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Otolaryngol Clin N Am 37 (2004) 347–364 Maxillary sinus disease of odontogenic origin Pushkar Mehra, BDS, DMDa,b,c,*, Haitham Murad, DMDb,c a Department of Oral and Maxillofacial Surgery, Boston University Medical Center, Boston, MA b Department of Oral and Maxillofacial Surgery, Boston University School of Dental Medicine, 100 East Newton Street, Boston, MS 02118, USA c Department of Dentistry, Boston Medical Center, Boston, MA The maxillary sinus, anatomically lying in an intermediate positionbetween the nasal and oral cavities is vulnerable to invasion by pathogenicorganisms through the nasal ostium or the mouth. Odontogenic sinusitisaccounts for approximately 10% to 12% of maxillary sinusitis cases .Sinus disease of odontogenic origin deserves special consideration becauseof some diﬀerences in pathophysiology, microbiology, and management ascompared with sinus disease of other origins. Sinusitis related to dentistryand odontogenic causes can occur when the Schneidarian membrane isviolated by conditions such as odontogenic pathology of the maxillary bone,infections arising from the maxillary teeth, maxillary dental trauma, oriatrogenic causes such as dental extractions, placement of dental implants,and maxillary osteotomies in orthognathic surgery. Management of sinusdisease of odontogenic origin often requires treatment of the sinusitis as wellthe odontogenic source.Anatomy and physiology The maxillary sinus is part of a series of paranasal sinuses, which includesthe frontal, ethmoid, and sphenoid sinuses. These pneumatic cavitiessurround the nasal cavity and are in close approximation to the orbital wallsand dura mater of the anterior cranial fossa. The maxillary sinus is the ﬁrst * Corresponding author. Department of Oral and Maxillofacial Surgery, Boston UniversitySchool of Dental Medicine, 100 East Newton Street, Suite G-407, Boston, MA 02118. E-mail address: firstname.lastname@example.org (P. Mehra).0030-6665/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.doi:10.1016/S0030-6665(03)00171-3
348 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364of the paranasal sinuses to develop in the third month of fetal life. Aprimary pneumatization process occurs as an invagination of nasalepithelium oﬀ the ethmoid infundibulum, a recess between two parts ofthe future ethmoid bone, the uncinate process and ethmoidal bullae. Duringthe ﬁfth month of fetal life, the maxillary sinus begins to grow into theadjacent growing maxilla. Final growth of the maxillary sinus takes place between 12 to 14 years ofage and corresponds with the eruption of permanent teeth and growth of thealveolar process of the upper jaw . In children and young teenagers thereis considerable distance between the ﬂoor of the sinus and the apices of themaxillary teeth, because the sinus has not reached an adult size. Atcompletion of growth the maxillary sinus is bounded by the orbital ﬂoor, thelateral nasal walls, and the dento-alveolar portion of the maxilla and mayextend into the palatine and zygomatic bones. The average volume ofa developed sinus at maturity varies between 15 and 20 mL, almost doubleits size at birth. Although these dimensions remain relatively stable once thepermanent maxillary teeth have erupted and growth of the maxilla iscomplete, continued expansion and pneumatization occurs in some patientsthroughout life . In the dentate individual, continued expansion causes inferior displace-ment of the sinus ﬂoor toward the roots of the maxillary posterior teeth(Fig. 1). The roots of the maxillary teeth may protrude into the sinus cavity,and occasionally the expansion can be so extreme so as to leave only thesinus mucoperiosteum surrounding the apical aspects of the dental roots[4,5]. In patients with maxillary tooth loss, the sinus often pneumatizesinferiorly to form a recess between the remaining teeth in the part of thealveolar bone that was previously occupied by the missing tooth (Fig. 2). Inthe completely edentulous person, the sinus may expand further andcontinue to extend into the alveolar bone, sometimes to the point that onlythin alveolar bone remains between sinus and the oral cavity (Fig. 3) .Therefore, there is a signiﬁcant diﬀerence in the height of the sinus ﬂoorbetween dentulous and