Removal of maxillary molars occasionally results in comt munication between the oral cavity and the maxillary sinus. If the maxillary sinus is large, if no bone exists between the roots of the teeth and the maxillary sinus, and if the roots of the tooth are widely divergent, then it is increasingly probable that a portion of the bony floor of the sinus will be removed with the tooth. If this complication occurs, appropriate measures are necessary to prevent a variety of sequelae. The two sequelae of most
concern are post operative maxillary sinusitis and formation of a chronic oroantral fistula. The probability that either of these two sequelae will occui is related to the size of the oroantral communication and the management
Qf the exposure. As with all complicatlons. prevention is the easiest and
most efficient method of managing the situation. Preoperative radio graphs must be carefully evaluated for the tooth-sinus relationship whenever maxillary molars are to be extracted. If the sinus floor seems to be very close to the tooth roots and the tooth roots are widely divergent, the surgeon should avoid a closed forceps extraction and perform a surgical removal with sectioning of tooth roots (see Fig. 11-8). Large amounts of force should be avoided in the removal of such maxillary molars (Box 11-8).
Diagnosis of the oroantral communication can be made in several ways: The first is to examine the tooth once it is removed. If a section of bone is adhered to the root ends of the tooth, the surgeon can be relatively certain
that a communication between the sinus and mouth exists. If a small amount of bone or no bone adheres to the molars, a communication may exist anyway. To confirm the presence of a communication, the best technique. is to use the nose-blowing test. Pinching the. nostrils together occludes the patient’s nose, and the patient is asked to blow gently through the nose while the surgeon observes t he area of the tooth extraction. If a communication exists, there will be passage of air through the . tooth socket and bubbling of blood in the socket area.
Prevention of Oroantral Communications
1. Conduct thorough preoperative radio graphic examination. .
2. lJie surgical extraction early and section roots.
3. Avoid excess apical pressure
After the diagnosis of oroantral communication has been established, the surgeon must determine the approximate size of the communication, because the treatment will depend on the size of the opening. If the communication is small (2 mm in diameter or less), no additional surgical treatment is necessary. The surgeon should take measures to’ ensure the formation of a high-quality blood clot in the socket and then advise the patient-to take sinus precautions to prevent dislodgment of the blood clot.
Sinus precautions are aimed at preventing increases or decreases in the maxillary sinus air pressure that would dislodge the dot. Patients should be advised to avoid blowing the nose, violent sneezing, sucking on straws,
and smoking. Patients who smoke and who cannot stop (even temporarily) should be advised to smoke in small puffs, not in deep drags, to avoid pressure changes. The surgeon must not probe through the socket .into
the sinus with a periapical curette or a root tip pick. It is possible that the bone of the sinus has been removed without perforation of the sinus lining. To probe the socket with an instrument might unnecessarily lacerate the membrane. Probing of the communication may also introduce foreign material, including bacteria, into the sinus and thereby further complicate the situation. Probing of the communication is therefore absolutely contraindicated. If the opening between the mouth and sinus is of moderate size (2 to 6 mm), additional measures should be taken. To help ensure the maintenance of the blood clot in the area, a figure-of-eight suture should be placed over the tooth socket (Fig. 11-11). The patient should also be told to follow sinus precautions. Finally, the patient should be prescribed several medications to help lessen the possibility that maxillary sinusitis will occur, Antibiotics, usually penicillin or clindamycin, should be prescribed for 5 days. In addition, a decongestant nasal spray should be prescribed to shrink the nasal mucosa to keep the ostium of the sinus patent. As long as the ostium is patent and normal sinus drainage can occur, sinusitis and sinus infection are less likely. An oral decongestant is also sometimes recommended. If the sinus opening is large (7’mm or larger), the dentist
should consider closing the sinus communication with a flap procedure. This usually requires that the patient be referred to an oral and maxillofacial surgeon, because flap , development and closure of a sinus opening are somewhat complex procedures that require skill and experience. The most commonly used flap is a buccal flap. This technique mobilizes buccal soft tissue to cover the opening and provide for a primary closure. This technique should be performed as soon as possible, preferably
the same day in which the opening occurred. The same sinus precautions and medications are, usually required, . (see Chapter 19)~ The recommendations just described hold true for ‘ patients who have no preexisting sinus disease. If a communication does occur, it is important that t’he dentist inquire specifically about a history of sinusitis and sinus
infections. If the patient has a history of chronic sinus disease, even, ~all oroantral communications will heal . poorly and may result in permanent oroantral communication. Therefore creation of an oroantral communication in patients with chronic sinusitis is cause for referral
to an oral and maxillofacial surgeon for definitive care (see Chapter 19). ,
The -majority of oroantral communications treated in the methods just recommended will heal, uneventfully. Patients should be followed up carefully for several weeks to ensure that this has occurred. Even patients who return within a few’ days with a small communication usually heal spontaneously if no maxillary sinusitis exists. These patients should be followed up closely and referred to an oral and maxillofacial surgeon if the communication persists for longer than 2 weeks. Closure of oroantral fistulae is important because air, water, food, and bacteria go from the oral cavity into the sinus” often causing a chronic sinusitis condition. Additionally, if the patient i~ wearing a full maxillary denture, suction is not as strong; therefore retention of the denture is compromised.