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Of Cons & Endo Contents : Contents Introduction Development & Age changes Developmental Anomalies Anatomy of Maxillary Sinus Functions of Maxillary Sinus Microscopy of Maxillary Sinus Diagnostic Evaluation Infections of the Sinus Dental implications of Maxillary Sinus Peri-radicular surgery of posterior maxilla References Introduction : Introduction Paranasal Sinuses (PNS) are air containing bony spaces around the nasal cavity Usually lined by respiratory mucous membrane of ciliated columnar epithelium 4 paired (bilateral) PNS are: Maxillary Frontal Sphenoidal Ethmoidal Slide 4: Paranasal Sinuses Slide 5: Definition of Maxillary Sinus: “Maxillary sinus is the pneumatic space that is lodged inside the body of the maxilla and that communicates with the environment by way of the middle meatus and the nasal vestibule” (Ref: Orban’s Oral Histology – 10th Ed.) Development & Age Changes : Development & Age Changes Maxillary sinus is the first of the PNS to develop 4th week I.U.L. – dorsal portion of 1st Pharyngeal arch forms the Maxillary process, which extends forwards and beneath the developing eye to give rise to the maxilla Initial development of the sinus follows a number of morphogenic events in the differentiation of nasal cavity in early gestation (32 mm CRL) Slide 7: Horizontal shift of the Palatal Shelves & subsequent fusion with one another Nasal Septum separates the 2° Oral cavity from the two nasal chambers Influences further expansion of the lateral nasal wall & 3 wall begin to fold 3 Conchae & Meatuses arise Slide 8: 3 Meatuses Superior & Inferior Meatus Middle Meatus Remain as shallow depressions along the lateral nasal wall for first half of I.U. life Expands immediately into lateral Nasal wall Expands in an inferior direction occupying more of the further Maxillary body Slide 9: Development of sinus starts at 12 weeks as an evagination of the mucous membrane in the lateral wall of the middle meatus of the nose when the nasal epithelium invades the maxillary mesenchyme (Kitamura 1989) Slide 10: In its development maxillary sinus is: Tubular at birth Ovoid in childhood Pyramidal in adulthood Slide 11: 3 GROWTH SPURTS BIRTH – 2.5 Yrs. 7.5 – 10 Yrs. 12 -14 Yrs. Slide 12: At birth: Maxilla is filled with deciduous tooth germs Max Sinus is a shallow, tubular cavity Dimensions of the max sinus are: - Antero-posterior length: 7mm - Vertical height: 4 mm - Width: 4 mm Expands 3 mm antero-posteriorly and 2 mm vertically each year until 9 yrs of age (Serber 1989) Slide 13: The alveolar & orbital process of maxilla are separated by cancellous bone, which resorbs as the max sinus enlarges Undergoes lateral expansion below the orbit (as far as the infraorbital canal) by the end of 1st year By end of 20th month, the max sinus develops posteriorly to the position of the rudimentary permanent first molars By end of 2nd year, sinus reaches half its adult size Slide 14: Maxillary sinus expands downwards, forwards and backwards and grows by pneumatization Slide 15: At age 3 & 4 years: Prominent growth in width after which facial growth at sutures is completed Sinus is related to upper 2nd dec. molars and crypt of developing 1st perm. Molar If large, it may involve the upper 1st dec. molar More prone to infections than other PNS Slide 16: At age 7 years: Dimensions of the max sinus are: - Antero-posterior length: 27 mm - Vertical height: 17 mm - Width: 18 mm Sinus grows rapidly as permanent teeth erupt At this stage, the max. canine develops in the antero-lateral wall of the sinus The canine raises a ridge on the anterior surface of maxilla but does not indent the sinus Slide 17: At age 12 - 15 years: Max sinus extends down to the same level as nasal floor Surgically accessible via the inferior meatus Adult sinus floor is centered over: - upper 1st and 2nd permanent molar - 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 (if AP length is more) Slide 18: Skull showing the proportion of middle 3rd to the rest of the face Slide 19: In old age: In edentulous patients, alveolus is resorbed and floor of the sinus becomes thin Anterior and infra-temporal surfaces undergo resorption and maxilla reverts to an infantile condition As a result of the resorption, there is an increase in the size of the sinus In adults, sinus floor lies 1.25 cm below floor of nose, while in children and edentulous it lies at the same level Slide 20: Pneumatization is the enlargement of the sinus by resorption of alveolar bone that formerly served to support a missing tooth or teeth and then occupies the edentulous space. A thin cortex remains over the alveolar ridge (arrow) to maintain a normal contour Developmental Anomalies : Developmental Anomalies Agenesis (complete absence), Aplasia and hypoplasia (altered development or under development) of the sinus occurs either alone or in association with other anomalies like: Choanal Atresia Cleft palate High palate Septal deformity Absence of concha Mandibulofacial dysostosis Malformation of the external nose Slide 22: Supernumerary maxillary sinus is the occurrence of two completely separated sinuses on the same side. This condition is initiated by outpocketing of the nasal mucosa into