Maxillary sinus & its dental implication

Maxillary Sinus and its Dental Implication

Dr. FirasKassab Page 1

Maxillary Sinus & Its Dental Implication

Dr. FirasKassab

08 Fall



Contents:

Introduction.

Development and age change.

Development anomaly.

Anatomy of maxillary sinus.

Applied surgical anatomy.

Microscopic features.

Physiology.

Diagnostic evaluation.

Infection of the sinus.

Trauma (Oro-antral communication (OAC), and fracture).

Other pathological conditions.



Maxillary sinus:

It’s the pneumatic space that is lodged inside the body of maxilla and that communicate

with the environment by the way of middle meatus and the nasal vestibule.

Introduction:

Paranasal sinuses (PNS) are air containing bony spaces around nasal cavity.

Usually lined by respiratory mucous membrane of ciliated columnar epithelium.

4 paired (bilateral) PNS are:

-Maxillary

-Frontal

-sphenoid.

- Ethmoidal.



Development and age changes:

It starts at 12 weeks as an invagination of the m.m in the lateral wall of the

middle meatus of the nose, when the nasal epithelium invades the maxillary

mesenchyme (kitamura 1989).

Development 2 : At this stage, Maxillary sinus averages 7mm in AP and 4mm in

SI(expands 3 mm AP and 2 mm SI each year) Downward growth of the maxillary

sinus leaves the ostium in an unfavorable position for gravitational drainage.

The expansion occurs in every dimension (downward, forwards and backwards).

Development 3:

3 growth spurts

Birth – 2.5 Years.

7.5 – 10 Years.

12-14 years.

Development 4: In It’s development maxillary sinus is:

Tubular in birth.

Ovoid in childhood.

Pyramidal in adulthood.



Development 5:

At age 3 -4 Years:

Prominent in width after which facial growth at sutures is completed.

Sinus is related to upper 2nd deciduous molars and crypt of developing 1st permanent

molar.

If large, it may involve the Upper 1st deciduous molar.

Development 6:

At age 7 years:

Dimension of max sinus are:

-antro-posterior length: 27 mm.

- vertical height :17 mm.

-width: 18 mm.

Sinus grows rapidly as permanent teeth erupt.

At this stage, maxillary canine develops in the antro-lateral wall of the sinus but

doesn’t indent the sinus.

Development 7:

At age 12-15 years:

Max. Sinus extends to the same level as nasal floor.

Surgically accessible via the inferior meatus.

Adult sinus floor is centered over:

* Upper 1st and 2nd permanent molars.

*Upper 2nd premolar.

*Upper 1st premolar or canine.

*Posteriorly to upper 3rd molar.

Facial size and shape reflect sinus dimensions and size varies from individual to

individual.

Development 8:

In Old age:



In edentulous patients the alveolus is resorbed and thesinus floor becomes thin.

Anterior and infra-temporal surfaces undergo resorption and maxilla reverts to

infantile condition.

Relatively, sinus size increases.

In Adult’s, sinus floor is 1.25cm from nasal floor while in children and edentulous, It

lies at the same level.



Development Anomalies:

Agenesis (complete absence),

Aplasia and hypoplasia (altered in development or under development of the sinus

either occur separately or with other anomalies like:

- Choanalatrasia.

- Cleft palate.

- High palate.

- Septal deformity.

- Absence of chonca.

- Mandibulofacialdysistosis.

- Malformation of external nose.

Supernumerary max.sinus: is the occurrence of two completely separated

sinuses on the same side.

Anatomy of Maxillary sinus:

Anatomy of maxillary sinus

It consist of pyramidal shaped cavity in the body of

maxilla,with it base at the lateral nasal wall and it’s

apex ending in zygomatic process of the maxilla.

A septa may divide the sinus into two or more

cavities that may or may not communicate.

It has an osteum that open into the nasal cavity at middle meatus through “Hiatus

semilunaris” beneath the middle turbinate.

The average dimension of an adult max sinus are 25-35mm (width) 36,45 mm (height) and

38-45mm (length).



It extends ant to canine-premolar region and post. May reach intra-temporal surface of

maxillary tuberosity.

The sinus floor is convex in a downward direction, reaches the maximum convexity at the

first molar region.

The volume of MS 10-20 cc =14 cc.

Capacity of maxillary sinus = 15 ml (may reach 30 ml).

Boundaries:

Apex – by zygomatic process of maxilla.

Roof –by orbital surface of maxilla (floor of the orbite).

Base – lateral nasal wall.

Floor – Alveolar process of maxilla.

Recesses:

Alveolar recess.

Zygomatic recess.

Frontal recess.

