Maxillary Sinus in Dentoalveolar Surgery Flashcards
Oro-antral Communication (O.A.C)
Invasion of the maxillary sinus and establishment of a direct communication with the
oral cavity is referred to as an “oro -antral communication”.
Factors influencing creation of oro-antral communication
(5)
- Teeth size and configuration of the roots.
- Hypercementosis and bulbous roots.
- Density of alveolar bone and thickness of sinus floor
- Relation of sinus to the root of upper teeth.
- Size of the sinus
Factors influencing creation of oro-antral communication
(5)
- Rough extraction and misguided manipulation.
- Apical pathosis.
- Periapical diseases which may erode sinus floor.
- Presence of cysts and neoplasm.
- Invasive surgery e.g. dental implants placement.
Prevention of Oroantral Communication –Intra operative Period
(2)
- Perform surgical extraction early, remove
some bone around the tooth and if
necessary section roots and remove them
separately i.e if they are multi-rooted. - Avoid excess apical pressure during
extractions of maxillary posterior teeth that
are in close proximity to the sinus
Removal of Root Fragments and Root Tips
Use root elevator as a wedge in a wiggling motion without excessive pressure - displacement
Policy of leaving root fragments
(5)
– Risk vs benefits (Maxillary sinus)
– Fragment must be small (< 5 mm)
– Root deeply embedded
– Absence of infection
– No radiolucency at root tip
Diagnosis of the oro-antral communication
During dental extractions in the posterior maxillary region, it is important to determine if it is just
an O.A.C or if it is a O.A.C with displacement of the tooth into the socket.
Diagnosis of the oroantral communication
(3)
– To confirm the presence of a communication, the best technique is to use the “Nose-blowing
test” (Valsalva Maneuver).
– The patient is asked to pinch their nostrils together to occlude the nose. The patient blows
gently to see if air escapes into the oral cavity via the maxillary sinus opening.
– Presence of OAF appears as bubbling of blood in the extraction socket.
Diagnosis of the oroantral communication
(3)
– If nose-blowing’ test is negative, don’t explore the opening with suction tip and/or
probes.
– Don’t attempt to irrigate the sinus to confirm diagnosis.
– Always check radiograph for the continuity of sinus floor and presence of tooth/root.
Signs and symptoms of newly created oro-antral Communication
(4)
- Bubbling of blood from the socket or nostril.
- Antral floor attached to roots apices of extracted tooth
or teeth. - Fracture of the alveolar process or the tuberosity.
- Radiographic evidence of sinus involvement
Management of oro-antral communication
Small Size - (2 mm in diameter or less)
(3)
- Small (2 mm in diameter or less), no additional surgical treatment is necessary
- Sinus precautions
- Surgeon must not probe through the socket into the sinus with a periapical curette or
a root tip pick
- Sinus precautions
(2)
– avoid blowing the nose, violent sneezing, sucking on straws, and smoking
– Patients who smoke and who cannot stop (even temporarily) should be advised to smoke in small
puffs, not in deep drags, to avoid pressure changes.
Management of oro-antral communication
Moderate Size O.A.C (2 to 6 mm)
(3)
- Ensure the maintenance of the blood clot in the area, a figure-of-eight suture should be placed
over the tooth socket . - Antibiotics, usually Augmentin, should be prescribed for 7 days.
- A nasal decongestant spray should be prescribed to shrink the nasal mucosa to keep the ostium of
the sinus patent.
Management of oro-antral communication
Large size O.A.C (7 mm or larger)
(3)
- Dentist should consider closing the sinus communication with a flap procedure.
- Usually requires that the patient be referred to an oral and maxillofacial surgeon.
- Flap development and closure of a sinus opening are somewhat complex procedures that require
skill and experience
Flap development and closure of a sinus opening are somewhat complex procedures that require
skill and experience.
– most commonly used flap is a buccal flap
* This technique mobilizes buccal soft tissue to cover the opening and provide for a
primary closure
Disadvantage of the Buccal advancement flap technique is loss of
vestibular depth
Advantage of the Palatal rotation flap
Advantage of the Palatal rotation flap
- Keratinized tissue is used to cover the O.A.C in relation to the alveolar ridge
There is no loss of vestibular depth on the buccal side
Postoperative care/ Sinus Precautions
(5)
Antibiotics (Augmentin)
Pain Medication (Combination of Acetoaminophen, Ibuprofen)
Local treatment
Saline Nasal decongestant
Steam inhalation
Local treatment
Nasal Decongestant
e.g. Afrin Sinus decongestant,
2 to 3 Nasal puffs 2 times daily for 3 to 4 days
Management of Oroantral Communication with displacement of tooth/root
into the sinus
(3)
- Assess size of root
- Presence of infection
- Health of sinus
Displacement of tooth or root into the maxillary sinus
(3)
- It is basically a mishap that results from a neglected act by the operator while
applying wrong force. - Occurs rarely but the maxillary 3rd molar and maxillary 2nd premolar are the most at
risk of dislodgment. - In association with poor surgical technique.
Displacement of tooth or root into the maxillary sinus
Immediate Management
(2)
- Confirm the existence of oro-antral communication and the presence of tooth or root in
sinus using Periapical X-rays, panoramic X-rays and C.B.C.T Scan if necessary. - Locate the precise position of the foreign body within the sinus lining or in the sinus
cavity.
Immediate management
(5)
- Reflect mucoperiosteal flap.
- Reduce alveolar bone height.
- Retrieve the tooth or the root by permitting their movement away from the sinus.
- If root or tooth dislodged into the sinus proper, consider Caldwell-luc approach.
- Undermine the flap and replace across the bony defect.
If the O.A.C is left untreated, The two sequelae of most concern are:
(2)
- Formation of a chronic oroantral fistula.
- Postoperative maxillary sinusitis
What is a Fistula ?
- Is a biological tract that connects an anatomical cavity with the external
surfaces or another anatomical cavity (unlike sinus tract). - It is always lined with a stratified squamous epithelium and the patency of
the tract is preserved until epithelial cells scraped off.
Oro-antral fistula
(5)
It might be a complication of:
Unrecognized (overlooked) fistula.
Untreated fistula.
Failure of spontaneous closure of OAC.
Failure of surgically repaired oro-antral fistula
Signs and symptoms of Oro Antral Fistula
Patient usually complains of
(5)
- Nasal regurgitation of liquid and reflux of food and drinks.
- Altered nasal resonance,
- Intermittent episode of pain and local tenderness.
- Foul-tasting discharge.
- Bad taste in the mouth and whistling sound while speaking.
Primarily management of Chronic Oro Antral Fistula
It is aimed to eliminate any sinus infection:
(4)
- Excision of any mucosal polyp or purulent granulation to promote drainage.
- Regular irrigation with warm water or saline.
- Single course of antibiotics and nasal inhalation and decongestant.
- Acrylic base plate.
Management of Chronic Oro Antral Fistula
Important Surgical Principles
(5)
- Success of operation is not always guaranteed.
- Flap should have good blood supply.
- Flap tissue must be handled gently.
- Flap should lie in its new position without tension.
- Good hemostasis must be achieved before discharging the patients
