surgical anatomy of maxillary sinus.

2. CONTENTs
 Introduction
 Development and Anatomy
 Blood supply, Nerve supply& Lymphatic
drainage
 Histology
 Functions of the Maxillary sinuses
 Diagnostic evaluation of sinus disease
 Developmental anomalies & Pathologic
conditions of maxillary sinus
 Clinical significance
 Conclusion
 References

3. INRODUCTION
Paranasal air sinus
 Paranasal air sinuses are the air filled mucosa
lined cavities which develops in the cranial and
facial bones.
 These are the spaces which communicates with
the nasal airway.
 These forms the various boundaries of the nasal
cavity.
 The sinuses are named for the bones in which
they are located.
 Paranasal sinuses are present in a variety of
animals (including most mammals, birds, and
crocodile).

5. MAXILLARY SINUS
Definition of maxillary sinus :-
“Maxillary sinus is the pneumatic space that is lodged
inside the body of maxilla and that communicates with the
environment by way of the middle meatus and nasal
vestibule.”
 Anatomy of the maxillary sinus was 1st described by
Nathenial Highmore in 1651.
 Also known as Antrum of Highmore.
 2 in number.
 Largest paranasal sinus.
 Volume:15-30 ml.
 Dimensions (Turner, 1902) :-
ANTEROPOSTERIOR: 3.5cm
HEIGHT: 3.2cm
WIDTH: 2.5cm

6. DEVELOPMENT
 Maxillary sinus is first of the PNS to develop.
 It starts as a shallow groove on the medial
surface of maxilla during the 4th month of
intrauterine life.
 Early stages it is high in maxilla ,later gradually
grows downwards by process of
Pneumatization.
1.Primary-(10th
week)
2.Secondary –(5th
month)
 Expansion occurs more rapidly until all the

7. The maxillary sinus development increases in size
during the growth of the midface of the maxilla and is
also related to the eruption of the deciduous teeth,

10. Anatomy
 Largest of PNS,communicate with other sinuses
through lateral nasal wall.
 Horizontal Pyramidal shaped.
Consists of – 1.Apex
2.Base
3. Walls – A) Superior
B) Inferior
C) Lateral
D) Anterior
 Wall thickness varies with
individual .

11.  Base - lateral wall of nose.
 Apex - zygomatic process of maxilla.
 Roof - floor of orbit traversed by the infraorbital canal.
 Floor –lateral hard palate maxillary alveolar process.

12.  Anteror wall-facial surface of maxilla
 Posterior wall- separates sinus from infratemporal and
pterygopalatine fossa.
MEDIAL WALL:-
 Formed by lateral nasal wall
 ◦ Below-inferior nasal conchae
 ◦ Behind-palatine bone
 ◦ Above- Uncinate process of
ethmoid bone and lacrimal bone
 Contains double layer of
mucous membrane
(pars membranacea)

13. MEDIAL WALL:-
Important structures
 Sinus ostium
 Hiatus semilunaris- The hiatus semilunaris
(or semilunar hiatus) is a crescent-shaped groove in
the lateral wall of the nasal cavity just inferior to the
ethmoidal bulla. It is the location of the openings for the
frontal sinus, maxillary sinus, and anterior ethmoidal sinus.
 Ethmoidal bulla- The ethmoid bulla forms the
posterior and superior walls of the ethmoid infundibulum
and hiatus semilunaris. The ethmoid bulla is the largest
anterior ethmoid air cell.
 Uncinate process
 Infundibulum

14. Ostium
 Opening of the maxillary sinus is called ostium.
 It opens in middle meatus at the lower part of the
hiatus semilunaris.
 Lies above the level of nasal floor.
 The ostium lies approximately 2/3rds
up the medial wall of the sinus, making
drainage of the sinus inherently
difficult.
 In 15% to 40% of cases, a very small,
accessory ostium is also found.
 Blockage of the ostium can easily occur
when there is inflammation of the mucosal lining of
the ostium.

