surgical anatomy of maxillary sinus

1. SURGICAL ANATOMY OF
MAXILLARY SINUS
Presented by
Sauvik Singha
1st year PG Student
Oral and Maxillofacial Surgery

2. CONTENTS
 Introduction
 Development
 Anatomy
 Functions of sinuses
 Relations
 Applied Anatomy
 Diseases Involving Maxillary Sinus
 Surgical Procedures Involving Maxillary Sinus
 Bibliography

3. Maxillary sinus
 Pneumatic space lodged in the body
of maxilla
 Described by Nathenial Highmore
(1651)
 Also known as antrum of Highmore
 2 in number
 Largest paranasal sinus
 Vol:15-30 ml
 Dimensions (Turner, 1902)
 ANTEROPOSTERIOR: 3.5cm
 HEIGHT: 3.2cm
 WIDTH: 2.5cm

4. ANATOMY
 Pyramidal in shape
 Consist of
base
Apex
Roof
Floor
Anteror wall
Posteror wall

5. ANATOMY contd….
 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.
 Anteror wall-facial surface of
maxilla
 Posteror wall-separates sinus
from infratemporal and
pterygopalatine fossa

6. Arterial supply
• Facial artery
• Maxiilary artery
• Infraorbital artery
• Greater palatine artery

7. Venous drainage
• Veins accompany artery
• Anterior facial vein
• Pterygoid venous plexus

8. Nerve supply
By last (1959)
• Anterior superior alveolar nerve
• Middle superior alveolar nerve
• Posterior superior alveolar nerve
• Greater palatine nerve

9. Surgical Importance of Nerve supply
• As there is chance of damage of nerve during
surgical procedure
• Asa-given off from infraorbital n about 15mm
form infraorbital foramen,courses down on
anteriror Wall
• Msa-seen in 50 % cases arise from lateral aspect
of infraorbital nerve
• Psa-sup branch runs at level of malar
tuberosity,inf branch-runs parallel to tranverse
facial part of anteior nerve

10. Embryology
• The sinus begin developing in the 3rd week of
gestation
• First sinus to develop
• Early stages it is high in maxilla
• later gradually grows downwards by process of
pneumatization

11. DEVELOPMENT & AGE CHANGES
Contemporary Oral & Maxillofacial Surgery – Peterson IV edition
Time Growth Shape
3months IU Out Pouching in middle
Meatus
Birth 7mm x 4mm x 4mm
3mm/year x 2 x 2mm.
Tubular
9 years 60% of adult size Ovoid
12 years Antral floor parallels nasal
floor
18 years Adult size ,antral floor is 1-
1.25 cm below nasal floor
Pyramidal

12. • Lined by respiratory epithelium
• Mucous scereting
Pseudostratified ciliated
columnar epithelium
• SCHNEIDERIAN MEMBRANE
• It has mucociliary mechanism
• Cilia moves the mucus and
debris towards osteum and
discharged in middle meatus
Physiology

13. Functions of sinus
1.Impart resonance to voice
2.Increase surface area and lighten skull
3.Moisten and warm inspired air
4.Filters debris from inspired air
5.Gives air padding to provide thermal insulation to
adjacent important tissues

14. RADIOLOGY OF MAXILLARY SINUS
• EXTRAORAL VIEWS
• OCCIPITOMENTAL/WATERS
• LATERAL SKULL
• SUBMENTOVERTEX
• ORTHOPANTOMOGRAPHY
• CT SCAN
• INTRAORAL VIEWS
• OCCLUSAL
• LATERAL OCCLUSAL
• PERIAPICAL

15. Occipitomental or waters view

16. Orthopantomograph

17. LATERAL SKULL

18. CT- SINUS –AXIALVIEW

19. CT- SINUS - CORONAL VIEW

20. Occlusal view

21. Periapical view

22. Endoscopy
• Direct optical evaluation of the antral floor
region..
Path of access used
1.Trans oral via canine fossa
2.Trans alveolar via connection between oral
cavity & antrum
3.Trans nasal approach

23. APPLIED SURGICAL ANATOMY
• 1)Relation of root apices with the floor of the
sinus
• 2)Lining of maxillary sinus
• 3)Foreign bodies in the sinus
• 4)Infections of sinus
• 5)Oro-antral communication
• 6) Tumors associated with maxillary sinus
• 7) Implant placement

24. 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 is in closest proximity to antral
floor followed by first molar, third molar,
second premolar & first premolar.

26.  Presence of an unerupted tooth in the maxillary
tuberosity is a potential line of fracture.
 Periapical infection of the tooth which are in
relation with antrum might cause an oroantral
fistula.
 Since walls of sinus are thin any tumour which
develops here may erode these walls and
present swelling on cheek, palate or in buccal
mucosa.

