Journal of Dental Implant Research 2023; 42(2): 30-34
Particulate ramal bone graft for longstanding oroantral fistula closure on sinusitis
Jeong-Kui Ku , Hoi-Bin Jeong
Department of Oral and Maxillofacial Surgery, School of Dentistry and Institute of Oral Bioscience, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University, Jeonju, Korea
Correspondence to: Jeong-Kui Ku,
Department of Oral and Maxillofacial Surgery, School of Dentistry and Institute of Oral Bioscience, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju 54907, Korea. Tel: +82-63-250-2113, Fax: +82-63-250-2089, E-mail:
Received: June 5, 2023; Revised: June 22, 2023; Accepted: June 22, 2023; Published online: June 30, 2023.
© The Korean Academy of Implant Dentistry. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
An oroantral fistula refers to an abnormal connection between the oral cavity and the maxillary sinus, which can result in chronic maxillary sinusitis. Combining a buccal fat pad and buccal advancement flap has certain limitations when correcting bone defects and providing prosthetic rehabilitation supported by implants. Autografts have been recommended, particularly for larger defects or when conservative methods are ineffective. This case report describes particulate autogenous bone grafts with a pouch graft technique to address a long-standing oroantral fistula and chronic sinusitis that did not improve after endoscopic sinus surgery. The proposed approach using particulate autogenous bone grafts with a pouch graft technique offers a solution for successfully closing the fistula and resolving the symptoms related to sinus issues. Oroantral fistulas need to be managed to prevent complications. Further research will be needed to evaluate the long-term ability of this method to regenerate bone.
Keywords: Bone graft, Oroantral fistula, Sinusitis

Oroantral fistula (OAF) is an unnatural epithelialized communication between the oral cavity and the maxillary sinus. When an oral maxillary sinus fistula occurs, foreign substances and bacteria in the oral cavity enter the maxillary sinus through the fistula and may cause chronic maxillary sinusitis. If inflammation of the maxillary sinus persists, the fistula is not naturally blocked, resulting in a vicious cycle in which sinusitis persists1). If the natural ostium is intact to spontaneous drainage in the sinus cavity, surgical success largely depends on primary closure of the defect.

Although various techniques used to close oroantral fistula include the buccal advancement flap, palatal rotation flap, combination flaps, bone grafts, and buccal fat pad, long-term successful closure of oroantral fistulas is still one of the most difficult problems confronting the surgeon working in the oral and maxillofacial region2). A combination flap of buccal fat pad and buccal advancement has also been utilized, however, this technique can lead to a mucosal healing without correction of the bone defect which makes implant-supported prosthetic rehabilitation very difficult3). If the sinus membrane can be adhered to the gingiva or scar tissue, the second approach become challenging4,5).

Therefore, the use of bone autografts for closing OAFs has been recommended especially for the defects larger than 10 mm or in the case of failure of conservative methods to close the defect6). Block type autogenous bone harvested from alveolar bone, ramus, or iliac crest is effective to reconstruction of maxillary defect and OAF closure. A monocortical block graft is harvested by using a burr with matching the size of the round bony defect. However, considerable effort is required to match the size, and in some cases, block bones require additional treatment for fixation. A sandwich or pouch graft technique, wrapping bone substitutes by using absorbable collagen membrane, yielded a more promising closure of OAF by provision of a more biologically apt base in terms of regeneration of lost bone structure at the floor of the maxillary sinus7,8). The aim of this case report is to suggest particulated autogenous bone graft with pouch graft technique to address disadvantage of block-type autogenous bone and to enhance bone quality and rapid bone healing.


A 51-year-old female healthy patient presented with a persistent foul odor and pus discharge from the right side of her mouth, which began after implant treatment two years ago. She had previously undergone endoscopic sinus surgery a year ago, but continued to experience the symptoms. Radiographic images confirmed a mucosal thickening on maxillary ostium and revealed sinusitis on the right side and a bone defect in the area of teeth #16-17 (Fig. 1). She reported that one implant fixture was removed during the initial implant treatment due to poor bone quality.

Figure 1. Pre-operative radiographs. (A) panoramic view showed alveolar bone defect on #16-17 with right sinus haziness. (B, C) Oroantral fistula (arrows) and intact natural ostium (*) were observed in CBCT.

