92
MAXILLARY SINUS 1

Maxillary sinus

Embed Size (px)

DESCRIPTION

maxillary sinus

Citation preview

Page 1: Maxillary sinus

MAXILLARY SINUS

Page 2: Maxillary sinus

2

Introduction

Development, anatomy and physiology

Blood , Nerve supply& Lymphatic drainage

Functions of the paranasal sinuses

Histology & Diagnostic evaluation of sinus disease

Differences between odontalgia and sinus pain

Developmental anomalies & pathologic conditions of maxillary

sinus

Clinical significance

Case report

Conclusion

References

Page 3: Maxillary sinus

3

Paranasal air sinus

Paranasal air sinuses are the air filled mucosa lined cavities which develops in the cranial and facial bones.

These are the spaces which communicates with the nasal airway.

These forms the various boundaries of the nasal cavity.

Introduction

Page 4: Maxillary sinus

4

•Paranasal sinuses are present in a variety of animals (including most mammals, birds, and crocodile).

• The sinuses are named for the bones in which they are located.

Page 5: Maxillary sinus

5

Page 6: Maxillary sinus

Introduction

Maxillary air sinusFrontal air sinusEthmoidal air sinusSphenoidal air sinus

Page 7: Maxillary sinus

Definition of maxillary sinus“Maxillary sinus is the pneumatic

space that is lodged inside the body of maxilla and that communicates with the environment by way of the middle meatus and nasal vestibule.”

Anatomy of the maxillary sinus was 1st described by Highmore in 1651.

Page 8: Maxillary sinus

8

Development Maxillary sinus is first of the PNS to

develop.

It starts as a shallow groove on the medial surface of maxilla during the 4th month of intrauterine life.

(Koch 1930).

Page 9: Maxillary sinus

9

Expansion occurs more rapidly until all the permanent teeth have erupted.

It reaches to maximum size around 18years of age.

(Bailey 1998, Sadler 1995)

Page 10: Maxillary sinus

AGE CHANGES

0-3

years

•Ovoid appearance•7 mm x 4mm x 4mm volume 6-8 ml •3rd year – ½ adult size

3-4

years

•↑ in width with facial growth •Position; 2nd deciduous molars and crypts of 1st permanent molars

7-9

years

•Dimensions 27 mm x 18 mm x 17 mm•Volume10-12ml

Page 11: Maxillary sinus

9-12 years

•Antral floor same level with nasal floor•Assumes pyramidal shape

12-

18 years

•Floor of sinus 5–12.5 mm below nasal floor •Dimensions 32-34 mm x 28-33 mm x 23-25 mm•Volume 15-20 ml•Floor i.r.t 1st and 2nd molars and 2nd premolar

Old

age

•Resorption of ridge – thinning of sinus wall •Extension of sinus till crest•Anterior & infratemporal surface reverts to infantile condition

Page 12: Maxillary sinus

12

Age changes

Page 13: Maxillary sinus

AnatomyLargest of

PNS,communicate with other sinuses through lateral nasal wall.

Horizontal Pyramidal shaped

Base Apex 4 walls

◦Wall thickness varies with individual

superior

inferiorlateral

anterior

Page 14: Maxillary sinus

Medial wallFormed by lateral nasal wall

◦ Below-inf . nasal conchae◦ Behind-palatine bone◦ Above-uncinate process of ethmoid,lacrimal bone

Contains double layer of mucous membrane(pars membranacea)

Page 15: Maxillary sinus

Medial wallImp structures

Sinus ostium Hiatus semilunaris Ethmoidal bulla Uncinate process Infundibulum

Page 16: Maxillary sinus

16

Osteum: Opening of the maxillary sinus is

called osteum.It opens in middle meatus at the

lower part of the hiatus semilunaris.Lies above the level of nasal floor.

Page 17: Maxillary sinus

17

The ostium lies approximately 2/3rds up

the medial wall of the sinus, making

drainage of the sinus inherently difficult.

Page 18: Maxillary sinus

18

In 15% to 40% of cases, a very small,

accessory ostium is also found.

Blockage of the ostium can easily occur

when there is inflammation of the mucosal

lining of the ostium.

Page 19: Maxillary sinus

Superior wallForms roof of sinus and floor of orbitImp structures

Infraorbital canal Infraorbital foramen Infraorbital nerve and vessels.

Page 20: Maxillary sinus

Posterolateral wall

Made of zygomatic and greater wing of sphenoid bone.

Thick laterally,thin mediallyImp structures

PSA nerve Maxillary artery Pterygopalatine ganglion Nerve of pterygoid canal

Page 21: Maxillary sinus

Anterior wallExtends from pyriform aperture anteriorly

to ZM suture & Inferior orbital rim superiorly to alveolar

process inferiorly.Convexity towards sinusThinnest in canine fossaImp structures

Infraorbital foramenASA, MSA nerves

Page 22: Maxillary sinus

Floor of sinusFormed by junction of

anterior sinus wall and lateral nasal wall

1-1.2 cm below nasal floor Close relationship between

sinus and teeth facilitate spread of pathology.

