957 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu Effectiveness of Calcium Sulfate Bone Graft with Platelet Rich Fibrin in Oroantral Fistula Closure Mahmoud Altabba, Issa Wehbeh, Ahmad Alnada Faculty of Den.stry, Damascus University, Syria Abstract Objec6ve: Oroantral communicaDon is a common complicaDon observed following the ex- tracDon of posterior maxillary teeth, oOen causing concern for both paDents and general pracDDoners. Various methods are employed to close these communicaDons. To idenDfy a closure technique with minimal complicaDons that is rapid and easily applicable by general pracDDoners, we evaluated the effecDveness of using calcium sulfate graO material mixed with platelet-rich fibrin, followed by clinical and radiographic assessment of closure success. Material and Methods: A moderate-sized oroantral communicaDons resulDng from recent tooth extracDons was radiographed to confirm the size and dimensions of the communica- Don. Subsequently, a 20 ml blood sample was collected from the paDent and centrifuged to obtain two tubes containing platelet-rich fibrin. Using the first tube, a platelet-rich fibrin plug was formed, applied, and sutured at the site of the communicaDon. Calcium sulfate graO material was then applied aOer being mixed with the platelet-rich fibrin clot from the second tube. The paDent was followed up at intervals of: day one, day three, one week, two weeks, and six months. Results: We showed successful closure of oroantral communicaDons in this case, with clinical and radiographic follow-up for 6 months post-procedure. Conclusion: Within the limitaDons of this study, it can be concluded that the technique of using calcium sulfate graO material with plate- let-rich fibrin is a successful, cost-effec- Dve, and easily applicable method for managing moderate-sized oroantral communicaDons. Open Access Cita%on: Altabba M, et al. (2025) Effec%veness of Cal- cium Sulfate Bone GraC with Platelet Rich Fibrin in Oro- antral Fistula Closure. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.957 Received: June 6, 2025 Accepted: June 26, 2025 Published: August 13, 2025 Copyright: ©2025 Altabba M, et al. This is an open ac- cess ar%cle licensed under a Crea%ve Commons AXribu- %on Work 4.0 United States License. Email: Mahmoud.tabba@damascusuniversity.edu.sy Introduc)on Oroantral communication (OAC) is an abnor- mal communication that results from the loss of both soft and hard tissues separating the oral cavity from the maxillary sinus [1]. The Birst signs that may indicate the occur- rence of an oroantral communication include the presence of signiBicant bleeding or an air bubble in the extraction socket of the re- moved tooth. The Valsalva test is a conBirma- tory diagnostic tool for this communication, as it causes air to escape through the alveolar socket [2]. There are numerous techniques described in the medical literature for the closure of this communication, each with its own indica- tions, advantages, and disadvantages. These include vestibular Blap displacement, rotational palatal Blap, and cheek fat pad with a pedicle Blap [3]. The sizes of oroantral openings have been classiBied by James Hupp into small (diame- ter < 3 mm), medium (3–6 mm), and large (> 6 mm) openings [4]. Small openings can heal spontaneously if their diameter is less than 2 mm [5], and the use of a Gelfoam, secured with sutures in the socket containing the communication in an "8" shape, may also help ensure complete closure [6]. On the other hand, openings larger than 2 mm but smaller than 5 mm have not been shown to close spontaneously without any intervention, according to a sys- tematic review conducted by Visscher [7]. If the oroantral communication remains open for more than 48 hours, it may lead to the formation of a oroantral Bistula, as the tract becomes lined with epithelial tissue, which increases the risk of maxillary sinus infections [1]. Several techniques have been proposed for closing oroantral communications, all of which primarily involve the closure of soft tissues [8]. Most of the methods for closing maxillary si- nus openings