Palatal recess.

Upper teeth are in close relation to floor of maxillary sinus:

According to its proximity to the sinus:

2nd molar.

1st molar.

3rd molar.

2nd premolar.

1st premolar.

Canine.

Anterior wall: related to infra-orbital plexus of vessels, nerves and origin of upper lip

muscles.

Posterior wall: pierced by the posterior superior alveolar nerve and vessels (from anterior

boundary of infra-temporal &pterygo-palatine fossae).



Sinus osteum is 3-6mm in diameter and rarely 2-3 openings are present (4-30 %

individuals).

- It is tunnel shaped and is 1-22 mm in length (avg. 5.5 mm)

- The osteumlies approx. 2/3 up the medial wall of the sinus, anatomically making

drainage inherently difficult.

Arterial Supply:

- Branches of Facial, Maxillary, Infra-orbital & greater palatine

- Periosteal supply is provided by Posterior Superior or Infra-orbital arteries (buccaly)

and Palatine artery (palatally)



Venous Drainage:

Facial and spheno palatine veins anteriorly and Pterygoid venous plexus posteriorly.

Lymph Drainage:

Into Submandibular, Deep cervical and Retro-pharyngeal lymph nodes.

Nerve Supply:

Branches from Anterior, Middle and Posterior Alveolar nerves, Infra-orbital and Greater

Palatine nerves.

Maxillary Sinus Pressure:

The mean pressure is:

- 116 mm Hg (normal).

- 75 mm Hg (sinusitis).

Applied Surgical Anatomy

Lesions within the sinus may penetrate through ant. And post. walls as they are thin walls.

Lesions may also penetrate through palatal or appear as swelling in the buccal vestibule.

Lesions may resorbe the alveolar bone and result in loosening of maxillary post teeth.

Anterior, middle and post. Superior alveolar nerves pass through the sinus wall, therefore

pathosis of the sinus may result in pain radiating to the teeth or facial bones at the side of

the sinus.

- Lesions may press on the pulp of the teeth in the affected side resulting in pulp

necrosis.

- Post, wall penetration by tumors may result in parasthesia of the gum in post.

segment due to destruction of Post. Sup. Alv. Nerve.

- According to the fact that venous drainage of the sinus is a part of maxillary

drainage, joining facial and jugular veins may drain in upward direction transferring

infection to ethmoidal, frontal and cavernous sinuses and may infect ant. cranial

fossa.



- Pneumatiztion of the sinus into alveolus or approximation of the roots of the teeth to

the sinus or even senile bone resorption may result in OAC during extraction or

surgery.

Infections related to the teeth that are close to the sinus, when progress resorb bone and

transfer infection to the sinus or may cause perforation in the sinus floor.

Microscopic Features

From inward outward the sinus is lined with 3 layers. Epithelial layer, basal lamina and sub

epithelial layer including periostium.

Epithelium:

- Pseudostratified columnar and ciliated (derived from olfactory epithelium of middle

meatus) containing mucous secreted goblet cells.

- Basal cells, columnar non ciliated.

- Cilia is composed of microtubules and provide mobile apparatus.

By ciliary beating, the mucous blanket lining the epithelial surface move from interior of the

sinus toward the nasal cavity.

Mucociliary Flow:

There are 3 types:

1- Smooth: moving at 0.58 cm/min.

2- Jerky: moving at 0.3 cm/min.

3- Mucostasis: moving less than 0.3 cm/min.

Physiology:

Reduction of weight of the facial skeleton.

Phonetic resonance and auditory feedback.

Insulation.

Air conditioning.



Water conservation.

Filtration

Olfaction.

Pathophysiology:

Gas exchange of the maxillary sinus mucosa.

Patency of the antronasal duct.

Mucous production and mucociliary transport.

Therefore Maxillary Sinus functions are summarized into:

Biological functions with the nose:

Warming inspired air.

Moisturizing inhaled air.

Accessory olfactory organ.

Production of bacterial lysozymes.

Brain protection:

Through warming inspired air.

Other functions:

Resonance of voice.

Lightening of skull weight.

Enhancement of craniofacial resistance to mechanical shock.

Resists infection via production of immunoglobulins.

Diagnostic evaluation :

- Detailed medical and dental history.

- Clinical evaluation (inspection, palpation, percussion, and transillumination).

- Radiographs (conventional, CT, MRI).

- Ultrasound.

- Special test (endoscopy).

Clinical evaluation:



Clinical evaluation should include the following:

Middle 3rd of the face should be inspected for:

Asymmetry

Deformity

Erythema

Eccymosis or hematoma.

