Maxillary sinus

surgical anatomy of maxillary sinus

1. SURGICAL ANATOMY OF MAXILLARY SINUS Presented by Sauvik Singha 1 st year PG Student Oral and Maxillofacial Surgery

2. CONTENTS Introduction Development Anatomy Functions of sinuses Relations Applied Anatomy Diseases Involving Maxillary Sinus Surgical Procedures Involving Maxillary Sinus Bibliography

3. Maxillary sinus Pneumatic space lodged in the body of maxilla Described by Nathenial Highmore (1651) Also known as antrum of Highmore 2 in number Largest paranasal sinus Vol:15-30 ml Dimensions (Turner, 1902) ANTEROPOSTERIOR: 3.5cm HEIGHT: 3.2cm WIDTH: 2.5cm

4. ANATOMY Pyramidal in shape Consist of base Apex Roof Floor Anteror wall Posteror wall

5. ANATOMY contd …. Base - lateral wall of nose. Apex - zygomatic process of maxilla. Roof - floor of orbit traversed by the infraorbital canal. floor –lateral hard palate maxillary alveolar process. Anteror wall-facial surface of maxilla Posteror wall-separates sinus from infratemporal and pterygopalatine fossa

6. Arterial supply Facial artery Maxiilary artery Infraorbital artery Greater palatine artery

7. Venous drainage Veins accompany artery Anterior facial vein Pterygoid venous plexus

8. Nerve supply By last (1959) Anterior superior alveolar nerve Middle superior alveolar nerve Posterior superior alveolar nerve Greater palatine nerve

9. Surgical Importance of Nerve supply As there is chance of damage of nerve during surgical procedure Asa -given off from infraorbital n about 15mm form infraorbital foramen,courses down on anteriror Wall Msa -seen in 50 % cases arise from lateral aspect of infraorbital nerve Psa -sup branch runs at level of malar tuberosity,inf branch-runs parallel to tranverse facial part of anteior nerve

10. Embryology The sinus begin developing in the 3 rd week of gestation First sinus to develop Early stages it is high in maxilla later gradually grows downwards by process of pneumatization

11. DEVELOPMENT & AGE CHANGES Contemporary Oral & Maxillofacial Surgery – Peterson IV edition Time Growth Shape 3months IU Out Pouching in middle Meatus Birth 7mm x 4mm x 4mm 3mm/year x 2 x 2mm. Tubular 9 years 60% of adult size Ovoid 12 years Antral floor parallels nasal floor 18 years Adult size , antral floor is 1-1.25 cm below nasal floor Pyramidal

12. Lined by respiratory epithelium Mucous scereting Pseudostratified ciliated columnar epithelium SCHNEIDERIAN MEMBRANE It has mucociliary mechanism Cilia moves the mucus and debris towards osteum and discharged in middle meatus Physiology

13. Functions of sinus 1.Impart resonance to voice 2.Increase surface area and lighten skull 3.Moisten and warm inspired air 4.Filters debris from inspired air 5.Gives air padding to provide thermal insulation to adjacent important tissues

14. RADIOLOGY OF MAXILLARY SINUS EXTRAORAL VIEWS OCCIPITOMENTAL/WATERS LATERAL SKULL SUBMENTOVERTEX ORTHOPANTOMOGRAPHY CT SCAN INTRAORAL VIEWS OCCLUSAL LATERAL OCCLUSAL PERIAPICAL

15. Occipitomental or waters view

16. Orthopantomograph

17. LATERAL SKULL

18. CT- SINUS –AXIALVIEW

19. CT- SINUS - CORONAL VIEW

20. Occlusal view

21. Periapical view

22. Endoscopy Direct optical evaluation of the antral floor region.. Path of access used 1.Trans oral via canine fossa 2.Trans alveolar via connection between oral cavity & antrum 3.Trans nasal approach

23. APPLIED SURGICAL ANATOMY 1)Relation of root apices with the floor of the sinus 2)Lining of maxillary sinus 3)Foreign bodies in the sinus 4)Infections of sinus 5)Oro- antral communication 6) Tumors associated with maxillary sinus 7) Implant placement

24. Relation of Root Apices with the floor of the sinus The chances of creating oroantral fistula in patient less than 15yrs are comparatively lesser than in adult. In adult, distance between apical end of maxillary posterior teeth with floor of sinus is approximately 1 to 1.5 cm. Second molar is in closest proximity to antral floor followed by first molar, third molar, second premolar & first premolar.