have focused on achieving clo- sure and preventing the formation of an oro- antral Bistula. However, with the develop- ment of biologically acceptable materials and the improvement of their physical and biological properties, it has become possible to focus on controlling both the short- and long-term outcomes of such closures, while minimizing the number of surgical proce- dures required and reducing their complica- tions and negative effects. EffecDveness of Calcium Sulfate Bone GraO with Platelet Rich Fibrin in Oroantral Fistula Closure Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu 2 Material and Methods Intervention A non-smoker 30-year-old-female patient was referred to the department of oral and maxillofacial surgery at the faculty of dentis- try, Damascus University in 8/2024. The main complaint was pain related to the tooth 26. Intraoral examination revealed badly de- cayed tooth indicated for extraction. Radiographic examination (Figure 1) re- vealed the presence of a long palatal root that might have been involved within the maxillary sinus. After taking the patient's medical history, it was determined that there was no contraindication to extracting the af- fected tooth. The roots were separated indi- vidually, and then the roots were extracted sequentially. To ensure the integrity of the maxillary sinus, we performed the Valsalva maneuver, which showed the release of air bubbles from the extraction site. When the area was rinsed with saline, Bluid leakage from the oral cavity into the maxillary sinus and then into the nose was observed (Figure 2). A 3D image was taken, which revealed an opening in the maxillary sinus from the pala- tal root measuring an average of 4 mm. The case was reviewed and approved by the local research ethics committee at Damascus university (No: 032024866). A Written in- formed consent was obtained for publication of this report and accompanying images. Pre-Surgical Phase Patient Interview A comprehensive clinical history was ob- tained from patients visiting the Oral and Maxillofacial Surgery Department at the Fac- ulty of Dentistry, Damascus University, who had undergone extraction of a maxillary pos- terior tooth and developed an oroantral com- munication. This included the patient's per- sonal information, general medical history, and dental history. Clinical and Radiographic Examination Before the Procedure A thorough examination of the extraction site was performed, and oroantral communica- tion was clinically conBirmed by conducting the Valsalva maneuver, along with a test for Bluid passage from the oral cavity to the nasal cavity using a syringe and saline solution. The size of the communication was then as- sessed, and its compliance with inclusion cri- teria was veriBied radiographically through three-dimensional cone beam computed to- mography (CBCT) imaging (Figure 3). Surgical Phase Patient Preparation and Site Preparation (Figure 4) Initially, 20 mL of venous blood was drawn from the patient and divided into two glass tubes, each with a capacity of 10 mL. These tubes are speciBically designed for the prepa- ration of platelet-rich Bibrin (PRF). The tubes were placed in a centrifuge and spun at 2700 RPM for 12 minutes [9]. After centrifugation, each tube separates into three distinct layers: • Red Blood Cell Layer (RCL): The layer of red blood cells appears at the bottom of the tube. • Platelet-Rich Fibrin (PRF) Layer: The middle layer, which contains the Bibrin matrix enriched with platelets. • Platelet-Poor Plasma (PPP): The top layer, which is plasma with a low platelet count. The PRF gel is then extracted from the tube and separated from the red blood cells. To prepare the PRF plug, the Birst tube is used, and the PRF gel is placed in a cylinder within the PRF box. It is gradually compressed using a piston to obtain the Binal PRF plug. After anesthetizing the patient, the area of oroantral communication is examined. Gran- ulation tissue is removed if more than 24 hours have passed since the tooth extraction. The edges of the extraction socket are care- fully inspected, and the socket is