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

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

Surgical aspects of the maxillary antrum Flashcards by Rachel Sladden

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

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Anatomy/ function

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

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Anatomical borders (5)

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

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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

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Anterior wall contains (3)

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

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Function (4)

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

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Injury: oro-antral communication (3)

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

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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
***

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What is an OAC?

An open communication between the oral cavity and the maxillary sinus

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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

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Diagnosis of oro-antral communication (6)

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

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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 **

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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)

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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

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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

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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

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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

1. 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)

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

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