15.  Superior wall:- Forms roof of sinus and floor of orbit.
IMPORTANT STRUCTURES
 Infraorbital canal
 Infraorbital foramen
 Infraorbital nerve and vessels
 Applied aspect 1.Vulnerable to trauma
2.Erosion of this wall by tumor.
 Posterolateral wall:-
 Made of zygomatic and greater wing of
sphenoid bone.
 Thick laterally,thin medially
IMPORTANT STRUCTURES
 PSA nerve
 Maxillary artery and Nerve
 Pterygopalatine ganglion
 Applied aspect 1. Involvement of PSA--
2. Surgical access by careful removal of segment of

16.  Anterior wall:-
 Extends from pyriform aperture anteriorly
to ZM suture & Inferior orbital rim superiorly
to alveolar process inferiorly.
 Convexity towards sinus
 Thinnest in canine fossa
 IMPORTANT STRUCTURES
 Infraorbital foramen
 ASA, MSA nerves
 Levator labii, orbicularis oculi muscles
Floor of sinus:-
• Formed by junction of anterior sinus wall and
lateral nasal wall.
• 1-1.2 cm below nasal floor.
• Close relationship between sinus and
teeth facilitate spread of pathology.

17. BLOOD SUPPLY
Arterial blood supply:-
 Greater palatine arteries
 Infraorbital artery
 Posterior superior artery
 Maxillary artery

18. Venous drainage:-
 Pterygoid venous plexus
 Sphenopalatine vein
 Facial vein
Anteriorly- sphenopalatine vein
Posteriorly- pterygoid venous
plexus drain into facial vein
Pterygoid plexus communicates with
the cavernous sinus by emissary veins.

19. 1. Anterior superior alveolar nerve (ASA)
2. Middle superior alveolar nerve (MSA)
3. Posterior superior alveolar nerve (PSA)
4. Infra-orbital nerve
5. Greater palatine.

20.  Surgical Importance of Nerve supply •
 As there is chance of damage of nerve during
surgical procedure
1. ASA- given off from infraorbital nerve about 15mm
from infraorbital foramen,courses down on anteriror
wall.
2. MSA- seen in 50 % cases arise from lateral aspect
of infraorbital nerve .
3. PSA- superior branch runs at level of malar
tuberosity,
inferior branch-runs parallel to transverse facial
part of anterior nerve.

21. LYMPHATIC DRAINAGE
1. Submandibular lymph nodes
2. Deep cervical lymph node
3. Retro pharyngeal lymph node
 The lymphatic drainage reaches
the specialized cells in the maxillary
sinus via infra orbital foramen or
through the anterosuperior wall and
then to the submandibular lymph
nodes.

22. HISTOLOGY
 Lined by respiratory epithelium
 Mucous secreting Pseudo stratified ciliated columnar
epithelium
 SCHNEIDERIAN MEMBRANE -is the membranous lining
of the maxillary sinus cavity. Microscopically there is a
bilaminar membrane with pseudostratified ciliated
columnar epithelial cells on the internal side and
periosteum on the osseous side.
 It has mucociliary mechanism.
 Cilia moves the mucus and debris towards ostium and
discharged in middle meatus.

23. Abstract
Kalyvas et al.
International
Journal of Implant
Dentistry (2018)
4:32

24. Clearance
 The mucus of the maxillary
sinuses is produced from
serous and goblet cells, which
produce 1 L of mucus each day
in healthy conditions.
 The cilia in the maxillary sinus
beat toward the ostium. A
blanket of mucus is propelled
toward the ostium by the
beating motion of the ciliated
lining cells.
 The mucous material of the
sinus in health has two layers:
(1) a top mucoid layer and (2) a
bottom serous layer .
 The top layer is sticky and

25. FUNCTIONS OF MAXILLARY SINUS
1. Warming of inspired air.
2. Humidification of dry air.
3. Lightening of skull weight.
4. Resonance of voice.
5. Filters debris.
6. Accessory olfactory organ.
7. Protects skull from mechanical shock.
8. Production of bactericidal lysozyme.
9. Gives air padding to provide thermal insulation to
adjacent important tissues.
10. Assisting in regulating intranasal pressure.

26. DIAGNOSTIC EVALUATION
 Detailed medical & dental history.
 Clinical examination:-
1) Inspection
2) Palpation
3) Percussion
4) Transillumination
• Radiographs .
• Ultrasound, CT scan, MRI.
• Endoscopy.

27. CLINICAL EXAMINATION
 INSPECTION :
 Middle third of the face should be
inspected for the presence of
asymmetry, deformity, swelling,
erythema , ecchymosis or
hematoma.
 EXTRAORAL PALPATION :
 Tapping of lateral wall of sinus over
prominence of cheek bone and
palpation intra-orally on lateral
surface of maxilla between canine
fossa and zygomatic buttress.

