Maxillary Sinus in Dentoalveolar Surgery

Question 1

Oro-antral Communication (O.A.C)

Answer 1

Invasion of the maxillary sinus and establishment of a direct communication with the
oral cavity is referred to as an “oro -antral communication”.

Question 2

Factors influencing creation of oro-antral communication
(5)

Answer 2

• 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 the sinus

Question 3

Factors influencing creation of oro-antral communication
(5)

Answer 3

• Rough extraction and misguided manipulation.
• Apical pathosis.
• Periapical diseases which may erode sinus floor.
• Presence of cysts and neoplasm.
• Invasive surgery e.g. dental implants placement.

Question 4

Prevention of Oroantral Communication –Intra operative Period
(2)

Answer 4

• Perform surgical extraction early, remove
  some bone around the tooth and if
  necessary section roots and remove them
  separately i.e 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

Removal of Root Fragments and Root Tips

Answer 5

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

Question 6

Policy of leaving root fragments
(5)

Answer 6

– Risk vs benefits (Maxillary sinus)
– Fragment must be small (< 5 mm)
– Root deeply embedded
– Absence of infection
– No radiolucency at root tip

Question 7

Diagnosis of the oro-antral communication
During dental extractions in the posterior maxillary region, it is important to determine if it is just

Answer 7

an O.A.C or if it is a O.A.C with displacement of the tooth into the socket.

Question 8

Diagnosis of the oroantral communication
(3)

Answer 8

– To confirm the presence of a communication, the best technique is to use the “Nose-blowing
test” (Valsalva Maneuver).
– The patient is asked to pinch their nostrils together to occlude the nose. The patient blows
gently to see if air escapes into the oral cavity via the maxillary sinus opening.
– Presence of OAF appears as bubbling of blood in the extraction socket.

Question 9

Diagnosis of the oroantral communication
(3)

Answer 9

– If nose-blowing’ test is negative, don’t explore the opening with suction tip and/or
probes.
– Don’t attempt to irrigate the sinus to confirm diagnosis.
– Always check radiograph for the continuity of sinus floor and presence of tooth/root.

Question 10

Signs and symptoms of newly created oro-antral Communication
(4)

Answer 10

• 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 11

Management of oro-antral communication
Small Size - (2 mm in diameter or less)
(3)

Answer 11

• Small (2 mm in diameter or less), no additional surgical treatment is necessary
• Sinus precautions
• Surgeon must not probe through the socket into the sinus with a periapical curette or
  a root tip pick

Question 12

• Sinus precautions
  (2)

Answer 12

– avoid blowing the nose, violent sneezing, sucking on straws, and smoking
– Patients who smoke and who cannot stop (even temporarily) should be advised to smoke in small
puffs, not in deep drags, to avoid pressure changes.

Question 13

Management of oro-antral communication
Moderate Size O.A.C (2 to 6 mm)
(3)

Answer 13

• Ensure the maintenance of the blood clot in the area, a figure-of-eight suture should be placed
  over the tooth socket .
• Antibiotics, usually Augmentin, should be prescribed for 7 days.
• A nasal decongestant spray should be prescribed to shrink the nasal mucosa to keep the ostium of
  the sinus patent.

Question 14

Management of oro-antral communication
Large size O.A.C (7 mm or larger)
(3)

Answer 14

• Dentist should consider closing the sinus communication 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 15

Flap development and closure of a sinus opening are somewhat complex procedures that require
skill and experience.

Answer 15

– most commonly used flap is a buccal flap
* This technique mobilizes buccal soft tissue to cover the opening and provide for a
primary closure

Question 16

Disadvantage of the Buccal advancement flap technique is loss of

Answer 16

vestibular depth

Question 17

Advantage of the Palatal rotation flap

Answer 17

Advantage of the Palatal rotation flap
- Keratinized tissue is used to cover the O.A.C in relation to the alveolar ridge

There is no loss of vestibular depth on the buccal side

Question 18

Postoperative care/ Sinus Precautions
(5)

Answer 18

Antibiotics (Augmentin)
Pain Medication (Combination of Acetoaminophen, Ibuprofen)
Local treatment
Saline Nasal decongestant
Steam inhalation

Question 19

Local treatment

Answer 19

Nasal Decongestant
e.g. Afrin Sinus decongestant,
2 to 3 Nasal puffs 2 times daily for 3 to 4 days

Question 20

Management of Oroantral Communication with displacement of tooth/root
into the sinus
(3)

Answer 20

• Assess size of root
• Presence of infection
• Health of sinus

Question 21

Displacement of tooth or root into the maxillary sinus
(3)

Answer 21

• It is basically a mishap that results from a neglected act by the operator while
  applying wrong force.
• Occurs rarely but the maxillary 3rd molar and maxillary 2nd premolar are the most at
  risk of dislodgment.
• In association with poor surgical technique.

Question 22

Displacement of tooth or root into the maxillary sinus
Immediate Management
(2)

Answer 22

• Confirm the existence of oro-antral communication and the presence of tooth or root in
  sinus using Periapical X-rays, panoramic X-rays and C.B.C.T Scan if necessary.
• Locate the precise position of the foreign body within the sinus lining or in the sinus
  cavity.

Question 23

Immediate management
(5)

Answer 23

• Reflect mucoperiosteal flap.
• Reduce alveolar bone height.
• Retrieve the tooth or the root 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 24

If the O.A.C is left untreated, The two sequelae of most concern are:
(2)

Answer 24

• Formation of a chronic oroantral fistula.
• Postoperative maxillary sinusitis

Question 25

What is a Fistula ?

Answer 25

• Is a biological tract that connects an anatomical cavity with the external
  surfaces or another anatomical cavity (unlike sinus tract).
• It is always lined with a stratified squamous epithelium and the patency of
  the tract is preserved until epithelial cells scraped off.

Question 26

Oro-antral fistula
(5)

Answer 26

It might be a complication of:
Unrecognized (overlooked) fistula.
Untreated fistula.
Failure of spontaneous closure of OAC.
Failure of surgically repaired oro-antral fistula

Question 27

Signs and symptoms of Oro Antral Fistula
Patient usually complains of
(5)

Answer 27

• Nasal regurgitation of liquid and reflux of food and drinks.
• Altered nasal resonance,
• Intermittent episode of pain and local tenderness.
• Foul-tasting discharge.
• Bad taste in the mouth and whistling sound while speaking.

Question 28

Primarily management of Chronic Oro Antral Fistula
It is aimed to eliminate any sinus infection:
(4)

Answer 28

• 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 29

Management of Chronic Oro Antral Fistula
Important Surgical Principles
(5)

Answer 29

• Success of operation is not always guaranteed.
• 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