Clinical decision-making algorithm for the management of Oroantral fistula: A comprehensive guide.

Abstract

Oroantral fistula (OAF) is a persistent pathological communication between the oral cavity and the maxillary sinus, often arising as a complication of dental extractions, trauma, or surgical procedures involving the maxilla. Despite various treatment options, a standardized, algorithmic approach remains lacking. To develop and present a comprehensive, evidence-based clinical decision-making algorithm for the diagnosis and management of OAF based on defect size, chronicity, sinus involvement, and infection status. A narrative review and synthesis of the literature were conducted, evaluating diagnostic modalities, microbiological profiles, and both conservative and surgical treatment options from 1990 to 2025. The resulting data informed the development of a stepwise flowchart that integrates clinical parameters and radiographic findings to guide practitioners in selecting the most appropriate therapeutic approach. The algorithm begins with an initial assessment including patient history, clinical and radiographic evaluation. Small asymptomatic OAFs (< 2 mm) are managed conservatively with hygiene protocols and nasal precautions. Infected small fistulas warrant antibiotics. Medium-sized OAFs (5-10 mm) in favorable locations are treated with local flaps, whereas large or unfavorably located fistulas (> 10 mm) require advanced surgical techniques such as buccal fat pad grafts, distant flaps, and regenerative materials like platelet-rich fibrin. Sinus health and chronicity are considered pivotal in determining treatment timing and method. This algorithm provides a structured, patient-centered framework for the management of OAF. By incorporating anatomical, pathological, and microbiological factors, it enhances clinical decision-making, improves treatment outcomes, and supports interdisciplinary coordination.