25. Presence of an unerupted tooth in the maxillary tuberosity is a potential line of fracture. Periapical infection of the tooth which are in relation with antrum might cause an oroantral fistula. Since walls of sinus are thin any tumour which develops here may erode these walls and present swelling on cheek, palate or in buccal mucosa.

26. Since sinus wall is very thin in area of canine fossa , it can be used for diagnostic aspiration and for Caldwell-Luc operation. Antral puncture can be carried out by puncturing into sinus cavity through medial meatus in children and the inferior meatus in adult.

27. Ohngrens Line Ohngrens line is an imaginary line extending from medial canthus of the eye to the angle of mandible which divide the sinus into the antero -inferior & postero -superior . It is significant in determining the stage of antral tumour. In general, the tumour below this line have a better prognosis than tumour above it.

28. Maxillary sinusitis It may be clinically defined as an inflammatory response involving mucous membranes of the nasal cavity and paranasal sinus.

29. Maxillary sinusitis

30. Maxillary sinusitis Diagnosis History Physical examination Inspection Palpation Percussion Diagnostic techniques Rhinoscopy Endoscopy Nasal valve examination Culture and sensitivity

31. Clinical Signs of Sinusitis Pain Fever Headache aggerevated on bending Nasal stuffiness Nasal discharge - mucoid , purulent, foul smelling Epistaxis Referred odontalgia

32. OROANTRAL FISTULA Oroantral fistula is a pathological communication between oral cavity and maxillary sinus.

33. Oroantral fistula Etiology Iatrogenic Presence of periapical lesions Injudicious use of instruments During attempted extraction Trauma Chronic infections Malignant diseases h/o sinus surgery like resections of cyst and tumors of maxilla

34. Oroantral fistula Diagnosis h/o previous extraction Mouth mirror test Cotton wisp test Inspection Transillumination test positive Radiological IOPA OPG OM

35. Oroantral fistula contd.. Management Less than 2mm heals spontaneously Larger than 3 mm requires surgical closure Ideal treatment :immediate surgery followed by Antibiotic prophylaxis

36. Oroantral fistula contd.. General Management Do gentle packing of the socket with wet gauze to control bleeding from the socket and for antral bleeding sinus is packed with roller gauze. Do not probe the sinus with sharp instruments Do not curette the socket Do not ask the patient to blow the nose Prescribe antibiotics and other symptomatic treatment

37. Treatment modalities for closure of OAF Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J   Oral Maxillofac Surg68:1384-1391, 2010 Temporalis Overview of the treatment modalities of Oro- Antral Communications

38. Immediate closure Mucoperiosteal flap, obtained by reducing the height of the bony socket, are loosely sutured over the defect.

39. Rehrmann Buccal Advancement flap Broad based trapezoidal muco periosteal flap is created and sutured over the defect. Broad base assure adequate blood supply (93%) Disadvantage Reduction of buccal sulcus depth. Post operative pain & swelling.

40. Moczair flap Recommended for edentulous patients In this method buccal sliding trapezoidal mucoperiosteal flap displaced 1 tooth distally is involved. Buccal sulcus depth is minimally influenced. Disadvantage Greater amount of dentogingival detachment May give rise to periodental disease in dentate patient.

41. Palatal flap The soft tissue lying either behind or in front of the defect are utilized. The bony base of the resultant palatal defect may be covered by pack. The rich blood supply of the palatal flap provide satisfactory healing.

42. Advantages Less vulnerable to rupture than buccal flap because of thickness of palatal mucosa Adequate blood supply by greater palatine vessels Buccal sulcus depth remain intact. Disadvantage Denuded palatal donor area Soft tissue bulge at the axis of rotation

43. Palatal rotational advancement flap Provides adequate mobility and tissue bulk to the flap Disadvantage Flap often kinks following the rotation of flap and can cause venous congestion.

