1. Maxillary
sinus
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IINNDDIIAA((AASSIIAA))

2. Development and
Anatomy

3.  The maxillary sinus is the first of the paranasal
sinuses to develop.
 Appears as a lateral evagination or pouch of
the mucous membrane of the middle meatus of
the nose at about the third month of intra-uterine
life.
 The neck of the pouch remains small and
forms the future ostium.

4.  At birth,
 less than a cm in any direction
 Expands by pneumatization into the
developing alveolar process
 Later on, extends anteriorly and inferiorly from
skull base closely matching the growth rate of
the maxilla and the developing dentition
 Expansion ceases after eruption of the
permanent teeth

7. Paranasal sinuses in the adult and there
communications

8.  Largest of the paranasal sinuses, pyramidal
shape, the base being the lateral nasal wall
and the apex extends into the zygomatic
process of the maxilla
 The upper wall or the roof of the sinus is also
the floor of the orbit
 The floor of the sinus forms the base of the
alveolar process

9.  The posterior wall extends the length of the
maxilla and dips into the maxillary tuberosity
 Anterolaterally the sinus extends into the
region of first bicuspid or cuspid teeth
 Opens into the nasal cavity through the middle
meatus
 The average diameter would be from 30-34mm
and volume being about 15cc

10.  Blood supply –
From small artery derived from the facial,
maxillary, infra-orbital, and greater palatine
arteries.
 Venous drainage –
Accompany the arteries and drain into
anterior facial vein pterygoid plexus
 Lymphatic drainage –
Submandibular lymphatic glands

11. Physiology
 Sinuses lined by respiratory epithelium –
mucous-secreting pseudostratified ciliated
columnar epithelium and periosteum.
 Mucociliary mechanism provides the means for
the removal of particulate matter and bacteria.
 Mucous and other debris discharged into the
middle meatus of the nose.

12. Functions
 Impart resonance to the voice during speech.
 Lighten the skull.
 Warm the inspired air
 Increases the surface area

13. Investigations

14. Radiological examination
Normal – WWeellll ddeeffiinneedd rraaddiioo ooppaaqquuee mmaarrggiinnss
wwiitthh rraaddiioolluucceennccyy tthhrroouugghhoouutt

15. CCoommmmoonn RRaaddiiooggrraapphhss
-- WWaatteerr’’ss VViieeww ((1155° OOcccciippiittoo –– mmeennttaall))
-- SSuubbmmeennttoovveerrtteexx vviieeww
-- LLaatteerraall vviieeww ooff tthhee ssiinnuusseess
-- IIOOPPAA rraaddiiooggrraapphh

16. WWaatteerr’’ss VViieeww ((1155° OOcccciippiittoo –– mmeennttaall))

17. SSuubbmmeennttoovveerrtteexx vviieeww

18. LLaatteerraall vviieeww ooff tthhee ssiinnuusseess

19. IIOOPPAA rraaddiiooggrraapphh

20. IInnffeeccttiioonnss
MMuuccoossaall LLiinniinngg tthhiicckkeennss
(( RRaaddiioolluucceennccyy ))
RRaaddiioo ooppaacciittyy
SSoolliidd MMaasssseess
AAnnttrroolliitthh
OOsstteeoommaa
FFiibbrroo oosssseeoouuss lleessiioonnss
DDeennssee rraaddiioo ooppaacciittiieess

21. Cysts
Round or oval radiolucency circumscribed by a
sharp radio opaque margin

22. ‘‘YY’’ sshhaappeedd lliinnee ooff EEnnnniiss
The line of junction of the lateral wall of the nose
and the nasal floor is represented by the long leg of
the letter ‘y’. A cyst in the area obliterates & modifies
the typical pattern.

