From Volume 48, Issue 6, June 2021 | Pages 487-491
Oro-antral communication is a well-recognized complication of dental extractions in the maxilla, but is rarely reported to occur from periodontal causes. This article describes the formation of an oro-antral communication following non-surgical periodontal therapy, and its subsequent management.
In this article, we report a case of oro-antral communication following non-surgical periodontal therapy. Oro-antral communication most commonly occurs during extraction of upper molar and premolar teeth due to the proximity of the roots of these teeth to the antral floor.1,2 The average distance of apices of maxillary molars from the sinus floor has been reported as 1.97 mm.3 Other well-accepted causes of an oro-antral communication include: tuberosity fracture; peri-apical infection; trauma; displacement of an implant or apex of a root into the antrum; maxillary cysts or tumours; osteoradionecrosis; and medicine-related osteonecrosis.4,5
Oro-antral communication may lead to significant complications and may have a considerable impact on quality of life. Consequent acute maxillary sinusitis with pain and discharge, that may potentially lead to serious complications, is common.6,7,8,9 When a communication persists, maxillary sinusitis may become intractable. However, symptoms may be less severe over time, reflecting a change to a chronic state. There is debate in the literature between conservative and surgical management of oro-antral communication, and evidence for definitive approaches is lacking.10 In many cases, small communications (<5 mm), in the presence of a healthy sinus may heal spontaneously and may occur more commonly than recognized. Larger communications typically require repair.11,12 Surgical splints can be used to keep the site clean and reduce symptoms during conservative management.13 Approaches for repair of an oro-antral communication all involve placing a material to fill the defect, and range from classical soft tissue with buccal or palatal advancement flaps, through fat pad grafts, to the use of autologous, allogeneous grafting materials, or xenografts.4,11,14
A literature review revealed a report of formation of an oro-antral communication believed to be a consequence of untreated chronic periodontitis, and a case of maxillary sinusitis and oro-antral communication following surgical periodontal therapy.15,16 However, to the authors' knowledge, there are no reports in the literature of an oro-antral communication following non-surgical periodontal management.
The patient, a 34-year-old male, was initially referred to the restorative department for management of localized periodontitis associated with the upper left first molar (UL6). The patient reported a history of root surface debridement at his dental practice every 3 months in this area. His oral hygiene regimen consisted of brushing his teeth twice daily, with supplementary use of interdental brushes. Medically, the patient reported an allergy to penicillin, hay fever, and asthma controlled by salbutamol inhaler as required. On examination, his oral hygiene was found to be good with minimal bleeding on probing and a BPE score of:
| 1 | 1 | 4 |
| 1 | 0 | 1 |
The UL6 had a deep mesio-palatal pocket with subgingival calculus detected and absence of bleeding on probing. The tooth was mesially inclined and mild spacing noted in the sextant. Radiographic examination showed a wide infrabony defect with a 60% vertical component and the appearance of diffuse bone loss (Figure 1). No peri-apical pathology was noted.
A diagnosis of localized aggressive periodontitis associated with the UL6 was made. The treatment plan consisted of oral hygiene instruction for interdental brush resizing, baseline periodontal indices and root surface debridement (RSD) of the UL6 under local anaesthetic. Review for subsequent use of adjunctive systemic antimicrobials was arranged on the specialty training clinic.
The first course of RSD proceeded uneventfully. At the 3-month periodontal reassessment, the bitewing radiograph obtained suggested a reduction in the bony defect, but without resolution (Figure 2). Further RSD and insertion of a Periochip (Dexcel Pharma, UK) in the mesio-palatal pocket of the UL6 was arranged. At this appointment, following subgingival calculus removal, probing depth of 13 mm and grade II mesio-palatal furcation involvement of UL6 was recorded, and a Periochip was placed. Additionally, a sharp ridge was noted on the palatal aspect of the mesio-buccal root.
The patient contacted the department later in the day to report that he was finding liquids to be passing from his mouth to his nose. He was reviewed urgently with additional input from an oral surgeon. The patient later mentioned that he had experienced a sensation of ‘drowning’ during the most recent ultrasonic debridement. There was an absence of swelling or discharge associated with the UL6, but the symptoms clearly suggested a diagnosis of oro-antral communication and conservative management in the interim was advised.
Arrangements were made by the oral surgery department for cone beam computed tomography (CBCT) of the UL6 region to assess the local anatomy and to aid treatment planning.
The imaging showed mild crestal periodontal bone loss with a mesial angular bony defect associated with the UL6. The left maxillary sinus was well pneumatized, invading the alveolus to expose the roots of the molar teeth. Mesial to the UL6 roots, the sinus floor was particularly thin, with a 3x3 mm focal break at the palatal aspect of the mesio-buccal root and mesial to the palatal root. There was evidence of an extensive inflammatory response within the antrum, and a radio-opacity lying horizontally between the UL5 and UL6 was noted (Figure 3).
