Surgical aspects of the maxillary antrum

Question 1

Anatomy of maxillary antrum

Answer 1

Pyramidal shape, apex facing laterally
Roof of antrum: orbital floor (brittle and thin), infraorbital bundle traverses
Medial wall: lateral wall of nose, contains ostium, cartilaginous in places
Floor of antrum: alveolar process of maxilla, hard palate
Anterior wall: the cheek area and lateral wall with lateral maxilla

Question 2

Anatomy/ function

Answer 2

Drains into nose via ostrium (middle)
Ostium halfway up medial wall
Not dependent on gravity
Efficient cilia - beat towards ostium

Question 3

Anatomical borders (5)

Answer 3

Infraorbital surface of maxilla (S)
Alveolar process (I)
Lateral wall of nose (M)
Zygoma (L)
Maxilla (A/M/L)

Question 4

Floor of antrum (4)

Answer 4

• Thinnest near tooth bearing alveolus
• In children adjacent to nasal floor
• In adults 5-10mm lower
• Close to apices of the teeth

Question 5

Anterior wall contains (3)

Answer 5

• Contains canine fossa
• Thinnest part <2mm thick
• Good for surgical access

Question 6

Function (4)

Answer 6

• Respiration – warm/humidfy
• Speech
• Weight
• Crumple zone (design or accident)

Question 7

Injury: oro-antral communication (3)

Answer 7

Floor can extend from molar region to canine
Root apices closely associated
Most common? - palatal root of first molar

Question 8

OAC Risk Factors (a lot)

Answer 8

Lon/ divergent/ dilacerated/ ankylosed roots
Lone standing molar
Hypercementosis, tooth shape: bulbous roots or bony sclerosis
Loss of apical periapical bone (perio, cyst, granuloma)
Pneumitisation of sinus
***

Question 9

What is an OAC?

Answer 9

An open communication between the oral cavity and the maxillary sinus

Question 10

Pre-operative (3)

Answer 10

Avoidance?
Probably not but…….
– Assessment pre and post extraction
• Age (Increased incidence with age)
• Ankylosis
• Root fractures/RCT
Warn patient of possibility

Question 11

Diagnosis of oro-antral communication (6)

Answer 11

• May be unnoticed
• Not by forced expiration
• Not by probing/poking
• Gentle observation
• Suspicion
• Radiograph?

Question 12

Clinical/ radiographic signs (6)

Answer 12

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
Radiograph **

Question 13

Signs and symptoms (4)

Answer 13

Purulent discharge
Bad taste
Liquid regurgitation through nose
Air escape - both directions (Valsalva manoeuvre: can have false negative result due to infection/ debris)

Question 14

Management of OAC (3)

Answer 14

If <2mm
-promote spontaneous healing
-gentle irrigation 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
>mm or OAF - surgical repair

Question 15

Conservative management of OAC (5)

Answer 15

Many OACs undetected - heal spontaneously
Instructions: No nose-blowing, OHI
Antibiotics - broad spectrum (Penicillin) - if risk factors present
Splints
Decongestants

Question 16

Active management of OAC (3)

Answer 16

Suturing
• Resorbable/Non-resorbable
Packing
• Resorbable: oxidised Cellulose
• Non-resorbable – fistula: BIPP (bismuth iodoform paraffin paste) soaked ribbon Gauze
Antibiotics, Decongestants etc

Question 17

Oro-antral fistula definition (2)

Answer 17

A Fistula is an abnormal connection or
passageway between two epithelium lined
organs or vessels that normally do not connect (.7 days after **)
Oro-Antral Communication may heal forming an
Oro-Antral Fistula.

Question 18

Signs and symptoms (7)

Answer 18

Purulent discharge
Bad taste 
Liquid discharge through nose
Air escape
Episodic sinusitis
Demonstration of communication
Radiographic evidence

Question 19

Buccal advancement flap advantages (3)

Answer 19

• Good success rate
• Low morbidity
• Good blood supply

Question 20

Buccal advancement flap disadvantages (1)

Answer 20

Decrease in vestibular sulcus depth –

prosthetic implications

Question 21

Palatal rotation flap (4)

Answer 21

Pedicle flap on the greater palatine artery
Length/width ratio important
• >2.5 = flap necrosis
Painful donor site
Seldom used, useful for larger OAF’s

Question 22

Buccal fat bad graft (2nd choice)

Answer 22

Buccal advcancement flap but incorporating some of the buccal fat with it??