irrigated us- ing a saline solution. Preparation of Calcium Sulfate Graft and Mixing with Platelet-Rich Fibrin (PRF) (Figure 5) The calcium sulfate graft is prepared by mix- ing the fast-set liquid with the powder to achieve the desired paste-like consistency, according to the manufacturer's instruc- tions. The mixture is then placed into the designated grafting tray. Subsequently, the graft is combined with pieces of platelet-rich Bibrin (PRF) obtained from the second tube after compressing the PRF gel using the PRF box. Application of Platelet-Rich Fibrin Plug and Mixed Graft The PRF plug is prepared Birst. Using 3/0 pol- yglactin (Vicryl) suture, a needle is passed through the vestibular gingiva, then through one side of the plug, and Binally through the palatal gingiva without tying any knots, en- suring no Blaps are raised. The PRF plug is then gently inserted into the area of oroantral communication. The ends of the suture are held to prevent the plug from displacing into the maxillary sinus. (Figure 6). After sealing the communication with the PRF plug, the mixed graft is applied gently over it until the entire socket is Billed. The su- ture is then tied to secure the graft in place. Then, we wait for 2 to 4 minutes while apply- ing proper isolation with sterile gauze until the graft solidiBies. Afterward, the graft is left exposed to the oral cavity without being cov- ered by any membrane. The patient is in- structed to bite down on a sterile gauze pad for one hour. Post-Surgical Phase In addition to the conventional post-extrac- tion instructions, the following strict guide- lines are provided: 1. Avoid eating or drinking during the Jirst two hours post-surgery. After that, only liquids should be consumed for the Birst 48 hours (liquid diet), ensuring that they are not hot. 2. Avoid rinsing the mouth for the Jirst 48 hours and stay away from all irritant odors. 3. Avoid using plastic straws for drinking during the week following sur- gery to prevent negative pressure, which can negatively affect the surgical site. 4. Avoid violent sneezing and force- ful expulsion of nasal secretions. If this is necessary, the patient should keep the mouth open during sneezing to prevent sudden pressure increases within the maxillary si- nus. 5. Do not use wind instruments or whistle. 6. Regular follow-up appointments are necessary for monitoring. The patient is given a prescription for a set of medications, provided there are no contrain- dications. The prescription includes: Rx I. Augmentin (Amoxicillin + Clavulanic Acid) 1000mg Tab, twice daily. Take one tablet every 12 hours for seven days. II. Ibuprofen 400mg Tab, three times daily. Take one tablet every 8 hours after meals for two days. III. Oxymetazoline HCL 0.05%. Spray in the nostril corresponding to the side of the oroantral communication, three times a day for Bive days. EffecDveness of Calcium Sulfate Bone GraO with Platelet Rich Fibrin in Oroantral Fistula Closure Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu 3 Clinical and Radiological Follow-up The patient is clinically evaluated at intervals (second day, third day, one week, and two weeks) post-surgery(Figure 7). Healing is monitored and graded on a scale from 1 to 5 according to the Landry criteria. Radiological evaluation is performed using cone-beam computed tomography (CBCT) imaging 6 months after the procedure. Results The application of this method showed suc- cessful closure of oroantral communication clinically and radiographically after 6 months of follow-up. Discussion Maxillary sinus perforation is considered one of the potential complications following the extraction of maxillary posterior teeth. The incidence of oroantral communication (OAC) following extractions in the posterior maxilla ranges from 0.31% to 4.79% [5]. Platelet-rich Bibrin (PRF) is a Bibrin-based bi- omaterial that promotes angiogenesis and directs epithelial cell migration across its surface. It accelerates wound healing and provides protection for the surgical site [10]. The objective of this case report was to eval- uate the efBicacy of platelet-rich Bibrin