the primordium of the maxillary body from two points either in the middle nasal meatus or in the middle and superior or middle and inferior nasal meatuses. Consequently, the result is two permanently separated ostia of the sinus Anatomy of Maxillary Sinus : Anatomy of Maxillary Sinus Previously called as “Maxillary Antrum of Highmore” Largest of the PNS Pyramidal shaped cavity within the body of the Maxilla Average Dimensions of adult Max. Sinus (Turner 1902) : Average Dimensions of adult Max. Sinus (Turner 1902) Vertical height– 3.5 cm (opp. the 1st molar) Transverse width – 2.5 cm Antero-posterior – 3.25 cm Capacity of each sinus – 15 ml (up to 30 ml) Floor of adult sinus lies 1.0 – 1.25 cm below floor of the nasal cavity Boundaries: : Boundaries: Apex – by zygomatic process of Maxilla Roof – by orbital surface of Maxilla (traversed by infra-orbital nerves & vessels) Base- by nasal surface of body of maxilla Slide 26: Floor – formed by alveolar process of maxilla In about 50% population, the floor expands into the alveolar process of the maxilla, forming an alveolar recess The sinus floor exhibits recesses extending between adjacent teeth or between individual roots of teeth Slide 27: Recesses Are expansions of the sinus beyond the maxillary bone Alveolar Recesses Zygomatic Recesses Frontal Recesses Palatal Recesses Slide 28: Upper teeth are in direct relation to the max sinus floor. An assessment of the distance between the root apices and the floor of the antrum was made by Von Bonsdroff in 1925 after studying 85 Finnish skulls. Paatero later in 1939 confirmed these findings after studying 11 more skulls. 2nd molars were in closest proximity, with next in order of frequency: 1st molars 3rd molars 2nd premolars 1st premolars Canine Slide 30: Anterior wall – Related to infra orbital plexus of vessels & nerves and origins of muscles of upper lip Posterior wall – pierced by post. superior alveolar nerves & vessels (forms ant. boundary of infra temporal & pterygo-palatine fossa) Slide 31: Relationship Of The Nasal Cavity To The Air Sinuses Superior, Middle And Inferior Conchae (3-5) With The Meatus Deep To Them Slide 32: The medial wall of the sinus or the lateral wall of the nose contains the “Sinus Ostium”, which opens into the –Middle Meatus of the nose and provides essential drainage It is 3-6 mm in diameter and rarely 2 or 3 accessory openings are present ( 4% – 30% individuals) The ostium lies approximately two-thirds up the medial wall of the sinus, anatomically making the drainage of the sinus inherently difficult Slide 33: It is tunnel shaped and is 1 – 22 mm in length (Avg 5.5mm) Usually opens into the posterior half of the ethmoidal Infundibulum Slide 34: Blockage of the ostium can easily occur when swelling or thickening of the mucosal lining of the ostium develops Slide 35: Arterial Supply: Supplied by branches of Facial, Maxillary, Infra-orbital & Greater Palatine Arteries Periosteal supply is provided by sinus membrane which is supplied by Posterior-Superior dental artery or by the Infraorbital artery (buccaly) and the Palatine artery (palatally) Slide 37: Venous Drainage: Via the Facial vein, Sphenopalatine vein anteriorly and the Pterygoid venous plexus posteriorly Anterior, middle and superior dental veins drain into the infra-orbital vein Pterygoid plexus communicates with the cavernous sinus by emissary veins Slide 38: The significance of the vascular drainage of the sinus lies in the fact that apart from the joining typical pathways in the maxilla to the jugular veins, it can also drain upward into the ethmoidal and frontal sinuses and eventually reach the cavernous sinus in the floor of the brain. Spread of infections via this route is a serious complication of maxillary sinus infections. Slide 39: Lymph Drainage: Into Submandibular lymph nodes and deep cervical lymph nodes and retro pharyngeal nodes Nerve Supply: Branches from Anterior, middle and posterior superior alveolar nerves, infra orbital nerves; greater palatine nerve Slide 40: The innervation of the sinus is important from a diagnostic standpoint Post wall of the sinus receives its supply from Posterior and Middle Superior Alveolar nerves while anterior wall is by Anterior Superior Alveolar Nerve These nerves travel enclosed in the wall of the sinus innervating the related teeth (Wallace 1996). Thus it is commonly seen that pain of the sinus is mimicked as toothache and vice versa and is difficult to distinguish Slide 42: The mean (Partial pressure ) O2 of the sinus has been reported to be 116 mm Hg in normal persons 75 mm Hg in those with sinusitis Applied Surgical Anatomy : Applied Surgical Anatomy The anterior and infra temporal walls of the max sinus are very thin. Tumors developing within the sinus can readily erode them and present as swellings in the cheek Tumors may also penetrate the floor of the max sinus and present as a lump in the palate or as a swelling in the buccal sulcus If teeth are present they may be loosened as a result of bone destruction in the vicinity of their roots Slide 44: Death of the pulp of such teeth as a result of interference with their blood supply may result in the development of acute apical abscess and this may be the first