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Oral Disease > Surgical Aspects of the Maxillary Antrum > Flashcards

Surgical Aspects of the Maxillary Antrum Flashcards

1
Q

What shape is the maxillary antrum?

A

Pyramidal shape

Apex is facing laterally

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2
Q

What is the roof of the antrum?

A 
Orbital floor (brittle and thin) = more likely to fracture - where infraorbital nerves come through
Infraorbital bundle traverses
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3
Q

Medial wall of the maxillary antrum?

A

Lateral wall
Contains ostium
Cartilaginous in places

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4
Q

Floor of the maxillary antrum?

A 
Alveolar process of maxilla
Hard palate
Thinnest near tooth bearing alveolus 
In children adjacent to nasal floor
In adults 5-10mm lower
Close to apices of teeth
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5
Q

Anterior wall of the maxillary sinus?

A

The cheek area

  • Also forms lateral wall with lateral maxilla
  • Should call antero-lateral wall
  • Contains canine fossa = infection of canine can extend into maxillary sinus
  • Thinnest part <2mm thick
  • Good for surgical access
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6
Q

What does the maxillary sinus drain into?

A

Drains into nose via ostium
Ostium is halfway up the medial wall
Efficient cilia - beat towards ostium

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7
Q

What is an oro-antral communication?

A

An open communication between the oral cavity and maxillary sinus

Floor can extend from molar region to canine
Root apices closely associated

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8
Q

Most common tooth/root to have an OAC?

A

Palatal root of first molar

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9
Q

How to diagnose an OAC?

A

Clinical/radiographic signs:

  • Movement of antral lining during respiration
  • Emanating bubbles from socket during respiration
  • Hollow sound when aspirating socket
  • Fogging of mirror
  • Extracted tooth attached to concave bone or fractured tuberosity
  • Post op radiograph - defect sinus floor
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10
Q

Conservative management of OACs?

A

Many OACs undetected
- Heal spontaneously

Instructions

  • No nose blowing
  • OHI

Antibiotics - broad spectrum (penicillin)
Splints
Decongestants (eucalyptus oil)

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11
Q

Active treatment for OACs?

A

Suturing
- Resorbable/non-resorbable
- Packing - resorbable/oxidised cellulose
Non-resorbable - fistula: BIPP (ismuth iodoform paraffin paste), ribbon gauze

Splints
Antibiotics, decongestants

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12
Q

What is a fistula?

A

Communication of the oral cavity and maxillary sinus lined by epithelium (>7 days after surgery)

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13
Q

What can a healed OAC form?

A

An oro-antral fistula

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14
Q

Signs and symptoms of oro-antral fistula?

A

Purulent discharge
Bad taste
Liquid discharge through nose
Air escape - both directions (do NOT do acutely)
- Can have false negative result due to infection/debris
Episodic sinusitis
Nasal voice
Epistaxis
Prolapse of antral mucosa into mouth
Whistling noise
Radiographic evidence - CBCT/Occipitomental

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15
Q

Types of surgical repair?

A

Buccal advancement flap
Buccal fat pad graft
Palatal rotation/palatal finger flap
Trapezoid flap

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16
Q

Surgical closure - buccal advancement flap features?

A

Raise full thickness mucoperiosteal buccal flap
Release periosteal fibres to bring it over the OAC
If a fistula cut the fistula out as well as the flap to remove the epi lining

Good success rate
Low morbidity
Good blood supply

BUT decrease in vestibular sulcus depth - prosthetic implications (E.G. difficulty with dentures)

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17
Q

Palatal rotation flap?

A 
Relies on greater palatine artery
Length/width ratio important
- >2.5 = flap necrosis
Painful donor site
Seldom used, useful for larger OAFs
Leave to heal by secondary intention
18
Q

Buccal fat pad graft features?

A

Do a buccal advancement flap and take buccal fat and pull it into the hole before closing it up

19
Q

What epi lines the maxillary sinus?

A

Lined by respiratory epithelium (ciliated pseudostratified columnar epithelium)

20
Q

What is the largest paranasal sinus?

A

Maxillary sinus

21
Q

Functions of the maxillary sinus?

A

Reduces weight of skull
Voice resonance
Humidification
Mucous production

22
Q

Anatomical borders of the maxillary sinus?

A 
Infraorbital surface of maxilla (Superior)
Alveolar process (Inferior)
Lateral wall of nose (Medial)
Zygoma (Lateral)
Maxilla (Anterior/medial/lateral)
23
Q

OAC risk factors?

A 
Long/ankylosed roots
Lone standing molar
Hypercementosis, bulbous roots 
Loss of apical periapical bone 
Pneumatisation of sinus
Impacted upper molar 
Poor technique - excessive force
Cleft lip and palate
Root fracture
24
Q

Risk factors of OACs?

