Maxillary sinus is the largest of the paranasal sinuses. It develops from a shallow groove in the maxilla and reaches its maximum size by age 18. It has multiple walls and communicates with the nasal cavity via the osteum. Maxillary sinusitis can result from dental issues like periapical abscesses, cysts, foreign bodies or trauma. Odontogenic tumors and cysts can also involve the maxillary sinus. Care must be taken during dental procedures near the maxillary sinus to prevent oroantral communications.

1. MAXILLARY SINUS
1

2. Introduction
Development, anatomy and physiology
Blood , Nerve supply& Lymphatic drainage
Functions of the paranasal sinuses
Histology & Diagnostic evaluation of sinus disease
Differences between odontalgia and sinus pain
Developmental anomalies & pathologic conditions of maxillary sinus
Clinical significance
Case report
Conclusion
References 2

3. 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.
3
Introduction

4. 4
•Paranasal sinuses are present in a variety of
animals (including most mammals, birds, and
crocodile).
• The sinuses are named for the bones in
which they are located.

5. 5

6. I
n
t
r
o
d
u
c
t
i
o
n
6
Maxillary air sinus
Frontal air sinus
Ethmoidal air sinus
Sphenoidal air sinus

7. 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 Highmore in 1651.
7

8. 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.
8
(Koch 1930).

9. Expansion occurs more rapidly until all the
permanent teeth have erupted.
It reaches to maximum size around
18years of age.
9
(Bailey 1998, Sadler 1995)

10. AGE CHANGES

12. Age changes
12

13. Anatomy
Largest of
PNS,communicate with other
sinuses through lateral nasal
wall.
Horizontal Pyramidal shaped
Base
Apex
4 walls
◦ Wall thickness varies with
superior
inferior
lateral
anterior

14. Medial wall
Formed by lateral nasal wall
◦ Below-inf . nasal conchae
◦ Behind-palatine bone
◦ Above-uncinate process
of ethmoid,lacrimal bone
Contains double layer of
mucous membrane(pars
membranacea)

15. Medial wall
Imp structures
Sinus ostium
Hiatus semilunaris
Ethmoidal bulla
Uncinate process
Infundibulum

16. Osteum:
Opening of the maxillary sinus is called
osteum.
It opens in middle meatus at the lower part
of the hiatus semilunaris.
Lies above the level of nasal floor.
16

17. The ostium lies approximately 2/3rds up the
medial wall of the sinus, making drainage of
the sinus inherently difficult.
17

18. 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.
18

19. Superior wall
Forms roof of sinus and floor of orbit
Imp structures
Infraorbital canal
Infraorbital foramen
Infraorbital nerve and vessels.

20. Posterolateral wall
Made of zygomatic and greater wing of sphenoid bone.
Thick laterally,thin medially
Imp structures
PSA nerve
Maxillary artery
Pterygopalatine ganglion
Nerve of pterygoid canal

21. 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
Imp structures
Infraorbital foramen
ASA, MSA nerves

22. 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.

23. VASCULAR SUPPLY:-
Arterial blood supply:-
Greater palatine arteries
Infraorbital artery
Facial artery
23

24. Venous drinage:-
• Pterygoid venous plexus
• Sphenopalatine vein and
• Facial vein
24
(Watzek et al. 1997)

25. yNerve supply
Maxillary division of the trigeminal nerve,
i.e. the posterior, middle and anterior
superior alveolar nerves, the infraorbital
nerve and the anterior palatine nerve.
25
Last 1959

26. 26
Lymphatic Drain
The lymphatic drains in to submandibular lymph
nodes.
The lymphatic drainage reaches the specialised cells
in the maxillary sinus via infra orbital foramen or
through the anterosuperior wall and then to the
submandibular lymph nodes.

27. Lymphatic drainage
27Submandibular lymph nodes

28. Functions of the maxillary sinus
Humidification and warming of inspired air,
Assisting in regulating intranasal pressure,
Lightening the skull to maintain proper head balance,
Imparting resonance to the voice,
Absorption of shocks to the head,
Filtration of the inspired air.
(Bailey 1998).
28

29. HISTOLOGY
Maxillary sinus is lined by three
layers: epithelial layer, basal
lamina and sub epithelial layer
with periostium.
Epithelium is pseudo stratified,
columnar and ciliated.
As cilia beats, the mucous on
epithelial surface moves from
sinus interior towards nasal
cavity.

30. 30
CLINICAL EXAMINATION
INSPECTION :
Middle third of the face should be inspected for the presence of
asymmetry, deformity, swelling, erythema , ecchymosis or hematom
EXTRAORAL PALPATION :
Include palpation of the facial wall of the sinus above the premolar
where the bone is thinnest.