presenting sign of malignancy If the tumor erodes in the posterior area or wall of the sinus, the posterior superior alveolar nerves may be destroyed and the patients initial complaint may be of anesthesia of the gums and teeth in the upper molar region Radiographic Anatomy of Maxillary Sinus : Radiographic Anatomy of Maxillary Sinus It is particularly complex because of 2 factors: Sinuses are projected in the radiograph over one another to a greater extent and anatomic detail is obscured There is a great range of normal variants of the sinuses among different individuals in various age groups Microscopic Features : Microscopic Features 3 layers surround the space of the max sinus Epithelial layer, Basal lamina and Sub epithelial layer including Periostium Epithelium: Pseudostratified, columnar & ciliated (derived from olfactory epithelium of middle meatus) Most numerous cells in max sinus are – Columnar ciliated cells Basal cells, columnar non ciliated cells, mucus secreting goblet cells Slide 47: Cilia is composed of 9+1 pairs of microtubules and provide mobile apparatus to the sinus epithelium By ciliary beating, the mucous blanket lining the epithelial surface moves from the interior of the sinus towards the nasal cavity Goblet cells (secretory cells) contains RER & SER along with the Golgi apparatus all of which are involved in the synthesis of secretory substances Pseudostratified Ciliated Columnar Epithelium : Pseudostratified Ciliated Columnar Epithelium Slide 49: In addition to epithelial secretion, the surface of the sinus is provided with a mixed secretory product This serous secretion consists of water, neutral lipids, proteins, carbohydrates and a mucous secretion consisting of compound glycoprotein's and mucopolysaccharides These are located in the sub epithelial layer of the sinus and reach the sinus by excretory ducts Slide 50: Ciliated Cells - Ciliary Beating Mucous blanket lining the epithelium Moves from sinus to nasal cavity Slide 51: Mucociliary Flow Three types of mucociliary flow have been described: Smooth - moving at 0.85 cm/min. Jerky - moving at 0.3 cm /min. Mucostasis - moving at less than 0.3 cm / min. Functions Of Maxillary Sinus : Functions Of Maxillary Sinus Biological Functions with nose: Warming of inspired air Moisturize the air in dry climates (avoids dry throat) Accessory Olfactory organ Production of bactericidal lysozyme to the nasal cavity Filters Debris Protects brain: By increasing the temperature of inspired air against exposure to cold air environment Slide 53: Other Functions: Resonance of voice Lightening of skull weight Enhancement of craniofacial resistance to mechanical shock Protects from infection via the production of immunoglobulins which diminish the frequency of infection from inhaled bacteria, molds and viruses Diagnostic Evaluation of Maxillary Sinus : Diagnostic Evaluation of Maxillary Sinus 1. Detailed medical and dental history 2. Clinical Examination - Inspection - Palpation - Percussion - Transillumination 3. Radiographs 4. Ultrasound, CT Scan & MRI 5. Specialized tests (Endoscopy) Slide 55: Clinical Examination: The clinical examination of a patient with suspected maxillary sinus disease should include the following: Middle 3rd of face should be inspected for - Asymmetry - Deformity - Swelling - Erythema - Ecchymosis Or Haematoma Slide 56: Palpation: Tapping of lateral walls of sinus over prominence of cheek bones and palpation intra-orally on lateral surface of maxilla between canine fossa and zygomatic buttress Slide 57: Affected sinus is markedly tender to gentle tapping or palpation Nasal passage to be checked for obstruction, epistaxis, discharge or odour In unilateral disease, one sinus may be compared with the sinus on the opposite side. The affected side shows decreased transmission of light secondary to accumulation of fluid, debris, pus and thickening of the sinus mucosa Slide 58: Transillumination: Transillumination of the maxillary sinus is done by placing a bright flash light or fiber optic light against the mucosa on the palatal or facial surfaces of the sinus and observing the transmission of light through the sinus in a darkened room This test helps to distinguish sinus disease which may cause pain in the upper teeth, from abscess or other pain of dental origin associated with molars and premolars Radiographs : Radiographs Intraoral: Periapical Occlusal Lateral occlusal Extraoral: Panoramic view Waters view ( 15 ° /30° Occipitomental view) Submentovertex view Frontal Tomograph PA view Radiography is the most important supplementary investigation to clinical examination of the sinuses Slide 60: Periapical X-Rays: The borders of max sinus appears as a thin, delicate tenuous radiopaque line In absence of disease it appears continuous, but on close examination have small interruptions in its smoothness Slide 61: Dental pathologic conditions such as cysts and granulomas may produce radiolucent lesions that extend into the sinus cavity. They may be distinguished from normal sinus anatomy by their association with the tooth apex, the clinical correlation with dental examination and the presence of a cortical osseous margin on the radiograph, which separates the area in question from