28.  TRANSILLUMINATION
 It is done by placing a bright
flash light or fiber optic light
against the mucosa on the
palatal or facial surface of the
sinus and observing the
transmission of light through the
sinus in the darkroom.
 Good transillumination indicates
presence of air in the sinus
while
the failure of transillumination
indicates presence of pus, fluid
,
solid lesion or mucosal
thickening.
 PRINCIPLE:-In the setting of

29. RADIOLOGY OF MAXILLARY SINUS
 EXTRAORAL VIEWS :-
 OCCIPITOMENTAL/WATERS
 LATERAL SKULL
 SUBMENTOVERTEX
 ORTHOPANTOMOGRAPHY
 OTHERS - CT SCAN
MRI
ULTRASOUND
ENDOSCOPY
 INTRAORAL VIEWS :-
 OCCLUSAL
 LATERAL OCCLUSAL
 PERIAPICAL

30. OCCIPITOMENTAL VIEW
(WATER’s VIEW)
LATERAL SKULL
VIEW

31. SUBMENTOVERTEX VIEW

32. ORTHOPENTOMOGRAPHY(OP
G)
OPG showing Maxillary Sinus and Molar Roots
Relationship

33. CT SCAN OF MAXILLARY SINUSMRI OF MAXILLARY SINUS

34. Occlusal
view
Lateral occlusal
view
The roots of maxillary molars usually lie in close
apposition to the maxillary sinus and may project into
the floor of the sinus, causing small elevations or
prominences.

35. Periapical
View
 Borders of the maxillary sinus appear as a thin,
delicate radiopaque line .
In the absence of disease it appears continuous, but
on close examination it has small interruptions in its
smoothness or density.
 Maxillary sinus
septum

36.  Ultrasound
 Ultrasound is becoming the diagnostic tool of choice for
more physicians in detecting sinusitis.
 It offers a fast ,reliable and radiation free method for
diagnosing sinusitis
 Ultrasound waves sent out by the sinus when waves are
reflected from the posterior wall of the sinus the sinus
contains fluid and from the anterior wall when the sinus
contains air.
 Ultrasound waves are generated by probe.

37. Ultrasound image of
maxillary sinus
Ultrasound
Examination

38. ENDOSCOPY
 It is an optimal method
especially for the
assessment of foreign
bodies (such as root filling
materials and root tips)
that have penetrated into
the maxillary sinus.
 Direct optical evaluation of
the antral floor region..
 Path of access used:-
1.Transoral via canine
fossa 2.Transalveolar via
connection between oral
cavity & antrum 3.Trans

39. DEVELOPMENTAL ANOMALIES AND
PATHOLOGIC CONDITIONS OF
MAXILLARY SINUS
Developmental anomalies
 1.Aplasia
 2. Agenesis
 3. Hypoplasia
 Along with Cleft palate, choanal atresia, high
palate, septal deformity, mandibular dysostosis,
malformation of external nose.
 Supernumery- two completely separated sinus
on same side

40. Pathologic conditions of maxillary sinus
 Maxillary Sinusitis
 Oro-antral fistula.
 Odontogenic cystic lesions of maxillary sinus
 Tumors of maxillary sinus.

41. Maxillary sinusitis
 When the inflammation develops in the sinus either
due to infection or allergy it is termed as sinusitis.
 It may be clinically defined as an inflammatory
response involving mucous membranes of the nasal
cavity and paranasal sinus.
 Most common involving the maxillary
sinus.

42. Maxillary sinusitis

43. Maxillary sinusitis
 Anatomical variations influencing the
development of sinusitis
a) Variations of uncinate process
b) Variations in bulla ethmoidalis
c) Variations of middle turbinate
d) Accessory ostium
e) Deviated nasal septum
f) Nasal masses
g) Haller cell
Preexisting skeletal and bony abnormalities of the
osteomeatal complex may compromise the unit, leading to

44. Etiology
Extrinsic causes
 1. Infectious causes
 a) Bacterial
 b) Viral
 c) Fungal
 d) Parasitic
 2. Non infectious causes
 a) Allergic
 b) Non allergic
 c) Pharmocologic
 d) Irritants
 3. Disruption of
mucociliary drainage
 a) Surgery
 b) Infection
 c) Trauma
Intrinsic
causes
1. Genetic
a) Structural
b) Immunodeficiency
c) Mucociliary abnormality
(cystic fibrosis, dismotility)
2. Acquired
a) Aspirin hypersensitivity
b) Autonomic dysregulation
c) Hormonal
d) Structural (Tumors,
cysts)
e)Idiopathic/ autoimmune