23. RReellaattiioonnsshhiipp ooff tthhee ssiinnuuss wwiitthh
tthhee MMaaxx.. MMoollaarrss

24. Additional Investigations
 CT
 MRI
 FESS
 Biopsy/FNAC
 Trans-illumination

25. CT SCAN

26. Diseases of
maxillary sinus

27. Inflammation
Benign lesions Malignancy
Maxillary Sinus
Fibro osseous lesions Fungal infections

28. Sinusitis (acute / chronic)
Commonly..
Causes:
 Spread of infection from a dental abscess
 Facial fracture involving the maxillary sinus
 Tooth or root in the maxillary sinus
 Oro-antral fistulae
 Cysts
 Polyps
 Thickening of the sinus walls
 Dental prosthetic material (rear)

29. Acute maxillary sinusitis
Symptoms:
 Heavy felling in the face.
 Throbbing pain in the upper part of the cheek or entire of
the face which increases on bending the head.
 Foul unilateral discharge
 Foul taste in the mouth
 Pyrexia
 Nocturnal coughing

30. Chronic maxillary sinusitis
Symptoms:
 History of repeated attacks of acute mucopurulent rhinitis.
 Pain and tenderness are common.
 Diagnosis depends on long history of standing nasal or
post nasal discharge.
 Inspection of oropharynx frequently confirm the existence
of a descending pharyngeal exudate.
 Pain is feature of chronic sinusitis of dental origin.
 Lump on the gum

31. Management of
sinusitis

32. Non – Surgical
Surgical
Management of sinusitis

33. Medical (non-surgical)…
 Analgesics (for acute form)
 Anti-histamines
 Topical intranasal steroid
 Antibiotics
 Remove source of infection
 If no improvement…surgical intervention
 Decongestants
 Steam inhalation

34. Surgical options…
 Caldwell-Luc antrostomy
 Needle sinusotomy
 Functional Endoscopic Sinus Surgery (FESS)
 Maxillectomy = malignancy

35. Trouble-shooting Areas Of
Dental Interest
 Displacement of root into the sinus
 Fracture of the maxillary tuberosity
 Oro-antral Fistula

36. Root displacement into the
antrum
 Sudden disappearance of the root from the
socket during extraction
 Accompanied by
a) Unilateral epistaxis
b) Escape of fluids from the mouth into the
nose
c) Passage of air into the mouth when the
patient sucks or swallows

37.  Alteration in vocal resonance
 Difficulty in blowing out the cheeks or
drawing on a cigarette

38. Delayed clinical
disturbances
 Unilateral nasal discharge of pus
 Foul or salty taste
 Facial pain
 Sinusitis

39. Radiological examination
 Periapical view positioned well apically
 True occlusal radiograph

40. Indications for removal
 Small fragments - probably unnecessary
surgery
 Secondary infection, severe sinusitis

41. Surgery for removal
Caldwell-Luc
Operation

42. CAUSES:
 Invasion of tuberosity by the antrum
 Common in isolated maxillary molars
 Divergent or hypercementosed roots

43. If fracture occurs…
 Bony fragment and the tooth should be freed from the
soft tissues followed by
apposition of soft tissue by mattress sutures

44. OOrroo--aannttrraall ffiissttuullaa
 It is a pathological or unnatural
communication between the oral cavity and
maxillary sinus
 Fistula always lined by epithelium and is
long standing

45. Contd..
 Acute form is oro-antral communication
 If oro-antral communication does not heal
or is untreated, epithelial tract forms

46. Predisposing factors
 When apices of the upper teeth and the
lining of the maxillary sinus are intimately
related
 Chronic apical or advanced periodontal
disease replaces apical bone with
granulation tissue
 In suspected cases traumatizing the socket

47.  When the sinus is infected, the infection
destroys the clot in the socket
 Excessive damage to the bone of the socket
the loss of the clot
 Upper first molar- risky

48. On examination..
 An obvious large opening leading into the
sinus
 Symptoms as per root in antrum
 Small perforation - difficult to detect
 Never probe or abuse a socket