Palpation:

Palpation of the lateral wall of sinus over prominence of cheek and intraorally on lateral

surface of maxilla between canine eminence and zygomatic buttress. Affected sinus is

markedly tender to gental tapping or palpation.

Transillumination:

Transillumination of maxillary sinus is done by placing flash or fiber optic light against the

palatal or facial surfaces of the sinus and observing transmission of the light through the

sinus in the darkened room.

The affected sinus shows less transmission of light due to accumulation of fluid, debris, pus

and thickening of antral wall mucosa.

The test helps to distinguish between sinus disease that may cause radiating pain to upper

teeth and exposure or abscess related to molars or premolars.



Radiograph:

Intra oral: Extraoral:

Periapical Panoramic view

Occlusal Water's view

Lateral-occlusal Submentovertex

Frontal tomography

PA view

CT - MRI

Ultrasound

Periapical radiograph:

First pic:

- Normally maxillary sinus border appears as fine radiopaque line.

- The apices of the roots appear surrounded with intact periodontal membrane and

lamina dura.

- There is also a cortical osseus margin and bone trabeculae in between.

Second pic:

- There is interruption of lamina dura around the apices of the roots and loss of bone

trabeculae between the sinus floor and the roots.

Panoramic radiograph:

- These are of value in locating and retrieving foreign bodies (radiodense) from the

maxillary sinus.

- Determine the size of the periapical lesions and cysts (both odontogenic and

mucosal).

- Distance between the periapical lesions and the mucous membrane of the sinus can

be calculated.

- Local swelling of the sinus membrane and opacities can be diagnosed.

Waters view (not sure):



- Normal antrum should appear radiolucent.

- Should be outlined in all peripheral areas by well demarcated area of cortical bone.

- It is helpful to compare one side to the other while examining.

- Should be no evidence of thickened mucosa which is seen in chronic sinusitis,

accumulation of pus or blood.

- There should be no discontinuity in the cortical outline near the apices of the roots.

Schematic showing positioning for a Waters projection. (CM, canthomeatal line; CR, central

ray) B. Radiograph of a Waters projection. The petrous ridge lies below the maxillary sinus.

(a, frontal sinus; b, medial orbital wall; c, innominate line; d, inferior orbital rim; e, orbital

floor; f, maxillary antrum; g, superior orbital fissure; h, zygomatic-frontal suture; i,

zygomatic arch)

Lateral view:

- Helps to confirm the presence of a fluid level and cyst.

- Also valuable in localizing the foreign body especially if the body is high up in the air

space.

- Allow all 4 pairs of PNS to be seen in one view.



CT & MRI:

High-resolution axial and coronal CT & MRI examinations are the most revealing non invasive

techniques for the paranasal sinuses.

Diagnostic endoscopy:

- Allows direct optical evaluation of the antral floor region.

- It is an optimal method for the assessment of the foreign body such as root filling

materials and root tips that have penetrated the maxillary sinus.

Maxillary Sinus Infection:

When inflammation develops in the sinus either due to infection or allergy, it is defined

"sinusitis" and it's the most common disease of the sinus.

Maxillary sinusitis could be broadly divided into:

• Acute

• Sub-acute

• Chronic

Acute sinusitis:

Etiology:



• Bacterial.

• Viral.

• Fungal.

• Allergic rhinitis.

• Odontogenic infection.

• Nasotracheal intubation.

• Barotrauma.

• Maxillofacial trauma.

• Iatrogenic (dentist).

Clinical Findings:

May occur at any age and has rapid onset.

Feeling of pressure, pain or fullness in the vicinity of the affected sinus.

Headache is common especially in the morning.

Discomfort increases in intensity and is accompanied with facial erythema &

swelling, malaise and fever.

Drainage of foul smelling mucopurulent material into nasal cavity and nasopharynx.

Pain is exacerbated on lying down or bending , due to increased intracranial

pressure from blood flow.

Dull pain may be present over premolars and molars upon mastication.

Tenderness to percussion in the affected side.

Nasal blockage and discharge.

Nocturnal cough.

Investigations:

Anterior Rhinoscopy- reveals erythema and oedema of mucosa with mucopurulant

discharge.

Transillumination-affected side, which is full of pus, will not transmit the fiber

optic light.

PNS view X-Ray- affected antrum is uniformly opaque and there is > 4 mm of

mucosa thickening.

CT & MRI Scans.



Treatment:

Treatment protocol

conservative surgical

Classical antral regimen Antral drainage or wash – LichwilsTrccar

Higginson type syringe

Nasal decongestant

Antibiotic

Mucolytic therapy

Culture and sensitivity

1. Nasal Decongestants:

Ephedrine sulpahate-0.5% or 1% in normal saline –dispensed as drops 6 hourly.