the sinus itself. Slide 62: Panoramic Views: 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 swellings of the sinus membrane and opacities can be diagnosed Slide 64: Occipitomental View: First described by Waters and Waldron in 1915 Also called as Water’s projection or PNS View Maxillary sinus is best demonstrated by the 15° Occipitomental radiograph Can be taken at 30 ° and 35 ° for comparison of internal anatomy & bony continuity, sinus pathology and foreign objects in the sinus Slide 65: Interpretation of a PNS Radiograph Normal antrum should appear radiolucent Should be outlined in all peripheral areas by well demarcated layer 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 (Ref: Contemporary OMFS, Peterson 4th ed.) Slide 66: Occipitomental View (PNS View) Normal View of Max Sinus Slide 67: Lateral View: Helps to confirm the presence of a fluid level and cysts Also valuable in localizing the a foreign body especially if the body is high up in the air space Allows all 4 pairs of PNS to be seen in one view Slide 68: Submentovertex View: Advantage of this film is that the posterior walls of the sinus are seen clearly Slide 69: Ultrasound: This is a non invasive, safe and quick diagnostic screening tool for sinus pathology introduced by Landman in 1986 The ultrasound waves are generated by a probe that contains peizo electric crystals stimulated by an alternating current oscillator. When applied to portions of the body, these waves are transmitted, reflected and scattered depending on the physical properties of the tissues Slide 70: CT Scan & MRI: These have become increasingly important for the evaluation of sinus disease and have virtually replaced conventional tomography. These modalities provide multiple sections through the sinus at different planes and therefore contribute to the diagnosis and determination of disease. High resolution axial and coronal CT & MRI examinations are the most revealing non invasive techniques for paranasal sinuses. Slide 71: CT scan is relatively normal + - border of max sinus; * - max sinus ostium; U - uncinate process, E - ethmoid sinuses; MT- middle turbinate; S - septum Slide 72: MT- middle turbinate, IT- inferior turbinate, P - polyp or cyst, E - ethmoid sinuses, O - maxillary sinus ostium, * - frontal sinus CT scan with fairly severe sinus disease Slide 73: MRI showing Sinus disease Slide 74: Endoscopy: Diagnostic endoscopy allows direct optical evaluation of the antral floor region. It is an optimal method for the assessment of foreign bodies such as root filling materials and root tips that have penetrated the maxillary sinus The following paths of access can be used: Trans oral via the canine fossa Transalveolar via the connection between the oral cavity and the antrum Slide 75: Endoscope – An endodontic application The 30° and 70 ° endoscope has been used as an adjunct to endodontic surgery involving the maxillary and mandibular molars This instrument has been found to allow visualization in inaccessible areas such as maxillary molar roots that are behind the distobuccal roots of maxillary 1st molar. There have been cases, where the maxillary root has been dislodged into the antrum during endodontic surgeries and the endoscope has aided the operator in identification and treatment of these diseased root apices following entry into the sinus (Ref: JOE, Vol. 22, No.6 June 1996) Slide 76: (Ref: JOE, Vol. 22, No.6 June 1996) Maxillary Sinus Infections : Maxillary Sinus Infections When inflammation develops in the sinus either due to infection or allergy, it is termed as “Sinusitis” and is the most common disease involving the max sinus Inflammation of all the PNS simultaneously is termed as “Pansinusitis” Maxillary Sinusitis can be broadly divided into: Acute Sub-acute Chronic or Recurrent Acute Sinusitis : Acute Sinusitis Etiology: Bacterial (Streptococcus pneumoniae & Haemophilus influenzae) Moraxella catarrhalis in Children Rhinovirus, Influenza virus & Parainfluenza virus are found alone or with bacteria History of allergy to allergens like dust, pollen, hay etc. Commonly odontogenic in nature because of the close proximity of maxillary teeth to sinus. The infections are acute & chronic periapical disease and periodontal disease Slide 79: Etiology: A viral URTI is the most common precursor of sinusitis Allergic rhinitis causes ostial obstruction, either by mucosal oedema or by polyps Nasotracheal intubation result in blockage of the ostia and is a major cause of “Nosocomial Sinusitis” Other causes include Barotrauma which results from deep sea diving or airplane travel Iatrogenic causes (Dentist induced) Slide 81: Clinical Features: Can occur at any age and usually has a rapid onset Patient describes it as a sense of pressure, pain or fullness in the vicinity of the affected sinus Headache is common esp. on waking up in the morning Discomfort increases in intensity and is accompanied by facial erythema & swelling, malaise and fever (< 102°F) Drainage of foul smelling mucopurulent material into the nasal cavity and nasopharynx Slide 82: Clinical Features (Cont.): Pain is exacerbated on lying down or on bending over due to increased intracranial pressure from blood flow Dull pain may be present