31. 31
INTRAORAL EXAMINATION
Examination should be performed for tenderness, or
paresthesia of upper molar and premolar region.
TRANSILLUMINATION TEST:
It is performed in a darkened room by inserting an electrically
safe light into the mouth ( with the lip closed). Good transilluminatio
indicates presence of air in the sinus while the failure of
transillumination indicates presence of pus, fluid , solid lesion or
mucosal thickening.

32. Radiographic examination
Radiography is the most important supplementary
investigation to clinical examination of the sinuses
Intra-Oral : Extra-Oral:
Periapical OPG View
Occlusal Waters view
(Occipitomental view)
Lateral Occlusal Submentovertex
view
PA view
32
Others:
• MRI & CT scan

33. Periapical radiograph
Borders of the maxillary sinus appear as a thin, delicate
radiopaque line .
(White & Pharoah 2000)
In the absence of disease it appears continuous, but on close
examination it has small interruptions in its smoothness or
density.
33

34. 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.
(White & Pharoah
2000) 34
Maxillary sinus septum

35. 35
Occlusal view Lateral occlusal view

36. 2. Panoramic radiography
Provides an extensive overview of the
sinus floor and its relationship with the
tooth roots.
36

37. 37
OPG

38. 38
Water’s projection

39. PA view Lateral Submentovertex

40. 5. Computerized tomography (CT) & Magnetic
resonance imaging (MRI)
 These modalities provide multiple sections through
the sinuses at different planes and therefore
contribute to the final diagnosis and the
determination of extent of the disease.
40

41. CT scan MRI

42. 6. Ultrasound
 Ultrasound is becoming the diagnostic tool of choice for
more and more physicians in detecting sinusitis.
 It offers a fast ,reliable and radiation free method for
diagnosing sinusitis and has been used successfully in
Finland for around 15 years. (Landman
1986)
42

43. 43
Ultrasound beam sent out by the sinus ultra is reflected fro
the posterior wall of the sinus when the sinus contains flu
and from the anterior wall when sinus contains air.

44. 7. Diagnostic 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.
(Kennedy et al. 1985)
44

45. Transoral access via the canine fossa.
Transalveolar access via an already existing
connection between the oral cavity and the
antrum.
 Access the inferior meatus of the nose.
45

46. 46

47. 47
DEVELOPMENTAL ANOMALIES AND
PATHOLOGIC CONDITIONS OF
MAXILLARY SINUS

48. Developmental anomalies
1.Aplasia
2. Agenesis
3. Hypoplasia
Aplasia

49. Pathologic conditions of maxillary
sinus
Maxillary Sinusitis
Odontogenic cystic lesions of maxillary
sinus
Tumors of maxillary sinus.
49

50. Maxillary Sinusitis
Acute Maxillary Sinusitis
 Sudden onset
 Duration of 4wks or less
Subacute Maxillary Sinusitis
 Duration of 4 – 12 wks
Chronic Maxillary Sinusitis
 Duration of atleast 12 wks
50

51. Maxillary sinusitis
1. Infectious causes
a) Bacterial
b) Viral
c) Fungal
2. Non infectious
causes
a) Allergic
b) Non allergic
c) Pharmocologic
d) Irritants
3. Disruption of
mucociliary drainage
a) Surgery
c) Trauma
Etiology

52. Maxillary sinusitis
Signs and symptoms associated with maxillary sinusitis
Major signs and symptoms Minor signs and symptoms
Facial pain/pressure Headache
Facial congestion/fullness Fever
Nasal obstruction/blockage Halitosis
Nasal discharge/purgulence/discolored postnasal
discharge
Fatigue
Hyposmia/anosmia Dental pain
Purulence in nasal cavity on examination Cough
Ear pain

53. Maxillary sinusitis of Dental Origin
1.Dental abscess(periodontal and periapical
abscess)
2.Infected dental cyst
3.Dental material
4.Oro-antral communication
53

54. 54
Spread of infection from periapical
region .

55. 55
Overextention 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.

56. 56
Oro-antral communication
(It is a pathologic tract that connects the oral cavity to the
maxillary sinus. )
Patient complained of regurgitation of food through the
nose while eating.
• 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.