The patient reported that he had experienced recurrent chronic sinusitis in the interim, which had been managed by his medical practitioner with multiple courses of clarithromycin and doxycycline. His last episode had resulted in trismus, swelling and discharge from the area. He reported, however, that he was no longer experiencing fluid exchange from his mouth to his nose and was now able to drink through a straw. Clinically, a deep periodontal pocket could be probed at the mesio-palatal surface of the UL6 (Figure 4).
The symptoms experienced by the patient were severe and repetitive, and a strong indicator for intervention with a surgical approach. Treatment options broadly discussed were surgical repair of the defect or extraction of the tooth with subsequent alveolar repair. However, extraction would produce a large defect in the floor of the antrum that would be difficult to repair. Consequently, exploration of the defect with localized repair by grafting was planned.
Under local anaesthetic, a two-sided, full thickness mucoperiosteal flap was raised with excision of the fistulous epithelial tract. Curettage of the surrounding bone was completed as well as root surface debridement. Clinically, there was a distinct communication from the oral cavity into the sinus from the mesio-palatal aspect of the UL6, with no exudate or fluid excretion.
The radiopaque body observed on imaging was retrieved from the site, and sent to histopathology for examination, revealing the tissue fragment to have an appearance more in line with cementum than bone. This cementum fragment may have inhibited healing and contributed to the chronic infection in the area, as well as being a local aggravating factor for the occurrence of localized periodontitis.
A bovine-derived xenograft, Bio-Oss (Geistlich, UK), was placed into the defect to facilitate bone regeneration, and the soft tissue repair was achieved with primary closure of the site using simple interrupted sutures (Figure 5). A membrane was not placed at this time. Conventional post-operative instructions and antibiotics were given.
At the 4-week follow-up, the patient's symptoms of sinusitis had resolved, and there was an absence of fluid passage between oral and nasal cavities. The 4-month follow-up and repeat CBCT showed closure of the communication with partial bony infill, and a soft tissue seal (Figure 6). The inflammatory changes in the antrum had largely resolved, with minor thickening only at the site of the communication. Review of the pre- and post-repair CBCTs obtained by the oral surgery team, highlighted the presence of the root cementum defect in the form of a spur.
An odontogenic origin for maxillary sinusitis is well known, although this is commonly related to peri-apical pathology.17,18 Sinusitis as an extension of periodontal disease into the maxilla has been previously suggested, with pervasive extension of inflammatory infiltrates found on histopathology in the antral lining in those with moderate to severe periodontal disease.19,20 CBCT imaging has been shown to be accurate in assessing bone defects in periodontal disease, and a useful resource in guiding periodontal therapy in areas in close proximity to the maxillary sinus.16,21 However, given the limited additional diagnostic yield compared to clinical assessment and conventional intra-oral radiographs, the routine use of CBCT cannot be justified, given that sinus complications following periodontal disease and therapy are exceptionally rare.
In this case, in the first instance, repair of the defect with a xenogenous bone graft was the treatment of choice. This technique has been previously documented for successful repair of oro-antral communications following exodontia.22,23 Although successful outcomes of bone grafting without the use of a membrane for tissue regeneration have been reported, in retrospect, the use of a membrane may have enhanced bony regeneration at the site.24 The benefit of this technique compared to conventional buccal advancement flap closure in this case is primarily the opportunity to maintain the UL6 in the dentition. Extraction of the tooth and subsequent creation of a vast defect would make repair of an oro-antral communication extremely difficult, with a high likelihood of subsequent repeated breakdown and chronic infection. In reality, design of a suitable flap for a conventional non-graft approach would be impossible in this particular set of circumstances.
This case highlights that extraction, although the most common aetiology of oro-antral communication is not a prerequisite of the condition. Diagnosis of oro-antral communication should be made based on clinical signs and reported symptoms, and the chosen surgical intervention should aim to resolve these signs and symptoms. This may require a surgical graft approach given that in these situations, the associated tooth remains in the dentition.
For this patient, the resolution of sinus symptoms was a priority, after having had significant and repeated symptoms. The absence of sinus infection over a 4-month period post-operatively indicates a positive outcome in this case. However, although the tooth is asymptomatic, deep periodontal probing depths remain and so the prognosis is guarded. Long term, should sinus symptoms recur, extraction of UL6 and conventional repair of the defect will remain as a management option.
This article reports on the formation of an oro-antral communication following non-surgical periodontal therapy in a patient with localized periodontitis and aberrant root morphology, later confirmed to be a root cementum spur. There are no other recorded cases in the literature.
Oro-antral communication formation should be considered a rare, but significant, risk of non-surgical periodontal therapy in deep vertical bony defects of maxillary posterior teeth, where the floor of the maxillary antrum is in close approximation to the base of the periodontal defect. Xenografting in this case allowed maintenance of the tooth in the arch and the elimination of recurrent maxillary sinusitis.