over the maxillary premolar & molar areas on mastication Pain typically radiates to all upper posterior teeth in the quadrant so all teeth are tender to percussion Nasal blockage and discharge is characteristic Nocturnal coughing Slide 83: Investigations: Anterior Rhinoscopy - reveals erythema & oedema of mucosa with mucopurulent 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 > 4mm of mucosal thickening CT & MRI Scans Slide 84: Conservative Classical Antral Regime: Nasal Decongesent Antibiotics Mucolytic Therapy Treatment Protocol Surgical Antral Drainage Or Wash - Lichwitz Trocar Higginson Type Syringe Culture & Sensitivity Ref: Contemporary OMFS, Peterson 5th Ed Textbook of Medicine, Harrison 16th Ed. Slide 85: Nasal Decongestants – Ephedrine sulphate – 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 Antihistaminics like Pseudoephedrine or Levocetrizine are administered orally Slide 86: Antibiotics: Emperical therapy is started with Amoxicillin 500 mg, TDS for 10 – 14 days (Oral) Others include: - Trimethoprim – Sulfamethoxazole (In 1st time cases) - Amoxicillin with Clavulanate (Augmentin), Cefuroxime axetil & Clarithromycin If pt. fails to respond to the initial Tt. within 72 hrs, Culture & 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 Tt. Slide 87: Mucolytic agent : Tincture Benzoin compound in boiling water (Steam inhalation) – 6 hourly Camphor, Chlorbutol & Menthol (Karvol plus) 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 Slide 88: 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. (Ref: J Allergy Clin Immunol. 2003;112:877-82.) Slide 89: Surgical drainage: For pain relief or unresponsive infection Slide 90: Lichwitz trocar( Higginson type) Chronic Sinusitis : Chronic Sinusitis Pt may be asymptomatic but will have repeated attacks of acute mucopurulent rhinitis Pain and tenderness are not common except in acute exacerbation of chronic disease Foul unilateral discharge is confined to drainage in post nasal space Diagnosis is confirmed by history and inspection of oro-pharynx which shows pharyngeal exudates PNS view X-Rays also show changes in sinus Slide 92: Treatment: Eradication of any dental problem (if any) Polyps are commonly involved and treatment is surgical removal Long term Antibiotics, Decongestants and anti histaminics are administered to the patient Dental Implications of Maxillary Sinus : Dental Implications of Maxillary Sinus Maxillary Sinusitis of Dental Origin Toothache of Sinus Origin Odontogenic Pain vs. Sinusitis Endo – Antral Syndrome Foreign Bodies of Dental Origin in Maxillary Sinus Sodium Hypochlorite Zinc Oxide based cements Intracanal Medicaments Gutta Percha Peri-radicular Surgery Maxillary Sinusitis of Dental Origin : Maxillary Sinusitis of Dental Origin Spread of infection from Periapical or Pdl. Abscess Due to overextension of Sealers, Cements, GP, Silver cones As a result Of Periapical Surgery of posterior maxillary teeth Due to iatrogenic Causes like Perforation of Sinus membrane Or breakage of Instrument Maxillary Sinusitis of Dental Origin : Maxillary Sinusitis of Dental Origin Spread of infection to the sinus from a dental abscess: Commonest cause of direct spread of oral infection to the sinus is a “Periapical abscess” Odontogenic sinusitis is seldom associated with acute abscess It is always secondary to chronic suppuration from a granuloma or a periodontal abscess Slide 96: When an acute exacerbation of periapical disease occurs with antral involvement, the following characteristic features are observed: Severe throbbing pain while pus is confined within the bone in apical region 12 – 24 hrs later, pain is moderate as there is a discharge of pus in the antral cavity Only a slight swelling of the cheek can be seen Pt. complains of discharge of foul pus down one nostril, an unpleasant smell and taste Once symptoms clear, the pt. is left with a loose, painful, periostotic tooth Toothache of Maxillary Sinus Origin : Toothache of Maxillary Sinus Origin In sinusitis, a feeling of constant dull, aching pressure or discomfort can be felt on the posterior maxillary teeth Etiology: The superior alveolar nerves supplying the maxillary posterior teeth pass along the thin walls of the sinus. The canaliculi of teeth often open toward the sinus; thus pulpal nerves are in contact with the inflamed sinus lining resulting in pain due to irritation Slide 98: Clinical characteristics of Sinus toothache: Dull, constant, non pulsating aching pain is present in several maxillary teeth Pt. reports of pressure or pain below the eyes (Infraorbital tenderness) Toothache is increased on lowering the head or bending forward (Ref: DCNA, Vol 41, April 1997) Slide 99: Pain is felt with palpation over the involved sinus Teeth feel “Elongated” when the pt. bites Teeth are sensitive to percussion, on mastication and hypersensitive to cold fluids History of URTI and Nasal congestion (Ref: DCNA, Vol 41, April 1997) Odontogenic Pain vs. Sinusitis : Odontogenic Pain vs. Sinusitis Due to the close anatomic juxtaposition between the sinus and the maxillary teeth, there are many common symptoms between the pain from pulpal disease and sinusitis Both diseases are commonly mis-diagnosed and thus it is imperative