45. Maxillary sinus
Diagnosis
1. History
2. Physical examination
 Inspection
 Palpation
 Percussion
Diagnostic techniques
 a. Rhinoscopy
 b. Endoscopy
 c. Nasal valve
examination
 d. Culture and sensitivity

46. Maxillary sinus
3. Radiological examination
 a) Water’s view
 b) Caldwell view
 c) Lateral view
 d) CT scan
 e) MRI
4. Tests for mucociliary functions
 a) Nasomucociliary clearance
 b) Ciliary beat frequency
 c) Rhinomanometry
5. Test for olfaction

47. Major & Minor sign and symptoms Associated with
the Diagnosis of Chronic
Rhinosinusitis
Major signs and symptoms Minor signs and symptoms
Facial pain/pressure Headache
Facial congestion/fullness Fever (non-acute cases)
Nasal obstruction/blockage Halitosis
Nasal
discharge/ purgulence /discolored
postnasal discharge
Fatigue
Hyposmia/ anosmia Dental pain
Purulence in nasal cavity on
examination
Cough
Fever (in acute rhinosinusitis
only)
Ear pain/pressure/fullness

48. Clinical features (Acute Maxillary sinusitis)
 Can occur at any age.
 Pt. complains of pain, pressure and heaviness at the
affected side.
 Headache is the most common.
 Facial erythema, swelling, fever.
 Drainage of foul smelling mucopurulant material into
the nasal cavity and nasopharynx.
 Pain is exacerbated on bending position.
 Dull pain may be present on premolar and molar
region.
Clinical features (Chronic Maxillary Sinusitis)
 Repeated attacks.
 Pain and tenderness.
 Foul unilateral discharge.
 Cacosmia i.e. Fetid odour with bad taste in mouth.

49. Maxillary sinusitis of Dental Origin
 1.Dental abscess
(periodontal and periapical abscess)
 2.Infected dental cyst
 3.Dental material
 4.Oro-antral communication

50. Overextension of dental material
like sealers, cements ,GP or silver
cones
A root tip of the maxillary first
molar accidentally pushed into
the sinus at the time of tooth
extraction.

52. Maxillary sinusitis
Management
MEDICAL
1. Antibiotics
2.Mucolytics(guaifen
esin,KI)
3. Decongestants
4. Analgesics
5. Antihistamines
6. Nasal spray &
saline irrigation
7.Hydration
8.Steroids
SURGICAL
1. Sinus aspiration and lavage
2. Maxillary needle
sinusotomy
3. Caldwell luc
4. FESS
(Functional endoscopic sinus
surgery )

53.  Nasal decongestants:
 Decongestants
 Systemic (phenylpropanolamine,
pseudoephidrine):
 Contraindications: hypertension,
hyperthyroidism, asthma
 Topical: phenylepinephrine HCl, oxymetazoline
HCl
 Adverse Effects- rhinitis medicamentosa
 Mucolytic agents:
1. Benzoin compound
2. Camphor
3. Methanol in boiling water

54. m

55. Steroids
 Corticosteroids work to reduce inflammation and swelling
in your sinuses. This makes it easier for nasal mucus to
drain into your stomach like it usually does.
 1st line of therapy: Topical intranasal
(betamethasone, dexamethasone, triamcinolone)
 Systemic steroids:
Prednisolone:0.5-1mg/kg x3-4 days

56.  Analgesics & antihistamine
Analgesics: for pain relief
 Opoid : Codeine
 NSAIDS: Acetaminophen
Antihistamines:
 Mequitazine, terfenad
 Contraindicated in Bacterial sinusitis
Adverse effect: sedation

57. Nasal lavage & sprays
 Removes debris & dead
tissue
 Washes inflammatory
secretions
 Methods of Nasal lavage
 Lavage pot
 Syringe
 Irrigating bulb
Techniques of nasal sprays
 1. Moffet position
 2. Mygind technique
Lavage
pot

58. Surgical management
Indications
 Bilateral chronic
sinusitis with
polyps
 Fungal sinusitis
 Presence of
complications
 Tumor of PNS
 CSF rhinorrhea
Contraindication
•Presence of
extensive polyps
• Patient with
complaint of
headache and
midfacial pain
• Medically
compromised
• Hypoplastic sinuses