57. 57

58. ODONTOGENIC CYSTIC LESIONS
AFFECTING THE MAXILLARY SINUS
58

59. 59
:
-Radicular cyst
-Dentigerous cyst
-Mucous retention cyst
Odontogenic Cystic Lesions of the maxilla

60. 60
Maxillary sinusitis caused by an apical
inflammatory lesion ( radicular cyst)
at the root apices of the 2nd molar
- NOTICE the cloudiness ( Radio-
opacity) of the sinus
Radicular cyst

61. 61
Dentigerous cyst
Also known as follicular cyst,2nd
most common cyst , it usually
appear on the impacted maxillary
3rd molar

62. 62
Mucous retention cysts
Mucous retention cysts in the sinuses are very common,
they are expansile and potentially destructive lesions

63. TUMORS OF MAXILLARY SINUS
63

64. 64
Benign tumor of MS:
Ameloblastoma:
Ameloblastoma is the most common benign
tumor affecting maxillary sinus.

65. 65
Malignant tumors of MS
They are Invasive and destructive lesions
For Examples :
Squamouse cell carcinoma

66. Clinical Considerations:
The chances of creating an oro-antral fistula in patient less than
15 yrs are comparatively lesser than in adults due to incomplete
development of sinus.
The distance between apical end of maxillary posterior teeth and
floor of sinus is approximately 1-1.2 cm. In some cases the gap
may be still lesser.
66
• 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.
Oro-antral communication and oro-antral fistula

67. Root which is most close to the sinus is
“palatal root of maxillary 2nd molar
Followed by :
1st molar
3rd molar
2nd premolar
1st premolar
canine
67

68. 68
 Lin et al. in 1991 reported that the maxillary
sinus is more developed in female and
therefore greater possibility of the occurrence of
oro-antal communication and oro-antral fistula in
female .

69. 69

70. 70
Symptoms of fresh oroantral communication:
Escape of fluids
Epistaxis
Escape of air
Enhanced column of air.
Excruciating pain

71. 71
Symptoms of established oroantral fistula:
Pain.
Persistent purulent unilateral nasal discharge.
Post nasal drip.
Popping out of antral polyp.

72. Buccal flap advancement
operation
Von Rehermann - 1936.
Operative technique

73. 73
www.indiandentalacademy.com

74. 74
PALATAL FLAPS
Rotational-advancement.(Ashley 1939)
www.indiandentalacademy.com

75. 75
SUBMUCOUS CONNECTIVE TISSUE
FLAP( Ito et al 1980)

76. 76
BUCCAL FAT PAD(Hanazawa et al
1995)

77. 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.
77

78. 78
Implants in the maxilla
Lack of sufficient bone height along maxillary
sinus, produces significant difficulty for
placement of implants in edentulous maxillary
jaw, in that case, we go for sinus lift, which is a
surgical procedure which aims to increase the
amount of bone in the posterior maxilla.

79. 79
SINUS LIFT
There are two
main approaches
to lift the maxillary
sinus
Direct( Caldwell
luc)
Indirect

80. `
I
D
R
E
C
T
Jensen and
Terheyden
in 2009,

81. 81
Direct sinus lift - advantage
1.It is clear
2. Easy access
3.More efficient work is done.

82. 82
Disadvantage
1. More painful.
2. More post operative discomfort
3. More time consuming
4. Needs highly efficient practitioner
5. More susceptible to infection

83. 83
INDIRECT TECHNIQUE
Invented by SUMMER IN 1994

84. ADVANTAGE
84
1. Minimally invasive surgical procedure
2. Requires less time and expertise than direct technique.
DISADVANTAG
E
1.Blind procedure
2.More chances of errors to occur.

85. 85
 Maxillary Sinusitis : Because of the thickned and inflammed sinus
lining compresses the nerve supply of the maxillary posterior teeth
causing tenderness of the maxillary teeth.
The infraorbital and superior alveolar vessels are freqently ruptured in
maxillary fracture causing hemotoma formation in the antrum.
Foreign body: Foreign body like GP, silver point, calcium hydroxide,
sodium hypochloride, sealers, root piece ,may sometimes be
accidentally forced into the maxillary antrum causing maxillary
sinusitis.

86. Differences between symptom of
odontalgia and sinus pain
History of cold, allergy, congestion or nasal
drainage.
Dull aching pain that is difficult to localized
Feel pressure in the cheek and below the
eyes
Position change like bending forward
produces pain
Dental local anesthetic blockade will not relief
sinus pain
Normal pulp vitality test.
86

87. 87

88. 88

89. 89

90. 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.

91. References
• Textbook of oral and maxillofacialsurgery, Neelima malik
Maxillary sinus and its implication Killey and Kay
Textbook of Maxillary sinus Mc’gowan
Orban’s, Oral histology and embryology, 11th edition.
Cate A.R. Ten, Oral Histology: development, structure, and function. 6th
edition.
ITI Treatment Guide , sinus floor elevation procedures, H. Katsuyama & S.S.
Jensen
Textbook of general anatomy, B.D. Chaurasia
IEJ vol 35 2002
J Endod. 2001 July;(27)
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