44. Combined local flaps Combination of two flaps Hinged and Palatal rotational advancement flaps Inversion flap and palatal rotational advancement flap Reverse palatal and buccal advancement flap

45. Combined flaps Hinged flap Hinged & palatal rotationl advancement Palatal reversal & buccal advancement flap

46. Pedicled buccal pad of fat Buccal pad of fat can be exposed by a vertical incision of 1cm long on the posterior aspect of the zygomatic buttress region. Following this the fat pad advanced along the defect and sutured to palatal tissue without any tension. Blood supply is from temporal, maxillary and facial arteries

47. Buccal pad of Fat

48. Advantages Easy mobilization Excellent blood supply Minimal donor site morbidity Complications Graft necrosis New fistula formation

49. Bridge flap Commonly employed in edentulous arch. Incisions are placed transversely across line of the arch. The bridge is shifted over the fistula and the raw area is allowed to epithelized .

50. Tongue flaps Distant full thickness pedicle flap Used to close large OAF Rich blood supply Disadvantage Requirement of GA Requirement of 2 stage and 3 stage procedure

51. Distant flaps Tongue flap

52. Grafts GRAFTS AUTOGENOUS Iliac crest Chin Retromolar area Zygoma ALLOGENOUS Collagen sheet Fibrin glue Gold foil Tantalum PMMA Hydroxyapatite XENOGRAFTS Porcine dermis Bio guide & Bio oss

53. Bone Press fit closure of Oro antral Fistula Indications If OAC is > 10 mm OAF and planned sinus floor elevation OAF along the neighboring root surface extending into maxillary sinus Chronic OAF with multiple successful attempts of closure

54. Bone graft for closure are often harvested from iliac crest, chin , retromolar area and zygoma , lateral wall of maxillary sinus. Autografts are considered a better option than allograft because of Risk of transmission of viral hepatitis Expense Diffusion of particulate graft into the sinus can produce foreign body reaction.

55. TRAUMATIC DISEASE Haematoma in Maxillary Sinus A fracture involving infraorbital artery or superior alveolar vessels frequently result in a haematoma formation in the maxillary sinus.

56. Usually the blood, which accumulate in the maxillary sinus, is eliminated by the activity of the ciliated epithelium of the antral membrane promoting normal drainage through the ostium . If the haematoma is not removed infection might occur.

57. IATROGENIC DISEASE Teeth Displaced into Sinus Foreign body that usually is displaced into maxillary sinus is a tooth or a tooth root. Aetiology Absence of intervening bone in between the tooth root and antrum . Aggressive instrumentation to retrieve fractured maxillary molar root.

58. ANTRAL RHINOLITHS Two types of rhinoliths Rhinoliths around an endogenous nucleus such as RBCs or pus cells, Those found around exogenous material such as root of teeth, or any other foreign body. Sometime they are covered with granulation tissue.

59. SURGICAL PROCEDURES INVOLVING MAXILLARY SINUS Caldwell-Luc Operation Intra nasal antrostomy Functional Endoscopic Sinus Surgery Sinus Lift Procedure Mid Face fractures

60. Caldwell luc sinusotomy By George Caldwell (1893) & Henry Luc (1897) Indications Fungal sinusitis Multiple antral lesions Antral polyp Excision of tumor Closure of OAF Removal of antral foreign body Antral revision procedures surgical approach for transantral sphenoethmoidectomy , orbital decompression

61. Surgical Procedure The surgical procedure can be performed under LA. Or GA. A semilunar incision is placed in the buccal vestibule from canine to second molar. A mucoperiosteal flap is elevated till infraorbital ridge. A round bony cut is marked over the canine fossa using a round bur( post stamp incision) Window is created and bone is removed using ronger

62. Then pus is sucked away from the sinus and thorough irrigation is carried out. Inspection and removal of foreign body from the sinus can be done at this stage. Antral cavity packed with iodoform ribbon gauze. The incision is closed with 3-0 0 silk. Pack removal on 5 th day.

63. Caldwell luc sinusotomy

64. Caldwell luc sinusotomy Complications Bleeding Dental sensitivity Infraorbital neuralgia Osseous defect in anterolateral wall Entrapment of inferior rectus muscle

65. Denker’s Approach Modification of Caldwell luc surgery Along with the Caldwell Luc surgery a slit of bone is removed from the anterior bony angle of the antrum right up to the lateral nasal aperture to render continuous free unimpeded drainage of sinus from nasal cavity and canine fossa

66. Functional Endoscopic Sinus Surgery Purpose The purpose of FESS is to restore normal paranasal air sinuses mucocilliary function.