A

Thinner antral floor (1-7mm)
Bone resorption related to chronic apical periodontitis
Early and complete increase risk of OAC

25
Q

OAC management?

A

<2MM:

  • Promote spontaneous healing
  • Gentle irritation of socket and debridement of sharp bone
  • Resorbable haemostatic agent (surgicel)
  • Suturing loose edges
  • Antral regime and review
  • Vacuum splint

2-4mm = conservative vs surgical repair - assess risk factors

> 4mm or OAF = surgical repair

26
Q

Common displaced foreign objects?

How to avoid displacing objects?

A

Upper 3rd molars 0.3-3.8% of iatrogenic cases of foreign body entrapment
Upper 6 palatal root >3rd molar > 2nd molar root

Avoid apical pressure
Controlled pressure and safe technique

27
Q

Transalveolar approach of retrieving a displaced foreign object?

A
  1. Fill sinus with saline - use suction to retrieve root
  2. 2 or 3 sided buccal flap - flap design should permit closure with advancement:
    - Flap elevated subperiostally
    - Bone removal to enable visualisation and removal of interdental septae
    - Retrieve root with tweezers
    - Closure with buccal advancement (+/- fat pad or collagen membranes)
28
Q

How to retrieve a displaced foreign object?

A
  1. Alveolar approach
  2. Caldwell-Luc approach
  3. Functional endoscopic sinus surgery (FESS)

Retrieve
Light
Suction
Locations - is it between mucosa and alveolar bone or between intact sinus lining and floor of sinus

29
Q

Caldwell-Luc procedure?

A

Create incision in lateral aspect (premolar region)
Create buccal window = access into sinus
Flush object out

30
Q

Pros caldwell-luc?

A 
Trapdoor approach
Good access
Preserves alveolar bone
Method of choice for delayed procedures
Direct vision
31
Q

Cons of caldwell-luc?

A 
Trauma, loss of vitality to adjacent teeth
Fistula formation
Epistaxis
Intraorbital nerve damage
- Neuralgia
- Paraesthesia
32
Q

Functional endoscopic sinus surgery features?

A

Conservative
Maxillary sinus access via enlarged middle meatus antrosotomy
Minimises complications associated with surgical options
Expensive, time consuming

33
Q

Risks of functional endoscopic sinus surgery?

A

Risks - infection, epistaxis, CSF leak, difficulty retrieving posterior/inferior or large foreign body

34
Q

When choosing to delay retrieving a displaced foreign object, what should you do?

A 
Document info (size, position)
Radiograph - PA, OPT, OM, CT
Suture socket
Antibiotics
Refer
35
Q

Fractured tuberosity features?

A 
Most distal aspect of maxilla
Contains socket of 3rd molar
Fracture - cause for concern:
- Large OAC
- Stability issue later for prosthetics
Associated with upper molar extractions - usually 7, 8
36
Q

Fractured tuberosity risk factors?

A 
Divergent/dilacerated/ankylosed roots
Removal of impacted upper molar
Lone standing upper molar
Pneumatised maxillary sinus 
Increased age
Poor technique - Uncontrolled force, inadequate maxillary alveolus support, excessive elevation
37
Q

Clinical signs of fractured tuberosity?

A

Tooth and tuberosity are felt to move synchronously with extraction
Fracture noise
Palatal tear
Bleeding

Assess - continue vs abandon extraction, immediate vs delayed repair?

38
Q

How to manage fractured tuberositys IF it’s still attached to the periosteum? (realising fracture early)

A
  1. Rigid spliting to adjacent teeth (composite and ortho wire)
    - Soft diet, antibiotics, rebook for surgical extaction in 6-8 weeks)
  2. Or section crown to enable roots and tuberosity to heal and suture
    - Soft diet, antibiotics. Rebook for surgical extraction 6-8 weeks
  3. Remove fractured tuberosity (if small) - subperiosteal dissection of mucoperiosteum off the fragment
39
Q

If fractured tuberosity completely separate from soft tissues +/- OAC management?

A

Smooth sharp edges residual bone
If no OAC - suture and antral regime and review
If OAC - treat according to defect size and antral regime and review

40
Q

Symptoms of sinusitis?

A 
Bacterial or viral
Mimic toothache
Nasal discharge
Pressure - tender
Pain when bending over/lying down
41
Q

Tx of chronic sinusitis?

A

Bacterial - broad spectrum antibiotics (amoxicillin - if not working then co-amoxiclav), decongestants
- If not resolved refer to ENT

Chronic - antral wash out, nasal surgery

Oral Disease (42 decks)

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