when does maxillary sinus formation occur?
3rd and 4th foetal months
- what are the functions of the paranasal sinuses?
- what are they?
- Resonance to the voice
Reserve chambers for warming inspired air
Reduce the weight of the skull - frontal
sphenoid
ethmoid air cells
maxillary
- what is the volumetric space and dimensions of maxillary sinus?
- epithelium of sinuses?
- 15ml volume
37mm high
27mm wide
35mm antero-posteriorly
opening of maxillary sinus middle meatus approx 4mm diameter - pseudo-stratified ciliated columnar epithelium
what are possible issues with maxillary sinus?
Oro-Antral Communication (OAC)
- Acute
Oro-Antral Fistula (OAF)
- Chronic
Root in the antrum
Sinusitis
Benign Lesions
Malignant Lesions
how do you diagnose OAC/F
what is difference between oac and oaf?
- Size of tooth
Radiographic position of roots in relation to antrum
Bone at trifurcation of roots
Bubbling of blood
Nose holding test (careful as can create an OAC)
Direct vision
Good light and suction - echo
Blunt probe (take care not to create an OAC) (doesn’t recommend) - fistula - chronic
communication created you manage it but doesn’t heal
communication - has just happened so you manage it
how can you tell this is an oac
still bleeding so must just been made
how can you tell this is oaf
less bone there where communication happened
what is manage for OAC?
- small (when do these usually heal)
- large
firstly inform patient
- If small or sinus lining intact:
Encourage clot
Suture margins
Antibiotic (area of debate)
Post-op instructions
Minimising pressure formation within the sinuses and mouth
Small OACs <2mm usually heal with normal blood clot formation and routine mucosal healing
- If large or lining torn:
Close with buccal advancement flap
what is manage for OAC?
- large
firstly inform patient
- If large or lining torn:
Close with buccal advancement flap
- what kind of sided flap should buccall advancement flap be ?
- what are steps of buccal advancement flap?
- 3 sided flap with 2 reliving incisions that are parallel and 1 creft incision
- flap design
raising flap
trimming of buccal bone
incising the periosteum
checking can be brought across the defect tension free
suturing
- how to treat an OAF?
- excision of sinus tract prior to buccal advancement flap
raising flap
antral washout (OAF cases) - not always done
what may patients complain of for chronic oaf?
- Problems with fluid consumption (fluids from nose)
Problems with speech or singing (nasal quality)
Problems playing brass/wind instruments
Problems smoking cigarettes or using a straw
Bad taste/odour/halitosis/pus discharge (post-nasal drip)
Pain/sinusitis type symptoms (discussed later)
- what is diagnosis for fractured tuberosity?
- Noise
Movement noted both visually or with supporting fingers
More than one tooth movement
Tear in soft tissue of palate
- what is management for fractured tuberoisity?
- Reduce and stabilise
>Orthodontic buccal arch wire with composite
>Arch bar
>Splints (lab-made)
Dissect out and close wound primarily
- what are flap design options for oaf?
- Buccal Advancement Flap
Buccal Fat Pad with Buccal Advancement Flap
Palatal Flap
Bone Graft/Collagen Membrane
Rotated Tongue Flap (Historical)
what is aetiology for fracture of maxillary tuberosity?
- Single standing molar
Unknown unerupted molar or wisdom tooth
Pathological gemination/concrescence
Extracting in wrong order
Inadequate alveolar support
what do you do if you splint it?
- Remove or treat pulp
Ensure it is out of occlusion
Consider antibiotic and antiseptics
Post-op instructions
Remove the tooth surgically 4-8 weeks later
- what should you rule out before you diagnose sinusitis?
- rule out a dental cause such as
Periapical abscess
Periodontal infection
Deep caries
Recent extraction socket
TMD
Neuralgia or atypical facial pain / chronic midfacial pain
- what are aims of treatment for sinusitis?
- what is treatment for sinusitis
- Treat presenting symptoms
Reduce tissue oedema
Reverse obstruction of the ostia - Decongestants reduce mucosal oedema
> Ephedrine nasal drops 0.5% one drop each nostril up to three times daily when required (use for a maximum of 7 days)
Humidified air is also helpful (steam/menthol inhalations
- what are antibiotics for sinusitis?
- Antibiotics should only be used if symptomatic treatment is not effective/symptoms worsen
AND
signs and symptoms point to a bacterial sinusitis
Amoxicillin 500mg, three times a day, for 7 days
or
Doxycycline 100mg, once a day, for 7 days (200mg loading dose)
what do you do if root or tooth in maxillary sinus?
Confirm radiographically by OPT, occlusal, or periapical (+/- CBCT)
Decision on retrieval
If in doubt or retrieval difficult - refer
how do you retrieve root in antrum/sinus?
OAF-type approach / through the extraction socket
- Open fenestration with care
- Suction – efficient and narrow bore
- Small curettes
- Irrigation or ribbon gauze
- Close as for Oro-Antral communication
Caldwell-Luc approach
- Buccal/Labial sulcus
- Buccal window cut in bone
ENT
- Endoscopic Retrieval
what is aetiology of sinusitis?
- effects of viral infection
Most are precipitated by the effects of a viral infection
- Inflammation and oedema
- Obstruction of ostia
- Trapping of debris within sinus cavity
what is aetiology of sinusitis?
- mucocillary cleareance patterns
Mucociliary clearance patterns may be altered by:
- Allergens
- Inflammation
- anatomic abnormalities
Normal physiological function is further disrupted by the cellular damage that occurs to the mucosal lining, this affects normal ciliary function