Page 23: Maxillary sinus

23

VASCULAR SUPPLY:-Arterial blood supply:-Greater palatine arteriesInfraorbital arteryFacial artery

Page 24: Maxillary sinus

24

Venous drinage:-• Pterygoid venous plexus • Sphenopalatine vein and • Facial vein (Watzek et al. 1997)

Page 25: Maxillary sinus

25

yNerve supplyMaxillary division of the trigeminal

nerve, i.e. the posterior, middle and anterior superior alveolar nerves, the infraorbital nerve and the anterior palatine nerve.

Last 1959

Page 26: Maxillary sinus

26

Lymphatic Drain

The lymphatic drains in to submandibular lymph nodes.

The lymphatic drainage reaches the specialised cells in the maxillary sinus via infra orbital foramen or through the anterosuperior wall and then to the submandibular lymph nodes.

Page 27: Maxillary sinus

27

Lymphatic drainage

Submandibular lymph nodes

Page 28: Maxillary sinus

28

Functions of the maxillary sinus

Humidification and warming of inspired air,

Assisting in regulating intranasal pressure,

Lightening the skull to maintain proper head balance,

Imparting resonance to the voice,

Absorption of shocks to the head,

Filtration of the inspired air.

(Bailey 1998).

Page 29: Maxillary sinus

HISTOLOGYMaxillary sinus is lined by

three layers: epithelial layer, basal lamina and sub epithelial layer with periostium.

Epithelium is pseudo stratified, columnar and ciliated.

As cilia beats, the mucous on epithelial surface moves from sinus interior towards nasal cavity.

Page 30: Maxillary sinus

30

CLINICAL EXAMINATION

INSPECTION :

Middle third of the face should be inspected for the presence of asymmetry, deformity, swelling, erythema , ecchymosis or hematoma.

EXTRAORAL PALPATION :

Include palpation of the facial wall of the sinus above the premolar , where the bone is thinnest.

Page 31: Maxillary sinus

31

INTRAORAL EXAMINATION

Examination should be performed for tenderness, or paresthesia of upper molar and premolar region.

TRANSILLUMINATION TEST:

It is performed in a darkened room by inserting an electricallysafe light into the mouth ( with the lip closed). Good transilluminationindicates presence of air in the sinus while the failure of transillumination indicates presence of pus, fluid , solid lesion or mucosal thickening.

Page 32: Maxillary sinus

32

Radiographic examination

Radiography is the most important supplementary investigation to clinical examination of the sinuses

Intra-Oral : Extra-Oral:

Periapical OPG View Occlusal Waters

view

(Occipitomental view) Lateral Occlusal

Submentovertex view

PA view

Others:• MRI & CT scan

Page 33: Maxillary sinus

Periapical radiograph

Borders of the maxillary sinus appear as a thin, delicate

radiopaque line .

(White & Pharoah 2000)

In the absence of disease it appears continuous, but on

close examination it has small interruptions in its

smoothness or density.

33

Page 34: Maxillary sinus

34

The roots of maxillary molars usually

lie in close apposition to the maxillary

sinus and may project into the floor

of the sinus, causing small elevations

or prominences.

(White & Pharoah

2000) Maxillary sinus septum

Page 35: Maxillary sinus

35

Occlusal view Lateral occlusal view

Page 36: Maxillary sinus

36

2. Panoramic radiography

Provides an extensive overview of the

sinus floor and its relationship with

the tooth roots.

Page 37: Maxillary sinus

37OPG

Page 38: Maxillary sinus

38

Water’s projection

Page 39: Maxillary sinus

PA view Lateral Submentovertex

Page 40: Maxillary sinus

40

5. Computerized tomography (CT) &

Magnetic resonance imaging (MRI)

These modalities provide multiple sections

through the sinuses at different planes and

therefore contribute to the final diagnosis and

the determination of extent of the disease.

Page 41: Maxillary sinus

CT scan MRI

Page 42: Maxillary sinus

42

6. Ultrasound

Ultrasound is becoming the diagnostic tool of choice for

more and more physicians in detecting sinusitis.

It offers a fast ,reliable and radiation free method for

diagnosing sinusitis and has been used successfully in

Finland for around 15 years. (Landman

1986)

Page 43: Maxillary sinus

43

Ultrasound beam sent out by the sinus ultra is reflected from the posterior wall of the sinus when the sinus contains fluid and from the anterior wall when sinus contains air.

Page 44: Maxillary sinus

44

7. Diagnostic endoscopy

It is an optimal method especially for the

assessment of foreign bodies (such as root filling

materials and root tips) that have penetrated

into the maxillary sinus.