Phenylephirine – 0.25%.

Xylometazoline HCL 0.1%.

Reduces the increased vascularity.

Mucosa shrink – Improves ostium size.

Antihistaminic like pseudoephedrine or Levocetrizine

Are administered orally.

2. Antibiotics:

Empirical therapy is started with amoxicillin 500 mg,TDS for 10-13 days (Oral).

Others Include:

Trimethoprim-Sulfamethoxazole (in 1st time cases).

Amoxicillin with Clavulanate (Augmentin), Cefuroxime axetil& Clarithromycin.

If Pt. fails to respond tiothe initial treatment within 72.

Culture and sensitivity should be considered.

For Nosocomial infections (Staph. Aureus and gram negative bacilli)- Broad spectrum

IV therapy eg. Naficillin with Ceftriaxone.C&S must be done prior to start of ttt.

3. Mucolytic Agent:

Tincture Benzoin compound in boiling water (Steam Inhalation)- 6 hourly.

Camphor,Chlorbutol& Menthol(Karvol Plus).

4. Analgesics:



Significant amount of pain is experienced in sinusitis.Thus analgesics like (NSAID's)

or opioids must be given to pt. after establishing a complete medical history.

Nasal irrigation with saline,or other therapeutic solutions, is directed towards the

medial canthus(inner margin of the eye).

This aims the irrigant towards the site of drainage of the frontal, ethmoid and

maxillary sinuses into the nose.

Chronic Sinusitis

Pt. may be asymptomatic but will have repeated attacks of actual mucopurulent rhinitis.

Pain and tenderness are not common except in acute exacerbation of chronic disease.

Foul unilateral discharge is confined to post nasal discharge.

Diagnosis :

is confirmed by history and inspection of oropharynx which shows pharyngeal exudates.

PNS view X-rays.

Treatment:

Eradication of predisposing factors(dental if any).

Surgical removal of polyps if present.

Long term antibiotics , decongestants , and antihistaminics are prescribed to the patient.

Dental Implication of Maxillary Sinus:

1. Maxillary sinusitis of dental origin.

2. Toothache of sinus origin.

3. Odontogenic pain versus sinusitis.

4. Endo-antral Syndrome.

5. Foreign body of dental origin in max. sinus:

• Sodium hypochlorite.

• Zinc oxide based cement.

• Guttapercha.

6. Peri-radicular surgery.



1. Maxillary Sinusitis of Dental Origin:

Spread of infection from peri-apical or periodontal lesions.

Over extension of sealers , cements , GP or silver cones.

Periapical surgery of maxillary posterior teeth.

Iatrogenic: sinus perforation or instrument breakage.

2. Toothache of Maxillary Sinus Origin:

In sinusitis a feeling of constant dull aching pressure or discomfort could be felt on the

posterior maxillary teeth.

Etiology:

Part of the nerve supply of the sinus is posterior superior alveolar nerve that supply the

posterior teeth at the same time.

Clinical Characteristics of Sinus Toothache:

Dull, constant, non-pulsating aching pain in maxillary posterior teeth and sometimes all

the teeth in the affected side.



Infra-orbital redness.

Toothache is increased with lowering or bending forward the head.

Pain on palpation of the affected sinus.

Pt. may complain of feeling of teeth elongation.

Teeth are sensitive to percussion or chewing and to cold drinks and food.

Similarities between Pulpal Pain & Sinusitis

Symptoms Pulpal disease Sinusitis

Tenderness to

percussion

+ +

Sensitivity to cold + +

Pain on mastication + +

Location of pain Usually single tooth Usually posterior teeth

(cannot identify a

specific tooth)

Feeling of tooth

elongation

Usually + Always +

Dissimilarities between Pulpal Pain & Sinusitis

Symptoms Pulpal disease Sinusitis

Radiating pain +/- +

Fever & malaise +/- +

Pain on mastication + +

Pain on tilting or

lowering the head

- +

Post nasal discharge - +

Foul taste or odor - +



Diagnostic methods

Clinical findings

Pulp testing

Place a cotton pellet with 5% lignocaine in the nostril of the affected side for 1-2

mins, if pain is modified or disappears, it is of sinus origin (Radman, 1983)

3. Oro-Antral Communication & Fistula

Oro-Antral Communication: (OAC)

Is an abnormal connection between the oral cavity

and antral cavity (maxillary sinus) as a result of loss

of the soft and hard tissues that normally separate

both compartments.