edentulous patients. Many edentulous patients nowrequest implant-supported denture-type dental prostheses. Lack of adequatebone resulting from sinus pneumatization does not permit placement ofdental implants, and thus these patients require preprosthetic surgicalprocedures such as alveolar ridge augmentation with bone grafting andsinus membrane elevation procedures (Fig. 4). In general, roots of the central and lateral incisor teeth are not in closeproximity to the maxillary sinus. The roots of the maxillary premolars andmolars, however, are consistently located below the sinus ﬂoor. The roots ofthe second molars are in closest proximity to the sinus ﬂoor, followed infrequency by the roots of the ﬁrst molar, third molar, second premolar, ﬁrstpremolar, and canine . One study using CT scanning of the humanmaxilla found that the apex of the mesiobuccal root of the maxillary secondmolar was closest to the sinus ﬂoor (mean distance of 1.97 mm), and the
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 349Fig. 1. (A) A panoramic radiograph showing pneumatization of the left sinus into the furcationof the maxillary molar roots. The roots appear to protrude into the sinus cavity. This patientrequired extraction, and a sinus perforation was expected. (B) The extracted maxillary molar.Notice the cup-shaped area between the roots; this was the actual ﬂoor of the maxillary sinus(solid arrow) with thin areas of intervening alveolar bone (open arrow).apex of the buccal root of the maxillary ﬁrst premolar was furthest from thesinus ﬂoor (mean distance of 7.5 mm) . The lateral wall of the maxilla forms the anterior wall of the sinus. Itsthickness varies from 2 to 5 mm, with the thinnest portion in the center ofthe canine fossa. The labial levator muscles and the orbicularis oculi muscleare attached to this wall above the infraorbital foramen. The attachments ofthese muscles usually direct the spread of infection from the maxillary teethto the maxillary sinus once it penetrates the anterior sinus wall.Microbiology There has been controversy as to the identities of the normal ﬂora of thesinuses because access for culture is diﬃcult and involves passage through
350 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364Fig. 2. Coronal CT scan view of a right maxillary sinus and associated maxillary teeth.Pneumatization has occurred into the area of a previously extracted tooth (arrow).the nasal or oral cavities. In a series of 12 patients, Brook  isolatedStreptococcus (S.) viridans, beta-hemolytic streptococci, Group A strepto-cocci, S. pneumonia, Staphylococcus aureus, Hemophillus (H.) parainﬂuenza,enterobacteria, anaerobes, other gram-positive and -negative cocci, andbacilli . Although few researchers still contend that the sinuses are sterile,it is generally accepted that the sinus has its own speciﬁc microﬂora, and thelist of organisms identiﬁed by Brook  is well accepted. Improved samplingusing needle aspiration of the sinus rather then sampling through the nareshas led to the identiﬁcation of anaerobes in more isolates. The ﬂoraresponsible for disease depend on the chronicity of the disease and thesource. It is generally accepted that the three most common isolates in acutesinusitis are S. pneumonia, H. inﬂuenza and, in children, Branhamellacatarrhalis . Medical therapy aimed at treatment of acute sinusitisincludes an antibiotic, which is eﬀective against these microorganisms.Repeated bouts of acute sinusitis or persistent acute sinusitis can eventuallyleave the patient with a chronically diseased sinus. The ﬂoral spectrum inchronic sinusitis diﬀers mainly because the obstructed ostium and in-ﬂammation produce changes in the Schneidarian membrane and reduce theoxygen tension within the sinus, thus providing an optimal environment forgrowth of anaerobic species. Purulence formation further reduces theoxygen tension, at times reducing redox potentials to negative values. Thegrowth of anaerobes further complicates treatment, because anaerobesdevelop greater antibiotic resistance than aerobes. Many species ofPropionobacterium, Eubacterium, and Actinomyces are now resistant tometronidazole . Penicillin, an excellent antibiotic for odontogenicinfections, is also ineﬀective because of increased beta-lactamase productionamong anaerobic gram-negative bacilli .
