Surgical aspects of the maxillary antrum Flashcards
Anatomy of maxillary antrum
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
Anatomy/ function
Drains into nose via ostrium (middle)
Ostium halfway up medial wall
Not dependent on gravity
Efficient cilia - beat towards ostium
Anatomical borders (5)
Infraorbital surface of maxilla (S) Alveolar process (I) Lateral wall of nose (M) Zygoma (L) Maxilla (A/M/L)
Floor of antrum (4)
- Thinnest near tooth bearing alveolus
- In children adjacent to nasal floor
- In adults 5-10mm lower
- Close to apices of the teeth
Anterior wall contains (3)
- Contains canine fossa
- Thinnest part <2mm thick
- Good for surgical access
Function (4)
- Respiration – warm/humidfy
- Speech
- Weight
- Crumple zone (design or accident)
Injury: oro-antral communication (3)
Floor can extend from molar region to canine
Root apices closely associated
Most common? - palatal root of first molar
OAC Risk Factors (a lot)
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
***
What is an OAC?
An open communication between the oral cavity and the maxillary sinus
Pre-operative (3)
Avoidance? Probably not but……. – Assessment pre and post extraction • Age (Increased incidence with age) • Ankylosis • Root fractures/RCT Warn patient of possibility
Diagnosis of oro-antral communication (6)
- May be unnoticed
- Not by forced expiration
- Not by probing/poking
- Gentle observation
- Suspicion
- Radiograph?
Clinical/ radiographic signs (6)
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 **
Signs and symptoms (4)
Purulent discharge
Bad taste
Liquid regurgitation through nose
Air escape - both directions (Valsalva manoeuvre: can have false negative result due to infection/ debris)
Management of OAC (3)
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
Conservative management of OAC (5)
Many OACs undetected - heal spontaneously
Instructions: No nose-blowing, OHI
Antibiotics - broad spectrum (Penicillin) - if risk factors present
Splints
Decongestants
Active management of OAC (3)
Suturing • Resorbable/Non-resorbable Packing • Resorbable: oxidised Cellulose • Non-resorbable – fistula: BIPP (bismuth iodoform paraffin paste) soaked ribbon Gauze Antibiotics, Decongestants etc
Oro-antral fistula definition (2)
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.
Signs and symptoms (7)
Purulent discharge Bad taste Liquid discharge through nose Air escape Episodic sinusitis Demonstration of communication Radiographic evidence
Buccal advancement flap advantages (3)
- Good success rate
- Low morbidity
- Good blood supply
Buccal advancement flap disadvantages (1)
Decrease in vestibular sulcus depth –
prosthetic implications
Palatal rotation flap (4)
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
Buccal fat bad graft (2nd choice)
Buccal advcancement flap but incorporating some of the buccal fat with it??
Displaced foreign object: incidence (3)
U8s - 0.6-3.8% oof iatrogenic cases
Upper 6 palatal root > 3rd molars (whole tooth) > 2nd molar root
How to avoid displaced foreign object (3)
Awareness….radiograph
• Age, RCT, Ankyloses, Proximity
Avoid apical pressure
Controlled force
Management of displaced foreign object (4)
Retrieve Light Suction Locations -between mucosa and alveolar bone -between intact sinus lining and floor of sinus
Transalveolar approach
- Fill sinus with saline, use suction to retrieve root
2. 2 or 3 sided buccal flap - flap design should permit closure ***
Caldwell-Luc procedure pros (5)
- Trapdoor approach
- Good access
- Preserves alveolar bone
- Risk of injury to adjacent teeth
- Method of choice for delayed procedures
Cons of Caldwell-Luc (4)
Trauma, loss of vitality to adjacent teeth Fistula formation Epistaxis Infra-orbital nerve damage -neuralgia -paraesthesia
FESS
Conservative approach
Maxillary sinus access via enalrged middle meatus antrosotomy
Minimises complications associated with other surgical options
Expensive, time consuming, skill
Risks of FESS
Infection
Epistaxis
CSF leak
Fifficulty retrieving posterior/ inferior or large foreign body
Displaced foreign object: delay
Document info Radiograph Suture socket Antibiotics Refer Inform patient
Post-op of procedure
Similar to conservative regimen
- decongestants
- abx
- avoidance of nose blowing
- OH
Fractured tuberosity
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
Fractured tuberosity
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
Risk factors for fractured tuberosity
Divergent / dilacerated/ akylosed roots
Removal of impacted upper molar
Lone standing upper molar
Pneumatised maxillary sinus ***
Clinical signs of fractured tuberosity
Tooth and tuberosity are felt to move synchronously with extraction movement **
If tuberosity still attached to periosteum (3)
- Rigid splinting to adjacent teeth (composite and ortho wire/ suc down splint)
- soft diet, abx. Re-book for surgical extraction 6-8 weeks - Or section to enable roots and tuberosity to heal and suture
- soft diet, abx. Re-book for surgical extraction 6-8 weeks - Remove fractured tuberosity (if small) - subperiosteal dissection of mucoperiosteum off the fragment
If fractured tuberosity completely separate from soft tissues +/- OAC
Smooth sharp edges residual bone
If no OAC - suture + antral regime + review
If OAC - treat according to defect size + antral regime + review
Implants - inadequate height
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
Sinusitis symptoms/ signs (5)
- Bacterial or viral
- Can mimic toothache
- Nasal discharge
- Pressure
- Pain when bending over/lying down
Treatment for sinusitis (2)
CT scan to diagnose
• Bacterial – antibiotics, decongestants
• Chronic – antral wash out, nasal surgery
