, B. G.: ORAL SURG.3: 713-?21,1950. ’ ’ ’ ’ 33. Wakefield, B. G.: J. Oral Surg. 6: 51-59, lQ48. 34. Wallace, A. F.: Brit. J. P&t. Burg. 19: 322, lQ66. 35. Williams, R. G. : Personal Communication, 1970. 36. Williams, R. G.: Eye Ear Nose Throat Monthly 44: 74, 1965. Reprint

requests to :

Dr. J. E. de B. Norman 32 Railway St. Chatswood, 2067 N. 8. W., Australia