that the clinician takes a detailed history and carries out various diagnostic tests to elicit the appropriate diagnosis and treatment Slide 101: Similarities between Pulpal Pain & Sinusitis Slide 102: Dissimilarities between Pulpal Pain & Sinusitis Slide 103: Diagnostic Methods: Conventional radiography - IOPA & bitewings will show changes in teeth affected with pulpal disease Electric Pulp testing – There may be an altered response in teeth suffering from pulpal disease, but teeth will respond within normal limits in sinusitis Place a cotton swab with 5% Lignocaine in the nostril of the affected side and leave for 1 – 2 mins. If pain is of sinus origin it will be modified or eliminated temporarily and lead to diagnosis of sinusitis (Radman,1983) Endo – Antral Syndrome : Endo – Antral Syndrome The pathologic disruption of both periapical and adjacent antral tissues resulting from endodontic infection has been widely studied and documented by Selden (1999) “The Spread of pulpal disease beyond the confines of the supporting tissues into the maxillary sinus is referred to as the ENDO ANTRAL SYNDROME” (Ref: JOE Vol.25, No.5, May 1999) Slide 105: The findings that characterize the EAS are: Pulpal disease in a tooth whose apex approximates the floor of the maxillary sinus Periapical radiolucency on pulpally involved tooth Radiographic loss of the lamina dura defining the inferior border of the maxillary sinus over the pulpally involved tooth (Ref: JOE Vol.25, No.5, May 1999) Slide 106: A faint radiopaque mass bulging into the sinus space above the apex of the involved tooth, connected neither to the tooth nor the lamina dura of the tooth socket (representing a localized swelling and thickening of the sinus mucosa) Varying degrees of radiopacity of the surrounding sinus space (comparison with contra lateral sinus is often helpful) The variable presentation of the EAS can create both diagnostic and therapeutic difficulties, because all cases do not always evidence all the 5 features Foreign Bodies of Dental Origin in Maxillary Sinus : Foreign Bodies of Dental Origin in Maxillary Sinus The Maxillary sinus poses a special challenge when RCT is performed in upper posterior teeth whose roots are in close proximity to the sinus Though it is well established that the endodontic instruments must remain within the confines of the root canal system, procedural errors are common Root canal instruments, medicaments, sealers, cements and obturating materials like GP and silver cones often cross the apical foramen Slide 108: Some degree of inflammatory response normally occurs after the canal preparation is kept within the root canal system (Seltzer) When root apices are in close proximity to the sinus membrane, the inflammatory response is seen in the sinus mucosa Extrusion of debris into the periapical tissues may occur, causing periapical inflammation, post operative pain and possibly delayed healing (Fairbourne, 1987) Overzealous reaming or filing can cause a more severe inflammatory response Slide 109: Foreign bodies like GP, Silver cones, broken instruments if are present in the sinus for a long time, get encrusted with calcific concentrations These calcareous bodies are called “Rhinoliths” When in the Antrum, they are called “Antroliths” Bowerman in 1969 defined them as complete or partial encrustations of an antral foreign body usually of endogenous or occasionally of exogenous origin Slide 110: Hard Mass consisting of a central nucleus Deposited with mineral salts usually Calcium Carbonate & Phosphate Radiopaque masses, Foul smelling and results in nasal discharge Gives rise to Sinusitis Treatment is usually surgical removal Caldwell – Luc Operation Slide 111: Antrolith (stone) in the maxillary sinus Antroliths are calcified masses found in the maxillary sinus Slide 112: Sodium Hypochlorite: NaOCl (5.25%) is a commonly used root canal irrigant and numerous incidents of soft tissue and max sinus complications have been reported The unintentional injection of NaOCl into the periapical tissues may impact the Max sinus (Ehrich et al, 1993) Pashley et al in 1995, found that NaOCl, elicited severe inflammatory reactions and was extremely toxic to all cells except the heavily keratinized cells Slide 113: Sequelae of NaOCl accidents: Severe pain, oedema Profuse haemorrhage both interstitially & through the tooth Several days of increasing oedema & ecchymosis Tissue necrosis, paresthesia and secondary infection (sometimes) Complete resolution Within a few days to weeks Long term Paresthesia & scarring (Ref: IEJ, 35, 127-141, 2002) Two cases of inadvertent injection of NaOCl into the maxillary sinus are reported (Ehrich & Taylor 1998) : Two cases of inadvertent injection of NaOCl into the maxillary sinus are reported (Ehrich & Taylor 1998) Case is reported for tooth 16, in which shortly after irrigation of the palatal canal with 5.25% NaOCl, the patient complained of a salty taste in his mouth, despite of a rubber dam. On irrigation of palatal canal with sterile water it was found that water passed through the canal into the max sinus, into the nasal cavity via the ostium and then into the pharynx. Apart from mild burning sensation in the maxilla and slight congestion, the