59.  Sinus aspiration & lavage
 Direct removal of bacteria laden secretions
 Indication: No response to medical therapy

60. Maxillary needle sinusotomy
 Requires force to enter anterior wall
 Alternatives : Mallet
Steinmann pin
Complications:
 Bleeding
 Infection
 Dental injury
 Sensory nerve disturbance
 Instrument breakage
Preparation of site
Infiltration
of LA
Transcutaneous
puncture anterior &
posterior to
canine eminence

61.  Caldwell luc sinusotomy
By George Caldwell (1893) & Henry Luc (1897)
Indications
• Chronic intractable maxillary sinusitis that fail to
respond to medical / FESS management
(Kartagener’s syndrome / Young’s syndrome)
 Fungal sinusitis
 Multiple antral lesions
 Antrochoanal polyp
 Excision of tumor
 Closure of OAF
 Removal of antral foreign body
 Antral revision procedures
 surgical approach for transantral
sphenoethmoidectomy, orbital decompression

62. Caldwell Luc procedure steps
1. Under LA with sedation or
under GA
2. A semilunar incision is planned
in the buccal vestibule from
canine to 2nd molar,just
above the gingival
attachment.
3. A mucoperiosteal flap is
elevated
4.An opening or window is
created in the anterior wall of
maxillary sinus.
5. It is then enlarged in all
directions
with Rongeur forceps, to permit
the inspection of sinus cavity.
6. Pus should be sucked away and
thorough irrigation of maxillary
sinus is carried out with saline
wash.

63. The thickened, infected lining of the sinus can be elevated with
Howarths periosteal elevator and removed and sent for
histopathology .In case of profuse bleeding- sinus is packed with ribbon gauze
soaked in adrenaline 1:1000 for 1 or 2 minutes
• The antral cavity is irrigated again and can be packed with
iodoform ribbon gauze.
• The incison is closed with 3-0 silk

64. Complications:-
1.Bleeding 6.Cheek
Edema
2.Dental sensitivity 7. Oroantral
fistula
3.Infraorbital neuralgia

65. Functional endoscopic sinus
surgery(FESS)
 A minimally invasive
surgical treatment which
uses nasal endoscopes to
enlarge the nasal
drainage pathways of the
paranasal sinuses to
improve sinus ventilation.
 Intranasal endoscopic
technique that allows
establishment of adequate
sinus drainage without
negative impact on sinus
mucosa physiology and

66.  The most suitable
candidates for this
procedure have recurrent
acute or chronic infective
sinusitis, and an
improvement in
symptoms of up to 90
percent may be expected
following the procedure.
 Fiberoptic telescopes are
used for diagnosis and
during the procedure,
and computed
tomography is used to
assess the anatomy and
Functional endoscopic sinus
surgery(FESS)

67. Functional endoscopic sinus
surgery(FESS)
 Functional endoscopic
sinus surgery should be
reserved for use in
patients in whom
medical treatment has
failed.
 The procedure can be
performed under
general or local
anesthesia on an
outpatient basis, and
patients usually
experience minimal
discomfort.
 The complication rate
for this procedure is

68. COMPLICATION of Untreated
Maxillary Sinusitis
 Facial cellulitis
 Orbital
extension
 Intracranial
extension

71. Oroantral fistula
 Oroantral fistula is a
pathological communication
between oral cavity and
maxillary sinus.
 It develops when the oro-
antral communication fails to
close spontaneously, remains
patent and gets epithelialized.
 Maxillary sinus perforation
occurs occasionally during the
extraction of a maxillary tooth,
and it may be a cause of
maxillary sinusitis or
oro-antral fistula.

72. Oroantral fistula

73. Oroantral fistula
Predisposing factors
 • Proximity of sinus floor /
tuberosity
 • Thickened tooth cement
( Hypercementosis) / tooth
fused to jaw bone
 • Infected teeth / long-
standing decay
 • Marked periodontitis /
gum disease
 • Previous history of
OAC’s.