(Kennedy et al. 1985)

Page 45: Maxillary sinus

45

Transoral access via the canine fossa.

Transalveolar access via an already existing

connection between the oral cavity and the

antrum.

Access the inferior meatus of the nose.

Page 46: Maxillary sinus

46

Page 47: Maxillary sinus

47

DEVELOPMENTAL ANOMALIES AND PATHOLOGIC CONDITIONS OFMAXILLARY SINUS

Page 48: Maxillary sinus

Developmental anomalies1.Aplasia2. Agenesis 3. Hypoplasia

Aplasia

Page 49: Maxillary sinus

49

Pathologic conditions of maxillary sinus

Maxillary Sinusitis

Odontogenic cystic lesions of maxillary sinus

Tumors of maxillary sinus.

Page 50: Maxillary sinus

50

Maxillary Sinusitis

Acute Maxillary Sinusitis Sudden onset Duration of 4wks or less

Subacute Maxillary Sinusitis Duration of 4 – 12 wks

Chronic Maxillary Sinusitis Duration of atleast 12 wks

Page 51: Maxillary sinus

Maxillary sinusitis1. Infectious causesa) Bacterial b) Viral c) Fungal

2. Non infectious causesa) Allergicb) Non allergicc) Pharmocologic d) Irritants

3. Disruption of mucociliary drainagea) Surgeryc) Trauma

Etiology

Page 52: Maxillary sinus

Maxillary sinusitis Signs and symptoms associated with maxillary sinusitis

Major signs and symptoms Minor signs and symptoms

Facial pain/pressure Headache

Facial congestion/fullness Fever

Nasal obstruction/blockage Halitosis

Nasal discharge/purgulence/discolored postnasal discharge

Fatigue

Hyposmia/anosmia Dental pain

Purulence in nasal cavity on examination Cough

Ear pain

Page 53: Maxillary sinus

53

Maxillary sinusitis of Dental Origin

1.Dental abscess(periodontal and periapical abscess)

2.Infected dental cyst

3.Dental material

4.Oro-antral communication

Page 54: Maxillary sinus

54

Spread of infection from periapical region .

Page 55: Maxillary sinus

55

Overextention of dental material like sealers, cements ,Gp or silver cones

A root tip of the maxillary first molar accidentally pushed into the sinus at the time of tooth extraction.

Page 56: Maxillary sinus

56

Oro-antral communication (It is a pathologic tract that connects the oral cavity to the maxillary sinus. )

Patient complained of regurgitation of food through the nose while eating.

• Maxillary sinus perforation occurs occasionally during the extraction of a maxillary tooth, and it may be a cause of maxillary sinusitis or oro- antral fistula.

Page 57: Maxillary sinus

57

Page 58: Maxillary sinus

58

ODONTOGENIC CYSTIC LESIONS AFFECTING THE MAXILLARY SINUS

Page 59: Maxillary sinus

59

:

-Radicular cyst

-Dentigerous cyst

-Mucous retention cyst

Odontogenic Cystic Lesions of the maxilla

Page 60: Maxillary sinus

60

Maxillary sinusitis caused by an apical inflammatory lesion ( radicular cyst) at the root apices of the 2nd molar - NOTICE the cloudiness ( Radio-opacity) of the sinus

Radicular cyst

Page 61: Maxillary sinus

61

Dentigerous cyst

Also known as follicular cyst,2nd most common cyst , it usually appear on the impacted maxillary 3rd molar

Page 62: Maxillary sinus

62

Mucous retention cysts

Mucous retention cysts in the sinuses are very common, they are expansile and potentially destructive lesions

Page 63: Maxillary sinus

63

TUMORS OF MAXILLARY SINUS

Page 64: Maxillary sinus

64

Benign tumor of MS:Ameloblastoma:Ameloblastoma is the most common

benign tumor affecting maxillary sinus.

Page 65: Maxillary sinus

65

Malignant tumors of MS They are Invasive and destructive lesions For Examples : Squamouse cell carcinoma

Page 66: Maxillary sinus

66

Clinical Considerations:

The chances of creating an oro-antral fistula in patient less than 15 yrs are comparatively lesser than in adults due to incomplete development of sinus.

The distance between apical end of maxillary posterior teeth and floor of sinus is approximately 1-1.2 cm. In some cases the gap may be still lesser.

• Maxillary sinus perforation occurs occasionally during the extraction of a maxillary tooth, and it may be a cause of maxillary sinusitis or oro- antral fistula.

Oro-antral communication and oro-antral fistula

Page 67: Maxillary sinus

67

Root which is most close to the sinus is “palatal root of maxillary 2nd molar

Followed by : 1st molar 3rd molar

2nd premolar 1st premolar

canine

Page 68: Maxillary sinus

68

Lin et al. in 1991 reported that the maxillary sinus is more developed in female and therefore greater possibility of the occurrence of oro-antal communication and oro-antral fistula in female .