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 351Fig. 3. (A) Panoramic radiograph of an edentulous maxilla showing severe resorption andpneumatization of the maxillary sinus (arrows). The treatment plan was for this patient toreceive an implant-supported maxillary denture. (B) Bilateral maxillary sinus lifts wereperformed to obtain an adequate height and width of bone for implant placement. Bone graftswere harvested from the iliac crest. Radiograph shows the implants placed into the region of thegrafted maxilla and sinus lifts (arrows). Notice the radiographically clear sinus. Sinusitis aftersinus lift and bone grafting is an uncommon complication. Viral upper respiratory tract infections are known to predispose themaxillary sinus to infection because of the interference with mucociliaryfunction and narrowing of the ostium . Viruses are present in themaxillary sinus in a signiﬁcant percentage of sinusitis cases, but no role ofa virus as a causative agent has been elucidated . Fungi are ubiquitous, and humans breathe in their spores. They rarelycause invasive disease in immune-competent patients. Acute or chronicinvasive fungal sinusitis mostly befalls immune-compromised individualssuch as uncontrolled diabetics, AIDS patients, or with those with drugimmunosuppression.
Fig. 4. (A) CT scan view of the anterior maxilla showing an edentulous region, with sinuspneumatization. The patient had suﬀered from loss of maxillary and mandibular teeth and bonebecause of maxillary and mandible fractures. An implant was planned for the area. (B) Becauseof inadequate bone height for dental implant placement, a sinus lift and bone grafting of thearea was performed. (C) Dental implants have been placed into the grafted maxilla. Notice thelack of radiographic signs of sinusitis.
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 353 The oral ﬂora responsible for odontogenic infections are the same asthose implicated in odontogenic maxillary sinusitis , that is, mixedaerobic and anaerobic ﬂora including Streptococci spp, Bacteriodes,Viellonella, Corynebacterium, Fusobacterium, and Eikenella . Oralsecretions are heavily contaminated, and quantitative estimations of thenumber of microorganisms in saliva and dental plaque, especially deep ina periodontally diseased pocket, can be as high as 1.8Â1011/g of material,the same levels as in human feces. Given these facts, it is not diﬃcult toimagine the high risk of sinus infection after insult with a bacteria-ladendisplaced tooth root.Pathophysiology Although most infections from the maxillary teeth usually occur assequelae of dental caries, other causes such as periodontal disease have beenimplicated in some cases. Dental decay initially aﬀects the outermost enamellayer and, if not treated, extends into the innermost dental pulp afterdissolution of the middle dentin layer. Once the infection enters the dentalpulp, it ultimately causes death of the pulpal elements, causing theformation of pus. Bacterial toxins such as those produced by group Ahemolytic streptococci damages the endothelial lining of the pulpal vessels.Bacterial enzymes such as collagenase are considered potent virulencefactors in the pathogenesis of bone invasion. The body is unable to eliminatethe source of the dental infection eﬀectively because the necrotic pulp isprotected in the root canal of the tooth. Lysosomal enzymes released fromphagocytic neutrophils cause immunopathologic tissue damage. A dentalabscess is thought to be the result of lysosomal enzymes released fromneutrophilic granulocytes participating in the defense of the host againstinfection. The action of these enzymes and toxins is tissue breakdown,including bone resorption, which follows a path of least resistance. Muscleattachments, fascial layers, and bone act as barriers to the spread ofinfection. Odontogenic infections, if left untreated, perforate into the alveolar bonethrough the foramina at the apex of the tooth root tips. In the maxilla,infections from the teeth generally spread through the thin buccal alveolarbone and into the buccal soft tissue vestibule. On occasion, infections,especially from the palatal root of the maxillary molars or from lateralincisor roots, can spread subperiosteally and dissect into the hard palate.Odontogenic infections can spread to the orbit through the sinus or by otherroutes (Fig. 5) . Although odontogenic infections are extremely common, the incidence ofsinusitis seen with these dental infections is extremely low. Only rarely doodontogenic infections penetrate directly into the maxillary sinus or ﬂoor ofthe nose, probably because the ﬂoors of the sinus and nose are composedof dense cortical bone when compared with the lateral wall of the maxilla.