com- bined with calcium sulfate graft material in the closure of oroantral communication post-extraction of maxillary posterior teeth, as well as in the preservation of the alveolar ridge. PRF was chosen due to its richness in growth factors, cytokines, and platelets that enhance both soft and hard tissue healing [11]. Calcium sulfate was selected as a bio- compatible material with a well-documented history of clinical use. It has been employed in periodontal regeneration, endodontic re- pair, alveolar bone resorption cases, and si- nus augmentation procedures. However, to date, it has not been reported in the closure of oroantral communication [12]. Moreover, calcium sulfate forms a barrier against Bibro- blast migration, eliminating the need for membrane application or Blap elevation fol- lowing graft placement [12,13]. The success of OAC closure was conBirmed using the following criteria: • Valsalva maneuver test with obser- vation of air bubble leakage. • Presence of Bluid leakage through the nose. • Necessity for a second surgical in- tervention. • Development of an oroantral Bis- tula. Cone-beam computed tomography (CBCT) imaging was performed at two time points: pre-operatively and six months post-proce- dure. Changes in alveolar ridge height and width were monitored, in addition to as- sessing radiographic bone density at the OAC site. After six months, radiographic density ranged between 570 HounsBield Units (HU) and 919 HU, with a mean value of 785.91 HU, consistent with D3 bone quality. This indi- cates a substantial improvement in bone ra- diodensity attributed to the combined use of PRF and calcium sulfate. This radiodensity enhancement may be due to PRF’s contribution to increasing bone den- sity through the presence of growth factors, such as transforming growth factor (TGF), which stimulates osteoblast proliferation during normal socket healing. Furthermore, the Bibrin scaffold promotes neovasculariza- tion, supports immune cell activity, and re- duces inBlammation. Calcium sulfate also plays a critical role, as its dissolution in- creases local calcium ion concentrations, stimulating osteoblastic activity [14]. Addi- tionally, it lowers the pH upon resorption, fa- cilitating the release of bone morphogenetic proteins (BMPs) from adjacent bone. This is followed by the formation of hydroxyapatite carbonate layers like natural bone mineral, which later remodels during bone matura- tion [12]. Historadiographic studies have shown that calcium sulfate grafts are fully re- sorbed within nine months and replaced by mature lamellar bone [15], indicating its sig- niBicant role in bone regeneration [13]. Minor reductions in both vertical and hori- zontal dimensions of the alveolar ridge were observed six months post-closure compared to pre-operative values. This suggests that the combination of calcium sulfate and PRF effectively minimized, but did not entirely prevent, post-extraction bone resorption. Finally, a significant reduction in the radio- graphic diameter of the oroantral communi- cation was observed six months post-graft- ing, decreasing from 4 mm to 0 mm. Statisti- cal analysis revealed a significant difference between pre- and post-grafting OAC diame- ters, confirming the clinical effectiveness of the applied treatment. Conclusions The application of calcium sulfate and PRF clot led to a complete closure when treating oroantral communication. References 1.Krishanappa, S. K. K., Prashanti, E., Sumanth, K. N., Naresh, S., Moe, S., Aggarwal, H., & Mathew, R. J. (2016). Interventions for treating oro-antral com- munications and Nistulae due to dental procedures. Cochrane Database of Systematic Reviews (5). ,1- 16. 2.Fragiskos, F. (2007). Perioperative and postop- erative complications Oral Surgery (pp. 181-203): Springer. 3.Fatani, B., Fatani, A., & Alomar, A. (2020). Oro- Antral Communication and Fistula: A Review of the Literature, Saudi Journal of Oral and Dental Re- search, e3-e9. 4.Hupp, J. R., Tucker, M. R., & Ellis, E. (2013). Con- temporary Oral and maxillofacial surgery-E-book: Elsevier Health Sciences.,123-131. 