74. Diagnosis
 History of previous
extraction
 Mouth mirror test
 Cotton wisp test
 Inspection
 Transillumination test
positive
 Radiological
• IOPA
• OPG
• Water’s
View
CT Scan

75. SYMPTOMS OF OAF
IN FRESH
OROANTRAL
FISTULA:
 5 Es:
 1. Escape of fluids
 2. Epistaxis(unilateral)
 3. Escape of air
 4. Enhanced column
of air
 5. Excruciating pain
IN LATE STAGE,
ESTABLISHED OROANTRAL
FISTULA:
5 Ps:
•1. Pain
•2. Persistent, purulent or
mucopurulent, . foul, unilateral
nasal discharge
•3. Postnasal drip
•4.Possible sequelae of general
systemic . . toxemic condition.
•5.Popping of Antral polyps

76. Management
1. 3mm-5mm heals spontaneously
2. Ideal treatment :Immediate surgery followed by
Antibiotic prophylaxis
3. Acute OAF: closure by simple reduction of buccal and
palatal socket walls, followed by acrylic splint.
4. Larger than 5 mm requires surgical closure.
 Precausion
 Do not probe the sinus with sharp instruments
 Do not curette the socket
 Do not ask the patient to blow the nose

77. Oroantral fistula Management
1) Antibiotics
2) Nasal decongestants:
Ephedrine drops
Inhalations( steam , benzoin ,menthol)
3) Analgesics:
Aspirin 500mg
Paracetamol 500mg
Ibuprofen 400 mg
 4) Antral lavage
 5) Denture(Acrylic) plate: It is indicated when surgical
repair of fistula is to be deferred. It provides barrier to
prevent entry of food particles in antrum.

78.  ANTRAL LAVAGE
 Whitehead’s Varnish
applied to ribbon
gauze and used as
a dressing in the
treatment .

79. Treatment Strategies for OAF Closure

80. Oroantral fistula Management
Surgical closure
 Factors determining flap
selection
 Size of communication
 Timeline of diagnosis
 Presence of infection
Immediate closure
 Mucoperiosteal flap,
obtained by reducing the
height of the bony socket,
are loosely sutured over the
defect.

81. Buccal flap

82. Rehrmann Buccal Advancement flap
 Broad based trapezoidal
mucoperiosteal flap is created
and sutured over the defect.
 Broad base assure adequate
blood supply(93%)
 Disadvantage
 Reduction of buccal sulcus
depth.
 Post operative pain &
swelling.

83. Rehrmann Buccal Advancement flap

84. Rehrmann Buccal Advancement flap

85. PALATAL FLAP

86. ASHLEY’S ROTATIONAL ADVANCEMENT
Flap
design
Palpation of bony edg
PALATAL FLAP

87. ASHLEY’S ROTATIONAL ADVANCEMENT
Excising the fistula and reflect the flap

88. Post-op follow-up
ASHLEY’S ROTATIONAL ADVANCEMENT

89. COMBINED FLAP

90. Moczair flap
Recommended for
edentulous
patients,.
• Buccal sulcus depth is
minimally influenced.
 Disadvantage
• Greater amount of
dentogingival detachment
• May give rise to periodental
disease in dentate patient.

91. BUCCAL FAT PAD
Grafting of the pedicled buccal fat pad is highly
considered as an efficient, safe and alternative closure
solution in case of a large oroantral fistula.

92. Tongue flap
 Distant full thickness
pedicle flap
 Used to close large
OAF
 Rich blood supply
Disadvantage
 Requirement of GA
 Requirement of 2
stage and 3 stage
procedure

93. Tongue flap
Posteriorly based Full
thickness Lateral tongue
flap
Anteriorly based Partial
thickness Dorsal tongue flap

94. INTRANASAL ANTROSTOMY
It is performed
to facilitate the
drainage at the
conclusion of an
operation
performed:
i. To close an
oroantral fistula
ii. To remove a
tooth or a root
from sinus.

95. GRAFTS
 Bone Press fit closure of Oro antral Fistula
Indications
 If OAC is > 10 mm
 OAF and planned sinus floor elevation.
 OAF along the neighboring root surface extending
into maxillary sinus.
 Chronic OAF with multiple successful attempts of
closure.
 Bone graft for closure are often harvested from iliac
crest, chin retromolar area and zygoma, lateral wall
of maxillary sinus.

97. Maxillary sinus Pneumatization :
 The expansion of the sinus
is larger following
extraction of several
adjacent posterior teeth,
 if dental implant placement
is
 planned in these cases,
immediate implantation
and/or immediate bone
grafting should be
considered to assist in
preserving the 3-
dimensional bony
architecture of the sinus
floor at the extraction site.