354 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364Fig. 5. (A) Axial CT showing a displaced tooth root into the right maxillary sinus causingsinusitis. (B) The sinusitis of odontogenic origin has caused an orbital cellulitis with subsequentinﬂammation of the right inferior rectus muscle.Because the weak lateral wall of the maxilla can be penetrated more readilythan the ﬂoor of the sinus, most odontogenic infections present as soft tissuevestibular or fascial space infections rather than sinusitis. In some patients,however, odontogenic infections can drain into the sinus, especially when the
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 355roots are in close proximity to the maxillary sinus ﬂoor. There may bepaucity of clinical symptoms because the sinus is an open cavity, and pressurein the unyielding tooth structure is relieved as the infection drains superiorlyinto an open space. Clinical symptoms gradually increase as sinusitisincreases in severity. In the authors’ experience, sinus infection from a dentalsource seen in clinical practice is caused more often by iatrogenicdisplacement of a maxillary tooth (Fig. 5) with its entourage of bacteriarather than by spread of infection from the tooth directly into the sinus. Some common causes of maxillary sinusitis related to dentistry are theiatrogenic displacement of a maxillary tooth root tip into the sinus duringextraction, perforation of the sinus membrane during exodontia, andextrusion of materials used in root canal therapy into the sinus. When teethadjacent to a lone-standing molar have been removed, alveolar bone isresorbed over time mesial and distal to the remaining tooth. This resorptionresults in thinner alveolar bone separating the oral cavity and sinus. If ata later time the lone-standing molar requires extraction, the risk of alveolarbone or maxillary tuberosity fracture with concomitant oroantral commu-nication is high. Other oral and maxillofacial surgery or dental procedures,such as maxillary orthognathic surgery, preprosthetic surgery, sinusmembrane lifts and sinus grafting, and dental implant placement, haveoccasionally been cited as causing sinusitis. The incidence of sinusitis withthese procedures, when properly performed is almost nonexistent, however(see Fig. 4) .Odontogenic pathology Lesions within the maxillary sinus can be derived from the sinus tissues orfrom the teeth and their surrounding structures. Cysts and similar processesarising from sinus mucosa are classiﬁed as pseudocysts, retention cysts, andmucoceles. The pseudocyst is not a true cyst in that it results from ﬂuid accumulationbeneath the inner sinus periosteum with subsequent ballooning of the sinusmucosal surface into the sinus cavity. Pseudocysts are seen in panoramicradiographs as dome-shaped soft tissue shadows within the antrum that areusually solitary although sometimes bilateral. Periapical and periodontaldisease of odontogenic origin have been implicated in the formation ofpseudocysts. They generally require no treatment, although removal of thedental source of infection through root canal therapy, periodontal therapy,or extraction of teeth may help resolve the pseudocyst. Sinus polyps, on the other hand are usually removed in cases of chronicsinusitis. Polyps are masses of accumulated ﬂuid in the connective tissue ofsinus mucosa. Of more concern are mucoceles. Mucoceles are expansile andpotentially destructive lesions, which occur rarely in the maxillary sinus butare more commonly found in the frontal and ethmoid sinuses. Odontogenicdisease does not directly cause sinus polyps.
356 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 Odontogenic cells may be precursors for lesions that invade the maxillarysinus. Examples of some lesions include odontogenic keratocysts, radicularcysts, ameloblastoma, odontoma, cementoma, calcifying odontogenic cyst,and ossifying ﬁbroma. By far the most common of these lesions is theradicular cyst, which may rarely cause erosion into the maxillary sinus.More often, radicular cysts cause expansion and thinning of the bony wallwithout perforating it. The radicular cyst is an inﬂammatory lesion found atthe apex of infected tooth roots and is characteristically seen as a periapicalradiolucent lesion associated with a carious tooth (Fig. 6). Periapicalgranulomas and abscesses may have a similar radiographic appearance.Radicular cysts are treated by removal of the odontogenic source (root canaltherapy or extraction of the tooth). Conservative enucleation may also beneeded in some cases. Odontogenic keratocysts (OKCs) are derived from the remnants of