5. Mourão, C. F. d. A. B. (2019). Which treatments are best for oro-antral Nistulae? Evidence-based dentistry, 20(2), 44-45. 6. Le, B. T., & Woo, I. (2007). Management of com- plications of dental extractions. A peer reviewed publication.,4-16. 7. Visscher, S. H., van Minnen, B., & Bos, R. R. (2010). Closure of oroantral communications: a review of the literature. Journal of oral and maxil- lofacial surgery, 68(6), 1384-1391. 8. Sandhya, G., Reddy, P. B., Kumar, K. J., Reddy, B. S., Prasad, N., & Kiran, G. (2013). Surgical manage- ment of oro-antral communications using resorb- able GTR membrane and FDMB sandwich tech- nique: a clinical study. Journal of maxillofacial and oral surgery, 12(3), 254-259. 9.Ghanaati, S., Booms, P., Orlowska, A., Kubesch, A., Lorenz, J., Rutkowski, J., Landes, C., Sader, R., Kirk- patrick, C., Choukroun, J. 2014. Advanced platelet- rich Nibrin: a new concept for cell-based tissue en- gineering by means of inNlammatory cells. J Oral Implantol, 40, 679-89. 10.Shah, R., Thomas, R., & Mehta, D. (2017). An Up- date on the Protocols and Biologic Actions of Plate- let Rich Fibrin in Dentistry. The European journal of prosthodontics and restorative dentistry, 25(2):64-72. 11.Caruana, A., Savina, D., Macedo, J. P., & Soares, S. C. (2019). From Platelet-Rich Plasma to Ad- vanced Platelet-Rich Fibrin: Biological Achieve- ments and Clinical Advances in Modern Surgery. Eur J Dent, 13(2):280-286. 12.Gupta H, Pandey A, Agarwal R, Mehra H, Gupta S, Gupta N, et al. (2024). Application of calcium sul- fate as graft material in implantology and maxillo- facial procedures: A review of literature. Natl J Maxillofac Surg; 15:183-7. 13.Yahav, A., Kurtzman, G. M., Katzap, M., Dudek, D., & Baranes, D. (2020). Bone Regeneration: Prop- erties and Clinical Applications of Biphasic Cal- cium Sulfate. Dental Clinics; 64(2), 453-472. 14.Boyle KK, Sosa B, Osagie L, Turajane K, Bostrom MP, Yang X. (2019). Vancomycin-laden calcium phosphate-calcium sulfate composite alloes bone formation in a rat infection model. PloS One;14:e0222034. 15.Laino, L., Troiano, G., Giannatempo, G., Graziani, U., Ciavarella, D., Dioguardi, M., Lo Muzio, L., Lauri- tano, F., Cicciu, M. (2015a). Sinus Lift Augmenta- tion by Using Calcium Sulphate. A Retrospective EffecDveness of Calcium Sulfate Bone GraO with Platelet Rich Fibrin in Oroantral Fistula Closure Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu 4 12 Months Radiographic Evaluation Over 25 Treated Italian Patients. Open Dent J, 9: 414-9. Figure 1. A panoramic image before the extraction of tooth 26. Figure 2. An image after the extraction and the occurrence of sinus perforation. EffecDveness of Calcium Sulfate Bone GraO with Platelet Rich Fibrin in Oroantral Fistula Closure Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu 5 Figure 3. A CBCT image in the coronal section before the procedure, showing the sinus perforation at the palatal root. Figure 4. Patient preparation and site preparation. A. Platelet-rich fibrin (PRF) gel after separation, B. Platelet-rich fibrin (PRF) plug, C. The perforation site after curettage. EffecDveness of Calcium Sulfate Bone GraO with Platelet Rich Fibrin in Oroantral Fistula Closure Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu 6 Figure 5. Preparation of calcium sulfate graft and mixing with Platelet-Rich Fibrin (PRF); A. Graft mixing according to the manufacturer's instructions, B. Graft mixed with pieces of platelet-rich Bibrin (PRF). Figure 6. Application of Platelet-Rich Fibrin plug and mixed graft: A. Passing the suture initially through the buccal gingiva, B. Passing the suture through the platelet-rich Bibrin (PRF) plug, C. Application of the calcium sulfate graft mixed with platelet-rich Bibrin (PRF), D. Graft hardening and performing the X-shaped suture. EffecDveness of Calcium Sulfate Bone GraO with Platelet Rich Fibrin in Oroantral Fistula Closure Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.957 http://dentistry3000.pitt.edu 7 Figure 7. Post-surgical phase. A: Follow-up on the next day, B: Follow-up after 3 days, C: Follow-up after one week, D: Follow-up after two weeks.