pt. had no severe consequences and healed asymp. in 4 days Case is reported for tooth 15. After irrigation with 5.25% NaOCl, the patient experienced acute severe facial pain & burning sensation along with a facial swelling. An attempt to drain the sinus through the tooth was made which was unsuccessful. Hence it was surgically drained by a Caldwell Luc approach. Despite an apparent healing of sinusitis, the tooth remanined painful and was extracted 3 months later (Ref: IEJ, 35, 127-141, 2002) Slide 115: Intracanal Medicaments: Ca(OH)2 is used commonly as an inter-appointment dressing It is irritating to the tissue and has immediate degenerative effects upon cells, before it is removed by macrophages or foreign body giant cells (Fava & Bystrom, 1992) Haanes in 1987 injected Ca(OH)2 into the maxillary sinus of monkeys to evaluate its clinical, radiological & histological effect on the sinus Slide 116: Results showed that sinusitis can occur when Ca(OH)2 is deposited into the sinus There is an inflammatory response of the sinus mucosa to the material initially acting as a chemical irritant and later as a foreign body Few cases of extrusion of Ca(OH)2 have been reported by Erickson (1964) and Marais (1996). There were symptoms of sinusitis but despite the effects on the tissue, the cases showed spontaneous healing Slide 117: Sealers: There have been a few reports of extrusion of sealer beyond the apex into the max sinus. Orlay in 1966 reported a case in which N2 was used Pt complained of severe pain radiating around the trigeminal region After removal of the lateral wall of sinus and thorough irrigation to remove the N2 ball, the area healed and pain did not return Slide 118: Zinc oxide based Cements: It has been suggested that ZnO based cements and root filling materials when pushed beyond the apex into the sinus, promote an Aspergillus infection Aspergillosis of the max sinus is a relatively rare disease and is caused due to Aspergillus fumigatus The fungus needs heavy metals like zinc oxide for proliferation and metabolism Slide 120: Case report: 25 yr old woman complained of pain and sensitivity on chewing in 16 after RCT Extraoral Exam showed no swelling or lymph node involvement. Intraoral exam showed no sinus tract invl. or swelling Tooth was sensitive to vertical percussion PNS View & OPG showed root fillings of 16 extruded into max sinus Well defined radiopaque mass near opening of nasal cavity was observed (Ref: JOE, Vol 27, July 2001) Slide 121: Treatment involved periapical surgery with retrograde filling of the buccal roots, Antroscopy and removal of the foreign mass Surgery revealed a yellowish mass with a diameter of 6 mm Histological Exam. showed Aspergillosis with the root canal cement at the center of the mass and some calcification Fungal culture revealed Aspergillus niger Healing was unremarkable (Ref: JOE, Vol 27, July 2001) Slide 122: Gutta Percha: Sjogren et al in 1995 showed that GP evokes 2 distinct types of tissue response and the size of the GP determined the response Large pieces were well encapsulated and the surrounding tissue was free of inflammation Fine particles of GP evoked an intense, localized tissue response characterized by macrophages and multi nucleated giant cells Case Report:Kalpowitz in 1985 reported 2 cases with penetration of max sinus by GP extending through the palatal root of the max 1st molar : Case Report:Kalpowitz in 1985 reported 2 cases with penetration of max sinus by GP extending through the palatal root of the max 1st molar In the 1st case, this caused a chronic maxillary sinusitis which persisted for a year. Condition was later resolved by extraction of the tooth and long term anti histamines In the 2nd case, no significant complications were noted (Ref: IEJ, Vol 35, 2002) Slide 124: Silver Cones: These have been shown to cause sinusitis when over extended into the sinus Corrosion is a well known property of silver and can be a potential hazard when over extended Silver points when come in contact with tissue fluids, get corroded with formation of silver sulphide, silver sulphate and silver carbonate These are cytotoxic and when pushed into the sinus can be very harmful Peri Radicular Surgery of Posterior Maxilla : Peri Radicular Surgery of Posterior Maxilla Periapical surgery of the posterior maxillary teeth is not as common as that of the anterior teeth due to: Anatomic Considerations Limited field of operation Limited vision High risk of iatrogenic errors (Perforations >50%) Inexperience of operators Surgical approach to posterior teeth : Surgical approach to posterior teeth Buccal or Transantral Approach Easier to perform Provides more field for operation Better reapproximation (on sound bone) Less risk of perforations Palatal Approach Limited visibility Palatal flaps are time consuming and inconvenient Difficult to reapproximate after surgery Limited field of operation Pooling of blood Greater palatine NAV Surgical approach to posterior teeth(Transantral approach) : Surgical approach to posterior teeth(Transantral approach) Premolars: For single rooted PM’s – Buccal approach For multi rooted PM’s – Palatal root poses a challenge Buccal root is superficially placed and easily exposed Inter