49.  Pinch nose and blow gently
 Whistling noise may be heard as air escapes
from the fistula

50.  Large Oro-antral fistula – good drainage,
seldom sinusitis
 Pin hole fistula- no drainage, chances of
sinusitis

51. Treatment
 Suture socket , antibiotics, nasal
decongesants, preserve and protect clot,
overdenture obturator- normally heal

52. PPrriimmaarryy cclloossuurree

53.  2-3 days delay…
same treatment

54. Late presentation…
 After a week
 Formation of fistulous tract - to be excised
 Maxillary sinusitis – if present to be treated
 Attempt surgical closure

55. Approaches
SSiimmppllee ssuuttuurreess
(( PPrriimmaarryy cclloossuurree))
Local Flaps Distant

56. Local Flaps
 Buccal approach= von Reherman’s flap
 Palatal approach= Ashley’s flap
 Combination of buccal and palatal flaps

58. Buccal approach
 Local anaesthesia
A) Excision of epithelial tract
B) Buccal flap, von Reherman’s flap- divergent
incision into the buccal sulcus-
3- 4 mm from each side of the resulting alveolar
defect
horizontal incision in taut periosteum to
mobilize the mucoperiosteal flap

59. Contd..
.. the free margin of the buccal flap rests on the
palatal mucoperiosteum on sound bone where
it is sutured covering the Oro-antral fistula

61. 2nd approach
 Palatal transposition flap (Ashley’s flap)
- based on greater palatine artery
- thicker flap
- longitudinal incision about 4-5 mms above
the gingival margin

62. Contd…
 Followed by a parallel incision
 Almost along the midline of the palate
 Both incisions connected anteriorly with a U
shaped cut
 The thick palatal flap is rotated to cover the
alveolar orifice with edges resting on sound
bone for healing

64. TTUUMMOOUURRSS IINNVVAADDIINNGG TTHHEE SSIINNUUSS
OOhhnnggrreenn’’ss lliinnee
IImmaaggiinnaarryy ppllaannee ddeeppiicctteedd
bbyy aa lliinnee jjooiinniinngg tthhee
mmeeddiiaall ccaanntthhuuss ooff tthhee
eeyyee ttoo tthhee aannggllee ooff tthhee
mmaannddiibbllee,, ddiivviiddiinngg tthhee
nnaassaall ccaavviittyy aanndd tthhee
aannttrruumm iinnttoo ttwwoo hhaallvveess

65. Infrastructure –– AAnntteerriioorr aanndd IInnffeerriioorr
–– RReeaaddiillyy aammeennaabbllee ttoo ssuurrggeerryy
wwiitthh ffaaiirr pprrooggnnoossiiss
SSuupprraa SSttrruuccttuurree –– PPoosstteerriioorr aanndd SSuuppeerriioorr
–– NNoott RReeaaddiillyy aammeennaabbllee ttoo
ssuurrggeerryy,, ppoooorr pprrooggnnoossiiss

66. Clinical Features
Ulcer, Swelling, Mobile Teeth &
Pain (Nerve Involvement)
Management
- Maxillectomy
• Partial/Limited
• Subtotal
• Total

67. Subtotal Maxillectomy
Larger lesions of the gums, palate or the antrum which
extend to the superior aspects or beyond the confines
of the antrum
Proposed Bony cuts

68. Total Maxillectomy
Primary Tumours filling the entire antrum
In some cases infra orbital rim is preserved

70. SSIINNUUSS LLIIFFTT
 PPoosstteerriioorr MMaaxxiillllaarryy HHeeiigghhtt DDeeffiicciieenncciieess
wwhhiillee ppllaacciinngg iimmppllaannttss
 CClloosseedd oorr ooppeenn mmeetthhoodd
 OOsstteeoottoommeess uusseedd ttoo iinn--ffrraaccttuurree tthhee aannttrraall
fflloooorr
 BBoonnee GGrraaffttss

71. Thank You