67. Indications Recurrent sinusitis with stenosis . Chronic hyperplastic sinusitis with obstructive nasal polyps. Chronic sinusitis with mucocele formation. Fungal sinusitis in patient with diabetes or immunocompromised status. Neoplasms Orbital cellulitis or abscess Unresponsiveness to medical treatment.

68. Surgical technique Performed under GA or LA Patient is placed in supine position at 15 degree reverse trendelenberg position. Nose is additionally anaesthetized with 4% cocaine soaked cotton pledgets placed in middle meatus . Additional injections are given at greater palatine foramen and middle meatus perimeter. Endoscopy of maxillary sinus is performed by canine fossa or through maxillary sinus antrostomy . All diseased mucous membrane and polyps if in case are present is removed. Overzealous removal of septa and normal appearing mucous membrane is not advocated.

69. SINUS LIFT PROCEDURES Done in resorbed maxillary posterior ridges.

70. Techniques Lateral window technique Modification of Caldwell Luc technique LA administration PSA nerve block ASA nerve block Palatal infiltration Crestal incision is given from maxillary tuberosity to the point just anterior to anterior border of sinus along with vertical releasing incisions Mucoperiosteal flap reflected, lateral wall of maxilla exposed. Linear osteotomy performed using #6 or #8 round bur

71. Diagram demonstrating the ideal location of sinus window preparation of the lateral maxillary wall. The inferior ostectomy should be approximately 1 mm superior to or level with the floor of the sinus. The posterior ostectomy should be at the corner of the maxillary buttress. The anterior ostectomy should be adjacent to and parallel with the lateral wall of the nose, and the superior ostectomy should be at the height of the intended graft. (From Block MS. Color atlas of dental implant surgery. 2nd edition. Philadelphia: Saunders;2007. p. 129)

72. Once the window is created membrane is exposed, adherent bone is either removed or rotated medially. Schnederian membrane is elevated using a freer or currete . Bone graft is placed under the membrane in anterior and inferior direction. Graft should contact the medial wall of maxillary sinus. Mucoperiosteal flap is repositioned and sutured. After 6 months implant is placed.

73. Sinus Intrusion Osteotomy Indicated when minimal bone height is needed. Crestal incision is made and implant drills are used to create an osteotomy , leaving 1 mm of bone between site and sinus membrane. Sequential osteotomies are done to compact the bone laterally and apically, which will elevate the sinus membrane. Bone graft is placed. Implant is placed with a coverscrew and primary closure is done.

74. Trephined bone core partially intruded into sinus cavity. ( FromFonseca RJ,MarcianiRD , Turvey TA. Oral and maxillofacial surgery. 2nd edition. Philadelphia: Saunders; 2008. p. 465;

75. Retention cyst Caused by blockage and subsequent dilation of ducts of the seromucinous gland and are subsequently lined with epithelium. Seldom seen on radiographs.

76. Mucoceles Rarely found in maxillary sinus. Expansive and potentially destructive lesions, which differentiate it from the pseudocyst . Usually formed when sinus ostium is obstructed. In advanced cases it may cause bony erision and destruction.

77. Carcinoma of maxillary sinus Clinical features Signs of chronic sinusitis Foul smelling nasal discharge Nasal stuffiness Epistaxis Loss of Transillumination

78. Surgical treatment Segmental maxillectomy Lower level of maxilla or only the involved segment is excised. Partial maxillectomy Excision of maxilla sparing the infra orbial floor Total maxillectomy Excision of maxilla with orbital floor but sparing the orbital content. Radical or extended maxillectomy Unilateral maxilla is excised along with the eyeball or including ethmoidectomy and sphenoidectomy in the procedure

79. BIBLIOGRAPHY B D Chaurasia , Text book of Anatomy Contemprory oral and maxillofacial surgery, Peterson IV edition Fonseca text book of oral and maxillofacial surgery II edition

80. Treatment of Oro antral Fistula using Bone press fit technique. American association of oral and maxillofacial surgeon 2012 Sinus Lift Procedure, An overview of current technique Avichai Stern, James Green. Dent clinics of N America 2012, 219-233

81. Thank you