radicular bone is drilled away The root tip is resected a greater length in order to provide sufficient access to the palatal root The palatal root is then resected obliquely Slide 128: Alveolar bone is removed from in front of and below the root apex. NEVER FROM ABOVE ! The root tip should be ground down, rather than resected in order to avoid displacement into the sinus Apicectomy technique for Buccal roots in proximity to antrum Slide 129: Apicectomy technique for 2 rooted premolars Slide 130: Post Operative of Apicectomy in Upper Premolars Slide 131: Molars: Periapical Surgery Treated by Transantral or Buccal Route Buccal & Palatal Approach May involve Sinus Lift procedure Buccal approach for buccal roots & Coventional Tt. Of Palatal Root Bucco Palatal Cross Section of Upper Molar : Bucco Palatal Cross Section of Upper Molar Slide 133: The surgical resection of the Palatal root needs proper treatment planning Palatal roots are relatively wide and straight, thus amenable to conventional RCT Palatal roots are closest to the sinus membrane A buccal approach for the palatal root is risky because: Palatal root is placed very deep thus instrumentation is difficult Antrum is likely to be perforated Slide 134: Transantral approach for Molars: Raise full mucoperiosteal flap & remove Buccal bone Resect both buccal roots & open lateral wall of sinus (antero-lateral wall of Max.) using bone bur Stop as soon as bluish periostium of sinus appears Loosen periostium from base Of sinus and palatal root is exposed Resect at desired level and retro fill Slide 135: Post op X-Ray of of Upper 6, in which obturation is done for palatal canal and resection of buccal root tips Post Op X-Ray - Resection done in all 3 roots. Preventing Root Tip Loss : Preventing Root Tip Loss Drill a hole at the apex with a No. 2 Round bur. Prep can be done mesially and distally. Pass a 3/8 circle needle with 6-0 black braided silk to secure the tip after resection (Ref: Jerome & Hill - JOE Vol.21, 1995) Slide 137: Perforations: Perforation of the sinus membrane is a common feature of surgical endodontics Invasion into the sinus does not result in permanent alteration of either the sinus membrane or its function, provided proper post operative care is taken The mucous membrane along with the cilia regenerates in about 5 months time (Benninger, 1989) Slide 138: To Check for Perforation during surgery: Ask the pt. to puff gently with his nostrils closed. If there is an exposure; the Schnederian membrane will expand suggestive of escaping air Post – Op care & Instructions: Proper closure of the raised flap Antibiotic course with decongestants Pt is instructed to avoid raising the intra antral pressure by vigorous blowing, sneezing, smoking Slide 139: Caldwell – Luc Procedure Suggested by Henri Luc & George Caldwell 19th century Semi lunar incision is made in the buccal vestibule from canine to second molar area, just above the gingival attachment A mucoperiosteal flap is elevated till the infra orbital ridge. Care is taken to prevent injury to the infra orbital nerve An opening or window is created in the anterior wall of the maxillary sinus with the help of chisels, gouges or dental drills. The opening is enlarged in all directions to permit the inspection of the sinus The window created should be well away from the roots of maxillary teeth Sinus Lift Procedure : Sinus Lift Procedure Is a surgery that adds bone to the upper jaw in the area of molars and premolars to make it taller The bone is added between the jaw and the maxillary sinuses To make room for the bone, the sinus membrane has to be moved upward or "lifted" It is done when not enough bone is present in the upper jaw, or the sinuses are too close to the jaw, for dental implants to be placed or to carry out a periapical surgery Slide 141: Materials Used: Autogenous bone Allogeneic bone Synthetic materials Procedure: A flap is raised adjacent to premolars and molars The tissue is raised, exposing the bone. A small, oval window is opened in the bone The membrane lining the sinus on the other side of the window separates the sinus from the jaw Slide 142: This membrane is gently raised up and away from the jaw Granules of bone-graft material are then packed into the space where the sinus was present Platelet-rich plasma, which contains the growth factors, is taken from the patients blood before surgery and mixed with the graft Sutures are then placed and post operative instructions and medications given Thank You : Thank You In Conclusion… References : References Pathways of Pulp (9th Ed.) – Cohen Textbook of Endodontics (5th Ed.) – Ingel Medical problems in Dentistry (5th Ed.) – Cawson & Scully Maxillary Sinus & its dental implications – Killey & Kay Textbook of Maxillary Sinus – Mc’Gowan Contemporary OMFS (5th Ed.) – Peterson & Tucker Oral Radiology (4th Ed.) – White & Pharoah Human Anatomy – B.D. Chaurasia & A.K. Dutta Surgical Endodontics Colour Manual – I.E. Barnes Surgical Anatomy - Pervez Last’s Human Anatomy Orban’s Oral Histology (10th Ed.) International Endodontic Journal Journal of Endodontics Dental Clinics of North America Journal of Allergy & Clinical Immunology You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.