The author suspected the presence of an oroantral fistula, which was concealed by the prosthesis, so the prosthesis was removed first. Upon oral examination, a small fistula was observed, but it was not of significant size (Fig. 2A). Considering the oral symptoms were likely caused by the defect in the maxillary bone, autogenous bone grafting was planned. She was prescribed Pseudoepedrine HCl 60 mg tid (Koreapharma., Seoul, Korea), Roxithromycin 150 mg bid (Ildong Pharma., Seoul, Korea), Acetaminophen 350 mg tid (Bukwang Pharma., Seoul, Korea), Almagate 500 mg bid (Yuhan Pharma., Seoul, Korea) for one month before the surgery and one week after the surgery.

Figure 2. Intra-oral images. (A) Small fistula (arrow) was observed on the gingiva under the prosthesis. (B) Gingiva was dissected from the maxillary sinus Schneiderian membrane. (C) The membrane was gently elevated without further tearing.

Under general anesthesia, caution was taken to gently detach the scar tissue adhering to the gingiva (Fig. 2B). The maxillary Schneiderian membrane was lifted with additional ostectomy (Fig. 2C). The author utilized a recently suggested harvesting technique, which involved making sagittal, coronal, and axial osteotomies with micro-saws to acquire cortical bone chips in a grid pattern. The harvested cortical bones were then crushed using a bone mill into fragmented bone particles (Fig. 3A∼C)9). To ensure the stability of the graft, a pouch-type graft with a collagen membrane (Remaix, Matricel GmbH, Herzogenrath, Germany) was performed by wrapping the autogenous bone to cover both the sinus membrane and the gingiva sides (Fig. 3D). The wound was closed with interrupted sutures using 4/0 Vicryl (Ethicon/Johnson-Johnson, New Brunswick, NJ) and horizontal mattress sutures using 3/0 Prolene (Ethicon/Johnson-Johnson) (Fig. 3E). The wound healed without any complications (Fig. 3F). The sinus-related symptoms were resolved (Fig. 4A, B), and the prosthesis was reinstalled two weeks after the surgery. The bone graft showed stable results at two months postoperatively (Fig. 4C). She has not reported any recurrence symptoms related her sinus.

Figure 3. Intra-operative images. (A) Ramal bone was exposed on the right posterior mandible. (B) Cortical bone was harvested without bone marrow invasion. (C) The cortical bone was crushed into the particle sized at 300∼800 µm by using a bone crusher. (D) The autogenous bone particles (*) were grafted by wrapped with an absorbable membrane (arrow). (E) Primary closure was achieved. (F) Wound was complete healed at one week after the surgery.

Figure 4. Post-operative radiographs. (A, B) CBCT showed improved sinus condition and well-maintained bone grafts at two weeks after surgery. (C) At 2 months postoperative x-ray, there was no the sinus related symptoms.

The management of oroantral fistula (OAF) poses a significant challenge to oral and maxillofacial surgeons. Various techniques have been employed to close OAFs, including buccal advancement flap, palatal rotation flap, combination flaps, bone grafts, and buccal fat pad10). However, long-term successful closure with only soft tissue closure remains elusive. In this case, the author utilized an autogenous bone graft to resolve the long-standing oroantral fistula with sinusitis. To overcome the drawbacks of block-type autogenous bone grafts, the author used particulated bone with a pouch graft technique11,12). The graft was then wrapped with an absorbable membrane, resulting in successful closure of the fistula and resolution of sinus related symptoms.

The successful closure of the OAF not only alleviated the patient's symptoms but also allowed for the reinstallation of the prosthesis. It is crucial to promptly address OAFs to prevent complications such as chronic sinusitis due to the persist invasion of the oral bacteria. Specifically, when suturing OAF with soft tissue, clinicians face the challenge of prolonged treatment duration due to the difficulty of treating additional bone defects that needed additional graft surgery for implant placement including sinus lift through the dissection between the adhesion on the schneiderian membrane and gingiva13,14). As autogenous bone is the most recommended option, extensive research has been conducted on its use for closing oroantral fistulas. To ensure graft stability, surgeons should carefully design the size of the harvested autogenous bone to precisely fit the defect and secure it with screws and platelet-rich fibrin11,12,15,16). The method described in this manuscript could offer better accessibility by utilizing autogenous bone regardless of the defect size and applying it with the collagen membrane. However, complete coverage of the graft may impede blood supply and result in incomplete graft incorporation17). Since this patient did not undergo additional implant surgery at the bone graft site, the histological confirmation of the bone graft's outcome could not be obtained. Nevertheless, even in the presence of maxillary sinusitis, the autogenous bone grafts demonstrated effective filling of the bone defect without any side effects such as infection. Further studies will be required to assess the bone regeneration capability for implant placement with particulated autogenous bone graft using this technique.


