Mouth-antrum connection (MAV) is the term used to describe the open connection of the oral cavity to the maxillary sinus. This can occur during tooth extractions, apicoectomies, or tooth transplants in the maxilla and requires immediate treatment to avoid lengthy and sometimes serious complications.
Symptoms – Complaints
If an oral-antral connection occurs during a tooth extraction, it should be recognized and treated immediately. However, if the MAV remains undetected, maxillary sinus infection occurs and symptoms similar to sinusitis maxillaris (maxillary sinusitis) occur:
- Infraorbital pressure dolence (below the orbit located pressure painfulness ).
- Pain maximum when leaning forward
Pathogenesis (disease development) – etiology (causes)
MAV may occur as a complication after tooth extraction in the maxilla. Due to unfavorable anatomic conditions, it is possible that opening of the maxillary sinus may occur during tooth extraction. This can happen, among other things, if roots are very long and protrude into the maxillary sinus. Pathological processes at the root – for example, periodontitis apicalis or even cysts – also favor the development of oral-antral connections. Other factors that increase the risk of MAV include:
- Root-treated teeth
- Retained (retained) or displaced teeth.
- Tooth transplantation in the maxillary posterior region.
- Root apex resection in the maxillary posterior region.
Consequential diseases
If the opening of the normally sterile maxillary sinus occurs, germs from the oral cavity enter the maxillary sinus and lead to infection. The development of an abscess or fungal infection – aspergilloma – is also possible. Infections can spread via the orbit (eye socket) – orbital abscess, orbitaphlegmone – to the interior of the skull. The most serious complication is infectious sinus cavernosus thrombosis with subsequent septic thrombophlebitis, which can lead to blindness, among other things. Furthermore, there is a risk of teeth or their fragments entering the maxillary sinus – radix in antro – which, if left untreated, will likewise result in infection of the maxillary sinus.
Diagnostics
To determine whether MAV has occurred after extraction of a tooth, there are several diagnostic tools. First, the extraction socket – the now empty tooth socket – is palpated with a probe to locate any openings. Another measure is the so-called nose blow test. In this test, the patient’s nose is held closed and he or she is asked to press air against the nose with the mouth open. If air now escapes from the empty alveolus, there is a MAV. If this is the case, the connection must be closed as soon as possible, but at the latest within 24 hours. If this is not done, there is a risk of maxillary sinus infection. If a tooth has not been completely removed and the root remnant cannot be found, it must be clarified radiographically whether it is a radix in antro. If necessary, diagnostic maxillary sinus irrigation should be performed through the oroantral connection – running from the mouth to the maxillary sinus. In cases of prolonged MAV, the maxillary sinus is inflamed, presenting as unilateral shadowing on radiograph.
Therapy
In case of infection, do not close the maxillary sinus. Signs of infection include pus flow or secretion flow from the MAV. To treat the maxillary sinus, irrigation is performed over the MAV until only clear secretion returns from the maxillary sinus. As a rule, this treatment takes up to 14 days. The mouth-antrum connection can then be closed with a mucosal flap. There are various techniques and removal sites for covering the defect. Among others, mucosa from the oral vestibule or from the palate can be used. If the maxillary sinus is bare (free), plastic coverage is performed directly after opening the maxillary sinus.Flapplasties for MAV coverage
- Trapezoidal flap according to Rehrmann – trapezoidal mucoperiosteal flap (mucosa and periosteum flap) from the vestibule – oral vestibule.
- Mobilization of the Bichat fat plug (cheek fat plug).
- Swing flaps according to Pichler (palatal swing flaps).
The disadvantage of Rehrmann plastic surgery is a subsequent flattening of the maxillary vestibule, which worsens the fit of any prostheses that may be required later and may then necessitate vestibuloplasty. Nevertheless, this is a proven technique that provides primary wound closure and involves only minor surgical effort. The palatal flap provides secure coverage of the MAV in cases of inadequate vestibulum or edentulous patients. If this technique is used, a palatal dressing must be used to protect the exposed bone on the palate after flap mobilization. This epithelializes within several weeks, i.e. the bone is gradually covered again with mucosa. Following plastic coverage, the patient must not blow his nose for about ten days to avoid exposing the mucosal flap to tension and to allow optimal healing. When sneezing, the mouth should be opened for the same reason. After about ten days, the sutures can be removed. If tooth extraction resulted in the displacement of root residues into the maxillary sinus, these must be surgically removed and the maxillary sinus closed, provided that no infection has yet occurred. A prolonged MAV is initially treated like sinusitis maxillares (sinusitis). This includes decongestant nasal drops to improve secretion drainage, inhalation, and heat applications such as red light. In some cases, antibiotic therapy is indispensable. If the infection threatens to spread orbitally (toward the orbit) or intracranially (within the skull), a determination of the pathogen by means of an antibiogram should be made in order to be able to intervene with targeted antibiotics.After the sinusitis has healed, plastic closure can be performed. An oral-antrum junction is a complication of tooth extraction.Once the perforation is covered, it usually heals well and rarely results in further complications.