Page 69: Maxillary sinus

69

Page 70: Maxillary sinus

70

Symptoms of fresh oroantral communication:

Escape of fluids

Epistaxis

Escape of air

Enhanced column of air.

Excruciating pain

Page 71: Maxillary sinus

71

Symptoms of established oroantral fistula:

Pain.

Persistent purulent unilateral nasal discharge.

Post nasal drip.

Popping out of antral polyp.

Page 72: Maxillary sinus

72

Buccal flap advancement operation

Von Rehermann - 1936.

Operative technique

Page 73: Maxillary sinus

73

www.indiandentalacademy.com

Page 74: Maxillary sinus

74

PALATAL FLAPSRotational-advancement.(Ashley 1939)

www.indiandentalacademy.com

Page 75: Maxillary sinus

75

SUBMUCOUS CONNECTIVE TISSUE FLAP( Ito et al 1980)

Page 76: Maxillary sinus

76

BUCCAL FAT PAD(Hanazawa et al 1995)

Page 77: Maxillary sinus

77

Maxillary sinus pneumatization :

The expansion of the sinus is larger following extraction of several adjacent posterior teeth, if dental implant placement is planned in these cases, immediate implantation and/or immediate bone grafting should be considered to assist in preserving the 3-dimensional bony architecture of the sinus floor at the extraction site.

Page 78: Maxillary sinus

78

Implants in the maxilla

 Lack of sufficient bone height along maxillary sinus, produces significant difficulty for placement of implants in edentulous maxillary jaw, in that case, we go for sinus lift, which is a surgical procedure which aims to increase the amount of bone in the posterior maxilla.

Page 79: Maxillary sinus

79

SINUS LIFTThere are two

main approaches to

lift the maxillary sinus

Direct( Caldwell luc)

Indirect

Page 80: Maxillary sinus

`I

D

R

E

C

T

Jensen and Terheydenin 2009,

Page 81: Maxillary sinus

81

Direct sinus lift - advantage

1.It is clear

2. Easy access

3.More efficient work is done.

Page 82: Maxillary sinus

82

Disadvantage

1.More painful.

2.More post operative discomfort

3.More time consuming

4.Needs highly efficient practitioner

5.More susceptible to infection

Page 83: Maxillary sinus

83

INDIRECT TECHNIQUE

Invented by SUMMER IN 1994

Page 84: Maxillary sinus

84

ADVANTAGE

1. Minimally invasive surgical procedure

2. Requires less time and expertise than direct technique.

DISADVANTAGE

1.Blind procedure

2.More chances of errors to occur.

Page 85: Maxillary sinus

85

Maxillary Sinusitis : Because of the thickned and inflammed sinus lining compresses the nerve supply of the maxillary posterior teeth causing tenderness of the maxillary teeth.

The infraorbital and superior alveolar vessels are freqently ruptured in maxillary fracture causing hemotoma formation in the antrum.

Foreign body: Foreign body like GP, silver point, calcium hydroxide, sodium hypochloride, sealers, root piece ,may sometimes be accidentally forced into the maxillary antrum causing maxillary sinusitis.

Page 86: Maxillary sinus

86

Differences between symptom of odontalgia and sinus pain

History of cold, allergy, congestion or nasal drainage.

Dull aching pain that is difficult to localizedFeel pressure in the cheek and below the eyesPosition change like bending forward produces

painDental local anesthetic blockade will not relief

sinus painNormal pulp vitality test.

Page 87: Maxillary sinus

87

Page 88: Maxillary sinus

88

Page 89: Maxillary sinus

89

Page 90: Maxillary sinus

ConclusionDue to close proximity of maxillary sinus to orbit,

alveolar ridge, maxillary teeth, diseases involving these structures may produce confusing symptoms. Hence a precise information about the surgical anatomy is essential to surgeons.•Knowledge of the anatomical relationship between the maxillary sinus floor and the maxillary posterior teeth is important for the preoperative treatment planning of maxillary posterior teeth. Clinicians must be particularly cautious when performing dental procedures involving the maxillary posterior teeth. 

Page 91: Maxillary sinus

91

References • Textbook of oral and maxillofacialsurgery, Neelima malik Maxillary sinus and its implication Killey and Kay Textbook of Maxillary sinus Mc’gowan Orban’s, Oral histology and embryology, 11th edition. Cate A.R. Ten, Oral Histology: development, structure, and

function. 6th edition. ITI Treatment Guide , sinus floor elevation procedures, H.

Katsuyama & S.S. Jensen Textbook of general anatomy, B.D. Chaurasia IEJ vol 35 2002 J Endod. 2001 July;(27)

Page 92: Maxillary sinus

92

THANK YOU