This case report demonstrates the successful closure of an oroantral fistula using a particulated autogenous bone graft with a pouch graft technique. This approach addressed the limitations of block-type autogenous bone grafts and resulted in the resolution of sinus-related symptoms. Prompt management of oroantral fistulas is crucial to prevent complications and the proposed technique offers an accessible and effective solution for closing these fistulas. Further research is needed to evaluate the long-term bone regeneration capability of this method.

  1. Galli M, De Soccio G, Cialente F, Candelori F, Federici FR, Ralli M, et al. Chronic maxillary sinusitis of dental origin and oroantral fistula: The results of combined surgical approach in an Italian university hospital. Bosn J Basic Med Sci 2020;20:524-30.
    Pubmed KoreaMed CrossRef
  2. Procacci P, Alfonsi F, Tonelli P, Selvaggi F, Menchini Fabris GB, Borgia V, et al. Surgical Treatment of Oroantral Communications. J Craniofac Surg 2016;27:1190-6.
    Pubmed CrossRef
  3. Franco Carro B, Barona Dorado C, Martínez González MJS, Rubio Alonso LJ, Martínez González JM. Meta-analytic study on the frequency and treatment of oral antral communications. 2011.
    Pubmed CrossRef
  4. Wang D, Tian J, Wang Y, Wei D, Lin Y. Clinical and radiographic outcomes of reentry lateral sinus floor elevation after a complete membrane perforation. Clin Implant Dent Relat Res 2020;22:574-81.
    Pubmed CrossRef
  5. Mardinger O, Moses O, Chaushu G, Manor Y, Tulchinsky Z, Nissan J. Challenges associated with reentry maxillary sinus augmentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:287-91.
    Pubmed CrossRef
  6. Proctor B. Bone graft closure of large or persistent oromaxillary fistula. Laryngoscope 1969;79:822-6.
    Pubmed CrossRef
  7. Hariram, Pal US, Mohammad S, Singh RK, Singh G, Malkunje LR. Buccal fat pad versus sandwich graft for treatment of oroantral defects: A comparison. Natl J Maxillofac Surg 2010;1:6-14.
    Pubmed KoreaMed CrossRef
  8. Baek JH, Kim BO, Lee WP. Implant Placement after Closure of Oroantral Communication by Sinus Bone Graft Using a Collagen Barrier Membrane in the Shape of a Pouch: A Case Report and Review of the Literature. Medicina (Kaunas) 2021;57.
    Pubmed KoreaMed CrossRef
  9. Ku JK, Ghim MS, Park JH, Leem DH. A ramus cortical bone harvesting technique without bone marrow invasion. Journal of the Korean Association of Oral and Maxillofacial Surgeons 2023;49:100-4.
    Pubmed KoreaMed CrossRef
  10. Parvini P, Obreja K, Sader R, Becker J, Schwarz F, Salti L. Surgical options in oroantral fistula management: a narrative review. International Journal of Implant Dentistry 2018;4:40.
    Pubmed KoreaMed CrossRef
  11. Haas R, Watzak G, Baron M, Tepper G, Mailath G, Watzek G. A preliminary study of monocortical bone grafts for oroantral fistula closure. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:263-6.
    Pubmed CrossRef
  12. Park WB, Xu Z, Lim HC, Kang P. Successful Management of Late Sinus Graft Infection via Functional Endoscopic Sinus Surgery and Press-fit Block Bone Graft: A Case Report. J Oral Implantol 2023. doi:10.1563/aaid-joi-D-22-00112.
    Pubmed CrossRef
  13. Liversedge RL, Wong K. Use of the buccal fat pad in maxillary and sinus grafting of the severely atrophic maxilla preparatory to implant reconstruction of the partially or completely edentulous patient: technical note. Int J Oral Maxillofac Implants 2002;17:424-8.
  14. Kraut RA, Smith RV. Team approach for closure of oroantral and oronasal fistulae. Atlas Oral Maxillofac Surg Clin North Am 2000;8:55-75.
  15. Scattarella A, Ballini A, Grassi FR, Carbonara A, Ciccolella F, Dituri A, et al. Treatment of oroantral fistula with autologous bone graft and application of a non-reabsorbable membrane. Int J Med Sci 2010;7:267-71.
    Pubmed KoreaMed CrossRef
  16. Kapustecki M, Niedzielska I, Borgiel-Marek H, Różanowski B. Alternative method to treat oroantral communication and fistula with autogenous bone graft and platelet rich fibrin. Med Oral Patol Oral Cir Bucal 2016;21:e608-13.
    Pubmed KoreaMed CrossRef
  17. Pikos MA. Maxillary sinus membrane repair: update on technique for large and complete perforations. Implant Dent 2008;17:24-31.
    Pubmed CrossRef

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