Maxillary Sinus in Dentoalveolar Surgery

Question 1

what is an oro antral communication

Answer 1

invasion of the maxillary sinus and establishment of a direct communication with the oral cavity

Question 2

what is done in the pre operative exam in prevention of oro antral communication

Answer 2

conduct thorough preoperative radiographic exam

Question 3

what are the factors influencing creating of oro antral communications

Answer 3

• 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 sinus
• rough extraction and misguided manipulation
• apical pathosis
• periapical diseases which may erode sinus floor
• presence of cysts and neoplasm
• invasive surgery such as implant placement

Question 4

how are oro antral communications prevented in the intra operative period

Answer 4

• perform surgical extraction early, remove some bone around the tooth and if necessary section roots and remove them separately if they are multi rooted
• avoid excess apical pressure during extractions of maxillary posterior teeth that are in close proximity to the sinus

Question 5

how should root fragments and root tips be removed to prevent an oro antral communication

Answer 5

use root elevator as a wedge in wiggling motion without excessive pressure - displacement

Question 6

what is the policy of leaving root fragments

Answer 6

• risks vs benefits (max sinus)
• fragment must be small ( less than 5mm)
• root deeply embedded
• absence of infection
• no radiolucency at root tip

Question 7

during dental extractions in the posterior maxillary region it is important to determine if it is just an ________ or ______

Answer 7

OAC or OAC with displacement of the tooth into the socket

Question 8

what is the best technique to confirm the presence of a communication

Answer 8

Nose blowing tests AKA valsalva maneuver

Question 9

what is a positive valsalva

Answer 9

presence of OAF appears as bubbling of blood in the extraction socket

Question 10

if nose blowing test is negative:

Answer 10

dont explore the opening with suction tip and/or probes
- dont attempt to irrigate the sinus to confirm diagnosis

Question 11

always check the radiograph for _____ of sinus floor and presence of_______

Answer 11

continuity; tooth/root

Question 12

what are the signs and symptoms of newly created oro-antral communication

Answer 12

• 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

Question 13

what is a small OAC

Answer 13

2mm in diameter or less

Question 14

what is the treatment for a small OAC and sinus precautions

Answer 14

• no additional treatment needed
• surgeon must not probe through the socket into the sinus with a periapical curette or root tip pick
• sinus precautions: avoid blowing nose, violent sneezing, sucking on straws and smoking, patients who smoke and cannot stop should be advised to smoke in small puffs, not in deep drags to avoid pressure changes

Question 15

what is a moderate size OAC

Answer 15

2-6mm

Question 16

what is the treatment for moderate size OAC

Answer 16

• ensure the maintenance of the blood clot in the area, a figure eight suture should be placed over the tooth socket
• antibiotics, usually augmentin should be prescribed for 7 days
• a nasal decongestnat spray should be prescribed to shrink the nasal mucosa to keep the ostium of the sinus patent

Question 17

what is the size of a large OAC

Answer 17

7mm or larger

Question 18

what is the tx for a large OAC

Answer 18

• consider closing the sinus 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

Question 19

what flap is used for the large OAC and why

Answer 19

buccal flap because this technique mobilizes buccal soft tissue to cover the opening and provide for a primary closure

Question 20

what is a disadvantage of the buccal advancement flap technique

Answer 20

loss of vestibular depth

Question 21

what is an advantage of the palatal rotation flap

Answer 21

keratinized tissue is used to cover the OAC in relation to the alveolar ridge
- there is no loss of vestibular depth on the buccal side

Question 22

what is the general post operative care/sinus precautions

Answer 22

• antibiotics (augmentin)
• pain medication ( combo of acetominophen, ibuprofen)
• local treatment: nasal decongestant- afrin- 2-3 nasal puffs 2 times a day for 3-4 days
• saline nasal decongestant
• steam inhalation

Question 23

what are the considerations in management of oroantral communication with displacement of tooth/root into the sinus

Answer 23

• assess size of root
• presence of infection
• health of sinus

Question 24

what is the displacement of tooth or root into the maxillary sinus caused by

Answer 24

a mishap that results from a neglected act by the operator while applying the wrong force
- in association with poor surgical technique

Question 25

is displacement of tooth or root into maxillary sinus common and where is the highest risk

Answer 25

no but most common place is maxillary 3rd molar and maxillary 2nd premolar

Question 26

what is the immediate management of displacement of tooth or root into max sinus

Answer 26

• confirm the existence of OAC and the presence of the tooth or root in sinus using PA xrays, pano or CBCT
• locate the precise position of the foreign body within the sinus lining or the cavity
• reflect mucoperiosteal flap
• reduce alveolar bone height
• retrieve the root or tooth 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

Question 27

if the OAC is left untreated what are the two biggest concerns:

Answer 27

• formation of a chronic oroantral fistula
• postoperative maxillary sinusitis

Question 28

what is a fistula

Answer 28

a biological tract that connects an anatomical cavity with the external surfaces or another anatomical cavity - unlike sinus tract

Question 29

oro antral fistula might be a complication of:

Answer 29

unrecognized fistula
- untreated fistula
- failure of spontaneous closure of OAC
- failure of surgically repaired oro antral fistula

Question 30

what is a fistula lined with

Answer 30

stratified squamous epithelium and the patency of the tract is preserved until epithelial cells are scraped off

Question 31

what are the signs and symptoms of oro antral fistula

Answer 31

• nasal regurgitation of liquid and reflux of food and drinks
• altered nasal resonance
• intermittent episodes of pain and local tenderness
• foul tasting discharge
• bad taste in the mouth and whistling sound while speaking

Question 32

what is the management of chronic oro antral fistula

Answer 32

• aimed to eliminate any sinus infection
• 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

Question 33

what are the important surgical principles of chronic oro antral fistula

Answer 33

• success of operation is not always guarunteed
• 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