98. SINUS LIFT PROCEDURES
 A sinus augmentation, or sinus membrane lift, involves adding
bone to fill in the bottom of that air space, essentially raising
the floor of the sinus cavity.
 Done in resorbed maxillary posterior ridges.
 Done for placement of Dental Implant.

100. ODONTOGENIC CYSTIC LESIONS
AFFECTING THE MAXILLARY SINUS
 -Radicular cyst
 -Dentigerous cyst
 -Mucous retention
cyst
Maxillary sinusitis caused by an
apical
inflammatory lesion ( radicular cyst)
at the root apices of the 2nd molar
- NOTICE the cloudiness
(Radioopacity)of the sinus
Radicular cyst

101. ODONTOGENIC CYSTIC LESIONS
AFFECTING THE MAXILLARY SINUS
Dentigerous cyst
 Also known as follicular
cyst,2nd most common cyst ,
it usually appear on the
impacted maxillary 3rd molar

102. TUMORS OF MAXILLARY SINUS
Benign tumor of Maxillary Sinus:-
 Ameloblastoma: is the most common benign tumor
affecting maxillary sinus.

103. TUMORS OF MAXILLARY SINUS
Malignant tumors of Maxillary
Sinus
 They are Invasive and destructive
lesions
 For Examples :Squamous cell
carcinoma

104. Clinical features
 Signs of chronic sinusitis
 Foul smelling nasal discharge
 Nasal stuffiness
 Epistaxis
 Loss of Transillumination
TUMORS OF MAXILLARY SINUS

105. TUMORS OF MAXILLARY SINUS

106. Surgical treatment
• Segmental maxillectomy
Lower level of maxilla or only the involved segment is
excised.
• Partial maxillectomy
Excision of maxilla sparing the infra orbial floor
• Total maxillectomy
Excision of maxilla with orbital floor but sparing the orbital
content.
• Radical or extended maxillectomy
Unilateral maxilla is excised along with the eyeball or
including ethmoidectomy and sphenoidectomy in the
procedure
TUMORS OF MAXILLARY SINUS

107. TRAUMATIC DISEASE
Haematoma in Maxillary Sinus
 A fracture involving infraorbital artery or superior
alveolar vessels frequently result in a
haematoma formation in the maxillary sinus.

109. Clinical Significance
 Relation of Root Apices with the floor of the
sinus
 The chances of creating oroantral fistula in patient
less than 15yrs are comparatively lesser than in
adult.
 In adult, distance between apical end of maxillary
posterior teeth with floor of sinus is approximately
1 to 1.5 cm.
 Second molar(palatal root) is in closest proximity
to antral floor followed by first molar, third molar ,
second premolar & first premolar.

111. Clinical Significance
Ohngrens Line
 Ohngrens line is an
imaginary line extending
from medial canthus of the
eye to the angle of
mandible which divide the
sinus into the antero-
inferior & postero-superior.
 It is significant in
determining the stage of
antral tumour. In
general,the tumour below
this line have a better
prognosis than tumour
above it.

112. Revision endoscopic sinus surgery (RESS)
 Why would I need sinus surgery revision?
 Revision endoscopic sinus surgery (RESS) is
performed when the initial surgery didn’t relieve your
symptoms or when the surgery causes a new
problem.:-
1. Nasal polyps may develop after sinus surgery.
2. Deviated nasal septum may also require revision
sinus surgery.
 RESS is an endoscopic procedure, during which
surgeon insert a small, flexible tube with an attached
camera into your nostril. As come across
abnormalities, will use a variety of surgical

115. CONCLUSION
 Due to close proximity of maxillary sinus to orbit,
alveolar ridge, maxillary teeth, diseases involving
these structures may produce confusing
symptoms. Hence a precise information about the
surgical anatomy is essential to surgeons.
 Knowledge of the anatomical relationship between
the maxillary sinus floor and the maxillary
posterior teeth is important for the preoperative
treatment planning of maxillary posterior teeth.
 Clinicians must be particularly cautious when
performing dental procedures involving the
maxillary posterior teeth.

116. REFERENCES
 Textbook of oral and maxillofacialsurgery, Neelima
malik
 Maxillary sinus and its implication Killey and Kay
 Orban’s, Oral histology and embryology, 11th
edition.
 Fonseca text book of oral and maxillofacial surgery
II edition
 Textbook of general anatomy, B.D. Chaurasia