Oro-Antral Fistula: (OAF)

Is a pathological fistular canal lined with epithelium

(stratified squamous epithelium) which may or may not be

filled with granulation tissue or polyposis of the sinus

mucous membrane.

Factors influencing creation of OAC:

Teeth size and configuration of the roots.

Hypercementosis and bulbous roots.

Density of alveolar bone and thickness of sinus floor.

Size of the sinus.

Fracture that may involve sinus walls.

Relation of sinus to the root of upper teeth.

Rough extraction and misguided manipulation.

Apical pathosis.

Periodontal diseases which may erode sinus floor.



Presence of cysts and neoplasm.

Invasive surgery e.g. cleft and dental implants placement.

Signs and Symptoms of OAC:

Signs: Symptoms:

Visible defect between mouth

and antrum.

Salty tasting discharge or

unpleasant smell.

Bone fragment with small

concave upper surface (antral

floor) adhering to the apex of

the extracted tooth.

Food and drink rhinorrhea.

Air bubbles at the socket. Discharge into the mouth.

Bubbling of blood from the

socket or nostril.

Escape of air when blowing the

nose.

Change in speech tone and

resonance.

Difficulty playing a wind

instrument or sucking.

Radiographical evidence of sinus

involvement.

Symptoms of acute or chronic

sinusitis.


Diagnosis:

History:patient’s complain.

Inspection:

Communication or fistula is visualized.

Radiographic examination (radio-opaque probe).

Air bubbles.

Fluid test.

Valsalva test.

Instrumentation (blunt probe).

Treatment:

General principles:

1. OAC 2mm or less

Don’t panic.

If antral membrane is intact avoid puncture.

Heals spontaneously without surgical intervention.

Patient instructions: 10-14 days

a. Avoid blowing the cheek or nose.

b. Avoid sucking straw.

c. Avoid smoking.

d. Open the mouth during sneezing.

e. Avoid catching cold.

Antibiotics.

e.g. penicillin or penicillin derivatives.

Analgesics and NSAI

e.g. paracetamol, profen (PRN)

Nasal decongestant

e.g. ephedrine or otrivin nasal drops

3 drops/ 3 times daily/ 7 days

Steam inhalation

e.g. menthal and benzoin

40 good sniffs

should follow nasal drops.

Maxillary sinus & ITS DENTAL IMPLICATION


2. OAC more than 2mm

Surgical intervention.

Keys for successful OAC closure:

1. A disease free sinus.

2. Coverage of OAC with vascularized tissue.

3. Tension-free closure.

4. Aggressive antibiotic coverge.

5. Emphasize firmly on patient's instriuction.

6. Any evidence of sinus infection:

Don’t close, drainage first with antibiotic coverage and culture and sensitivity test

if needed and when the infection is controlled. You can now surgically close.

4. Chronic Oro-Antral fistula / Persistent OAC

It might be a complication of:

Unrecognized (overlooked) fistula.

Untreated fistula.

Failure of spontaneous closure of OAF.

Failure of surgically repaired fistula.

Primary management of Chronic OAF:

It is aimed to eliminate any sinus infection:

Excision of any mucosal polyp or purulent granulation to promote drainage.

Regular irrigation with warm water or saline.



Single course of antibiotics and nasal inhalation and decongestant.

Acrylic base plate (surgical stent).

Surgical management:

Principles & requirements:

Success of operation is not always granted.

Flap should have good blood supply.

Flap tissue must be handled gently.

Flap should lie in its new position without tension.

Good homeostasis must be achieved before discharging the patient.

Types of repair:

Buccal advancement flap.

Bridge (pedicle) flap.

Palatal rotation flap.

Tongue based flap.

Buccal fat pad.

5. Displacement of A Root or Tooth into Maxillary Sinus Lining or Sinus

Proper

It is basically a mishap incident results from a

neglected act by the operator while applying

wrong force.

Occurs rarely but the 3rd molar and 2nd

premolar are the most at risk of dislodgement.

May occur with severe maxillofacial injuries.

Immediate Investigation & Management

Confirm the existence of oro-antral fistula and

the presence of tooth or root in sinus using dental, occlusal, panoramic and occipito-

mental radiographs.

Locate the precise position of the foreign body within the sinus lining or in the sinus

cavity proper.

Reflect mucoperiosteal flap.



Reduce alveolar bone height.

Retrieve the tooth or the root by permitting their movement away from the sinus.

If root or tooth dislodged into the sinus proper, consider Caldwell-luc approach.

Caldwell Luc Operation

Caldwell-Luc is the fenestration of the anterior wall of the maxillary sinus and the

surgical drainage of this sinus into the nose via an antrostomy.

Health & Medicine

Maxillary sinus & its dental implication