Question 23

Displaced foreign object: incidence (3)

Answer 23

U8s - 0.6-3.8% oof iatrogenic cases

Upper 6 palatal root > 3rd molars (whole tooth) > 2nd molar root

Question 24

How to avoid displaced foreign object (3)

Answer 24

Awareness….radiograph
• Age, RCT, Ankyloses, Proximity
Avoid apical pressure
Controlled force

Question 25

Management of displaced foreign object (4)

Answer 25

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

Question 26

Transalveolar approach

Answer 26

1. Fill sinus with saline, use suction to retrieve root

2. 2 or 3 sided buccal flap - flap design should permit closure ***

Question 27

Caldwell-Luc procedure pros (5)

Answer 27

• Trapdoor approach
• Good access
• Preserves alveolar bone
• Risk of injury to adjacent teeth
• Method of choice for delayed procedures

Question 28

Cons of Caldwell-Luc (4)

Answer 28

Trauma, loss of vitality to adjacent teeth
Fistula formation
Epistaxis
Infra-orbital nerve damage
-neuralgia
-paraesthesia

Question 29

FESS

Answer 29

Conservative approach
Maxillary sinus access via enalrged middle meatus antrosotomy
Minimises complications associated with other surgical options
Expensive, time consuming, skill

Question 30

Risks of FESS

Answer 30

Infection
Epistaxis
CSF leak
Fifficulty retrieving posterior/ inferior or large foreign body

Question 31

Displaced foreign object: delay

Answer 31

Document info
Radiograph
Suture socket
Antibiotics
Refer
Inform patient

Question 32

Post-op of procedure

Answer 32

Similar to conservative regimen

• decongestants
• abx
• avoidance of nose blowing
• OH

Question 33

Fractured tuberosity

Answer 33

Most distal aspect of maxilla
Contains socket of third molar
Fracture - cause for concern
-large OAC
-stability issue later for prosthetics
Assoc with U molar extractions, usually 7,8

Question 34

Fractured tuberosity

Answer 34

Most distal aspect of maxilla
Contains socket of third molar
Fracture - cause for concern
-large OAC
-stability issue later for prosthetics
Assoc with U molar extractions, usually 7,8

Question 35

Risk factors for fractured tuberosity

Answer 35

Divergent / dilacerated/ akylosed roots
Removal of impacted upper molar
Lone standing upper molar
Pneumatised maxillary sinus ***

Question 36

Clinical signs of fractured tuberosity

Answer 36

Tooth and tuberosity are felt to move synchronously with extraction movement **

Question 37

If tuberosity still attached to periosteum (3)

Answer 37

1. Rigid splinting to adjacent teeth (composite and ortho wire/ suc down splint)
   - soft diet, abx. Re-book for surgical extraction 6-8 weeks
2. Or section to enable roots and tuberosity to heal and suture
   - soft diet, abx. Re-book for surgical extraction 6-8 weeks
3. Remove fractured tuberosity (if small) - subperiosteal dissection of mucoperiosteum off the fragment

Question 38

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

Answer 38

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

Question 39

Implants - inadequate height

Answer 39

Inlay grafts
-sinus lift/ graft
Internal sinus lift: Summers technique
Aim: 
-maintain integrity of sinus lining
-limit ****
Lateral window approach using Piezosurgery kit: push window up and pack with artificial bone particulate, left for a few months, then implant can be placed

Question 40

Sinusitis symptoms/ signs (5)

Answer 40

• Bacterial or viral
• Can mimic toothache
• Nasal discharge
• Pressure
• Pain when bending over/lying down

Question 41

Treatment for sinusitis (2)

Answer 41

CT scan to diagnose
• Bacterial – antibiotics, decongestants
• Chronic – antral wash out, nasal surgery