thedental lamina. An OKC is an odontogenic lesion, which usually presentsincidentally on a dental radiograph as a radiolucency associated with animpacted tooth (Fig. 7). Large lesions may be associated with pain, swelling,and facial asymmetry. Odontogenic keratocysts have characteristic histologyand are divided into three subtypes based on their keratinization character-istics. The parakeratinized variant is the most common subtype, andrecurrence rates of approximately 35% over a 5-year period have been citedin the literature . At times dysplastic changes can occur in the walls ofthese lesions. Because of their locally aggressive destruction of bone, theyreadily extend from the maxillary bone into the maxillary sinus. Enucleationand curettage with peripheral ostectomy of the bony walls is the acceptedtreatment for most OKCs (Fig. 7). Chemical curettage with Carnoy’s solutionand cryosurgery have also been used in an attempt to decrease recurrencerates. Occasionally, these cysts present as multiple lesions as in patients withGorlin-Goltz syndrome (Fig. 8). Because OKCs are locally aggressive andhave a high rate of recurrence, and because there is a generalized lack ofcortical boundaries in the maxilla, some clinicians advocate aggressive radicalsurgery for maxillary OKC lesions. Although odontogenic tumors are relatively infrequent, many have beenreported to occur in the maxilla. Benign odontogenic tumors seen in themaxillary sinus include ameloblastoma, calcifying epithelial odontogenictumor, squamous odontogenic tumor, odontogenic myxoma, and adeno-matoid odontogenic tumor. The ameloblastoma is a relatively commontumor representing 1% to 5% of all odontogenic lesions. Management isdiﬃcult because of its aggressive nature and inﬁltration into medullaryspaces that may appear clinically and radiographically normal. Recurrenceis relatively high with conservative surgery. Involvement of the maxillarysinus may result from direct extension from the maxillary alveolus or fromameloblastic changes in a dentigerous cyst . The dentigerous cyst isa benign expansive lesion derived from hydrostatic expansion of a dentalfollicle and surrounds the crown of an unerupted tooth. Because of the
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 357Fig. 6. (A) Parulis on the buccal gingival opposite a premolar tooth. (B) Plain radiographshowing the premolar tooth with a radiolucent bone-lytic lesion surrounding the apex of thetooth root. The arrow indicates where the lesion invades the ﬂoor of the sinus. (C) Odontogenicperiapical pathology originating from the premolar tooth has invaded the ﬂoor of the maxillarysinus (arrow). There is associated reactive sinus mucosal thickening.ameloblastoma’s aggressive nature, a 1-cm radiographic margin of healthytissue resection is indicated. Unfortunately, once invasion of the maxillarysinus occurs, complete excision can be diﬃcult because of surrounding vitalstructures. Access can be obtained through a modiﬁed Caldwell-Lucapproach with the osteotomy window made more posteriorly or a LefortI osteotomy with down-fracture of the maxilla.Clinical presentation Diagnosing sinus disease of odontogenic origin requires a thoroughevaluation of the patient’s subjective symptoms and past medical history
358 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 Fig. 6 (continued )and their correlation with physical ﬁndings. Patients may complain of toothpain, headaches, and anterior maxillary tenderness in addition to symptomsof sinusitis-like nasal congestion and discharge with or without a postnasaldrip. A history of sinus disease, allergic rhinitis, oroantral communication,or foreign body displacement into the sinus will help amplify the diagnosis.Dental symptoms can range from acute sharp pain associated with anexposed tooth nerve to the dull ache of a dental infection that has extendedinto the bone surrounding the apex of a root (periapical periodontitis).Periodontal disease or disease of the gums and supporting structures of thetooth can cause pain. Patients with acute sinusitis frequently complain oftoothaches and sensitivity of multiple adjacent maxillary teeth. Referredpain from symptomatic teeth to adjacent structures is also common. It issometimes diﬃcult to elicit whether symptoms are of odontogenic or sinusorigin, and this diﬃculty unfortunately can lead to noninfected teeth beingsubjected to root canal therapy or extraction. A thorough dental and sinusevaluation with appropriate radiographs will help with the diagnosis. Physical examination includes inspection of the buccal soft tissue andbuccal vestibule for swelling and erythema, although this ﬁnding isuncommon with maxillary sinusitis. Maxillary sinusitis rarely causes softtissue swelling because of the lack of anastomosing veins connected to theoverlying subcutaneous tissue, although long-standing chronic sinusitismay erode the sinus wall and produce a visible intraoral soft tissue swelling. A tooth with a diseased apical root may be a nidus for sinusitis. Palpationof the anterior maxilla may produce dull pain. Percussion of the maxillaryteeth should be cautiously performed with a dental mirror to see if the pain
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 359Fig. 7. (A) A third molar tooth impacted within the right maxillary sinus and surrounded bya large pericoronal radiolucent lesion (arrows). (B) Postoperative panoramic radiograph afterremoval of tooth and curettage of associated lesion. Histopathologic examination resultsconﬁrmed the cyst to be a parakeratinized odontogenic keratocyst.can be localized to one tooth or if multiple teeth are symptomatic. Electricor thermal pulp testing can be used to assess vitality of teeth to further aid indiagnosis. Further evaluation using rhinoscopy, nasal endoscopy, sinusendoscopy, aspiration of sinus contents, and aspiration cytology helps in thediagnosis.Diagnostic imaging The panoramic radiograph is a standard radiograph used in dental oﬃces.This view is useful for evaluating the relationship of the maxillary dentition tothe sinus, pneumatization, and pseudocysts (see Fig. 1). The overlap of thehard palate limits the usefulness of this examination for thorough evaluation
360 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364Fig. 8. Axial CT scan of a patient with Gorlin-Goltz syndrome showing multiple small OKCsof the right maxillary sinus and a large OKC of the mandible. The patient was treated withcurettage and application of Carnoy’s solution in the maxilla. The anterior mandible wasresected and reconstructed with iliac crest bone graft and platelet rich plasma.of the sinuses. A panoramic radiograph is useful for identifying displacedroots, teeth, or foreign bodies in the sinus. Alternatively, a Water’s view plain-ﬁlm radiograph can be used. The ability to visualize bone and soft tissue andobtain thin sections and multiple views makes the CT scan the standard formaxillary sinus imaging. Axial and coronal views of the sinus may show therelationship of a periapical odontogenic abscess to a sinus ﬂoor defect anddiseased sinus tissue (see Fig. 6). Also, the exact location of a foreign bodywithin the maxillary sinus can be determined with this technique.
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 361Management Treatment of odontogenic sinusitis usually requires a combination ofmedical and surgical management. Elimination of the source (eg, removalof a foreign tooth root from the sinus or treatment of an infected toothby extraction or root canal therapy) is required to prevent recurrence of thecondition. Medical management often includes a 7- to 14-day course of oralantibiotics with adequate sinus and oral ﬂora coverage. Antibiotics may becombined with use of systemic nasal decongestants and 2 to 3 days of localnasal decongestant therapy in addition to moisturizing nasal drops andsaline sprays. The proximity of the maxillary teeth to the antrum, especially ina pneumatized sinus, can sometimes leave only the mucoperiosteum(Schneidarian membrane) separating the sinus cavity from the tooth roots.In sinus surgery this condition sometimes can be seen as maxillary teethroots covered in sinus membrane protruding into the sinus ﬂoor. Duringtooth extraction, forces are placed on the alveolar bone encasing the rootsand on the teeth themselves. Widely divergent roots, carious teeth, or heavilyrestored teeth make extraction diﬃcult, because the roots tend to fractureunder luxation. Remaining roots can sometimes be removed only byjudicious removal of alveolar bone surrounding them; at times this processmay remove thin bone separating sinus membrane from the oral cavity witha resultant sinus exposure. Apical force on the roots during extraction candisplace the root into the maxillary sinus. If a periapical cyst, granuloma, orperiapical infection has eroded the surrounding bone, the tooth may bedisplaced more easily. An entire tooth can be displaced into the sinus,especially during removal of a maxillary third molar (wisdom tooth). Ifdisplacement occurs, a conservative eﬀort to remove the root tip through thesocket is indicated. If no perforation of the sinus membrane is seen, and it isbelieved the root fragment is 3 mm or less in size and uninfected, the root canbe left in place to reduce morbidity to the patient . The patient is givenstandard sinus precautions and medical treatment including decongestantsand antibiotics. The patient should have frequent follow-up visits until thedefect heals completely and no signs of sinusitis develop. If the dental root tip is infected or is greater than 3 mm in size, primaryretrieval is indicated . To verify the position of the foreign body,intraoperative radiographs, including panoramic, periapical, or anteropos-terior skull views, can be used. Once the position of the dental foreign bodyis veriﬁed, primary removal is indicated. Removal is best accomplished byreﬂecting a full-thickness mucoperiosteal ﬂap superior to the extractionsocket or in the canine-premolar recess. A window is made in the buccalalveolar process with judicious bone removal using a bone drill underirrigation. Once access to the sinus is achieved, the root tip can usually bevisualized and retrieved. The advantages of this technique over widening theextraction socket are the ability to cover the osteotomy with the reﬂected
362 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364buccal ﬂap at a non–gravity-dependent site and better visualization from ananterior and buccal approach, especially in maxillary posterior (second andthird molar areas). If one elects to remove the root from the extractionsocket, a large oroantral communication at the extraction socket results thatis much more diﬃcult to cover primarily. If primary closure with a simplebuccal ﬂap is unsuccessful, more signiﬁcant ﬂap advancement (use of localﬂaps from the palate, buccal fat, facial artery-muscle combination, or othertechniques) may be indicated. A double-layered closure using the buccal fatpad with another local ﬂap is also commonly employed in the oral andmaxillofacial surgery oﬃce setting . Although extremely simple toperform, the buccal sliding ﬂap does have the signiﬁcant disadvantage ofdecreaseing the depth of the buccal vestibule. This reduction in vestibularsize frequently causes a problem during restoration of the edentulous areas,because conventional dentures need adequate vestibular depths for re-tention. If primary retrieval cannot be accomplished, a radiograph is taken tovisualize the displaced root. The patient is treated with antibiotics anddecongestants and is given sinus precaution instructions. Classically,delayed retrieval through a modiﬁed Caldwell-Luc approach is indicatedwhen primary retrieval is unsuccessful. Sources of infection must beremoved. Generally, maxillary sinus mucosa should be preserved, and onlychronically diseased and irreversibly damaged mucosa should be judiciouslycurettaged. Lavage of the sinus cavity with saline or antibiotic solution isusually performed, and a nasal antrostomy is made if needed to keep theostium patent. The value of a nasal antrostomy in the presence of a patentostium is questionable, however. Finally, in selected cases, sterile gauzedressing impregnated with bacitracin can be used temporarily to pack thesinus. This dressing is pulled through the nasal antrostomy and out throughnares after 48 to 72 hours because keeping it in place can causecomplications such as toxic shock syndrome. More recently, less invasive endoscopic shaver-assisted techniques havebeen advocated for treatment of chronic maxillary sinusitis of dental origin.The technique entails antrostomy and removal of irreversibly diseasedtissue, polyps, and foreign bodies through the antrostomy window .Delayed retrieval of a foreign body from the maxillary sinus may requirefurther imaging studies, such as a CT scan, if the position cannot be veriﬁedby the radiographs taken in the dental clinic or if signiﬁcant sinus disease isinvolved. Oroantral communication is another relatively common complication ofdental surgery. Successful management depends largely on primary closureof the defect and adequate medical management. Once a sinus communica-tion has been diagnosed following dental surgery such as extraction, the sizeof the defect must be assessed. Defects of 5 mm or less generally closespontaneously in compliant patients. Use of a resorbable barrier, such asabsorbable gelatin sponge (Gelfoam, Ferrosan Inc., Soeborg, Denmark) to
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364 363cover and protect the defect during the initial stages of healing is prudent. Ifthe size of the defect is greater than 5 mm, primary closure is indicated andcan generally be accomplished with standard surgical techniques such asbuccal advancement ﬂaps, palatal island ﬂaps, full- or split-thickness palatalpedicle ﬂaps, gold foils, or buccal fat pad pedicle ﬂaps . For refractorycases, other surgical techniques such as buccinator ﬂaps, temporalis ﬂaps, andtongue ﬂaps are indicated. In the author’s experience, all these techniques,when properly executed with sound surgical principles, have good successrates. For predictable results, it is paramount to perform any reconstructiveeﬀort in a disease-free sinus environment. Performing surgery at the oro-antral communication site in the presence of acute infection in the sinus itselfwill most likely result in failure of the surgery.Summary Odontogenic sinusitis is a well-recognized condition and accounts forapproximately 10% to 12% of cases of maxillary sinusitis. An odontogenicsource should be considered in patients with symptoms of maxillary sinusitiswho give a history positive for odontogenic infection or dentoalveolarsurgery or who are resistant to standard sinusitis therapy. Diagnosis usuallyrequires a thorough dental and clinical evaluation with appropriate radio-graphs. Common causes of odontogenic sinusitis include dental abscessesand periodontal disease perforating the Schneidarian membrane, sinusperforations during tooth extraction, or irritation and secondary infectioncaused by intra-antral foreign bodies. The typical odontogenic infection isnow considered to be a mixed aerobic–anaerobic infection, with the latteroutnumbering the aerobic species involved. Most common organisms includeanaerobic streptococci, Bacteroides, Proteus, and Coliform bacilli. Typicaltreatment of atraumatic odontogenic sinusitis is a 3- to 4- week trial ofantibiotic therapy with adequate oral and sinus ﬂora coverage. Whenindicated, surgical removal of the oﬀending odontogenic foreign body(primary or delayed) or treatment of the odontogenic pathologic conditionscombined with medical therapy is usually suﬃcient to cause resolution ofsymptoms. If an oroantral communication is suspected, prompt surgicalmanagement is recommended to reduce the likelihood of causing chronicsinus disease.References Maloney PL, Doku HC. Maxillary sinusitis of odontogenic origin. J Can Dent Assoc 1968; 34:591–603. Abubaker A. Applied anatomy of the maxillary sinus. Oral Maxillofac Clin N Am 1999; 11(1):1–14. Sicher H. The viscera of head and neck. In: Oral anatomy. St Louis (MO): CV Mosby; 1975. p. 418–24.
364 P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364  Kelley HC, Kay LW. The maxillary sinus and its dental implications. In: Dental practice handbook. Bristol (UK): John Wright and Sons; 1975. p. 1–13.  Skillern RH. Maxillary sinus. In: The catarrhal and suppurative diseases of the accessory sinus of the nose. Philadelphia: JB Lippincott; 1947. p. 104–25.  Eberhardt JA, Torabinejad M, Christiansen EL. A computed tomographic study of the distances between the maxillary sinus ﬂoor and the apices of the maxillary posterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1992;73:345.  Brook I. Aerobic and anaerobic bacterial ﬂora of normal maxillary sinuses. Laryngoscope 1981;91:372–6.  Weymouth W. Microbiology of the maxillary sinus. Oral Maxillofac Surg Clin N Am 1999; 11(1):21–34.  Su W-Y, Liu C, Hung S-Y. Bacteriological study in chronic maxillary sinusitis. Laryngoscope 1983;93:931–4. Finegold SM, Wexter HM. Present status of therapy for anaerobic infections. Clin Infect Dis 1996;23(Suppl 1):S9–S14. Sandler NA, Johns FR, Braun TW. Advances in the management of acute and chronic sinusitis. J Oral Maxillofac Surg 1996;54(8):1005–13. Mehra P, Caiazzo A, Bestgen S. Odontogenic sinusitis causing orbital cellulitis: a case report. J Am Dent Assoc 1999;130:1086–92. Timmenga N, Raghoebar GM, Boering G, Weissenbruch RV. Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 1997;55:936–9. Eversole L. Craniofacial ﬁbrous dysplasia and ossifying ﬁbroma. Oral Maxillofac Clin N Am 1991;3:173–90. Diecidue R. Diagnosis of benign lesions of the maxillary sinus. Oral Maxillofac Surg Clin N Am 1999;11(1):35–44. Rafetto L. Clinical examination of the maxillary sinus. Oral Maxillofac Surg Clin N Am 1999;11(1):35–44. Gonty A. Diagnosis and management of sinus disease. In: Peterson LJ, editor. Principles of oral and maxillofacial surgery, vol. 1. Philadelphia: J.B Lippincott; 1992. p. 225–66. Kraut R, Smith R. Team approach for closure of oroantral and oronasal ﬁstula. Atlas Oral Maxillofac Surg Clin N Am 1999;8:55–75. Lopatin A, Sysolyatin SP, Sysolyatin PG, Melnikov MN. Chronic maxillary sinusitis of dental origin: is external surgical approach mandatory? Laryngoscope 2002;112:1056–9.
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