27.  Since sinus wall is very thin in area of canine
fossa, it can be used for diagnostic aspiration
and for Caldwell-Luc operation.
 Antral puncture can be carried out by
puncturing into sinus cavity through medial
meatus in children and the inferior meatus in
adult.

28. 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.

29. Maxillary sinusitis
Classification
According to duration
a) Acute: 7 days - 4 week
b) Subacute: 4-12 week
c) Chronic : > 12 week
d) Recurrent acute: 4 episodes per year
Presence/absence of polyps/etiology
a) Bacterial
b) Fungal
c) Viral
d) Mycobacteria
e) Parasite
It may be clinically defined as an inflammatory response
involving mucous membranes of the nasal cavity and paranasal
sinus.

31. Maxillary sinusitis
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
f) Immunodeficiency

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

33. Clinical Signs of Sinusitis
• Pain
• Fever
• Headache aggerevated on bending
• Nasal stuffiness
• Nasal discharge - mucoid, purulent, foul
smelling
• Epistaxis
• Referred odontalgia

34. Management
Medical
1. Antibiotics
2.Mucolytics(guaifenesin,KI)
3. Decongestants
4. Analgesics
5. Antihistamines
6. Nasal spray & saline irrigation
7. Hydration
Surgical
1. sinus aspiration and lavage
2. Caldwell luc
3. FESS

35. OROANTRAL FISTULA
Oroantral fistula is a pathological
communication between oral cavity and
maxillary sinus.

36. Oroantral fistula
 Etiology
• Iatrogenic
• Presence of periapical lesions
• Injudicious use of instruments
• During attempted extraction
• Trauma
• Chronic infections
• Malignant diseases
• h/o sinus surgery like resections of cyst and tumors of
maxilla

37. Oroantral fistula
 Diagnosis
h/o previous extraction
Mouth mirror test
Cotton wisp test
Inspection
Transillumination test positive
Radiological
• IOPA
• OPG
• OM

38. Oroantral fistula contd..
• Management
• Less than 2mm heals spontaneously
• Larger than 3 mm requires surgical closure
• Ideal treatment :immediate surgery followed by
Antibiotic prophylaxis

39. Oroantral fistula contd..
General Management
 Do gentle packing of the socket with wet gauze to control
bleeding from the socket and for antral bleeding sinus is
packed with roller gauze.
 Do not probe the sinus with sharp instruments
 Do not curette the socket
 Do not ask the patient to blow the nose
 Prescribe antibiotics and other symptomatic treatment

40. Treatment modalities for closure of OAF
Closure of Oroantral Communications:A Review of the Literature, Susan H. Visscher et al, J Oral Maxillofac
Surg68:1384-1391, 2010
•Temporalis
Overview of the treatment modalities of Oro-Antral Communications

41. Immediate closure
 Mucoperiosteal flap, obtained by reducing the
height of the bony socket, are loosely sutured
over the defect.

42. Rehrmann Buccal Advancement flap
 Broad based trapezoidal
muco periosteal 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.

43. Moczair flap
• Recommended for edentulous
patients
• In this method buccal sliding
trapezoidal mucoperiosteal
flap displaced 1 tooth distally
is involved.
• Buccal sulcus depth is
minimally influenced.
Disadvantage
• Greater amount of
dentogingival detachment
• May give rise to periodental
disease in dentate patient.

44. Palatal flap
 The soft tissue lying either behind or in front
of the defect are utilized.
 The bony base of the resultant palatal defect
may be covered by pack.
 The rich blood supply of the palatal flap
provide satisfactory healing.

45. Advantages
• Less vulnerable to rupture than
buccal flap because of thickness
of palatal mucosa
• Adequate blood supply by
greater palatine vessels
• Buccal sulcus depth remain
intact.
Disadvantage
• Denuded palatal donor area
• Soft tissue bulge at the axis of
rotation

46. Palatal rotational advancement flap
• Provides adequate mobility and tissue bulk to
the flap
Disadvantage
• Flap often kinks following the rotation of flap
and can cause venous congestion.

47. Combined local flaps
 Combination of two flaps
 Hinged and Palatal rotational
advancement flaps
 Inversion flap and palatal rotational
advancement flap
 Reverse palatal and buccal advancement
flap

48. 2. Combined flaps
Hinged flap Hinged & palatal rotationl
advancement
Palatal reversal & buccal advancement flap

49. Pedicled buccal pad of fat
 Buccal pad of fat can be exposed by a vertical
incision of 1cm long on the posterior aspect of
the zygomatic buttress region.
 Following this the fat pad advanced along the
defect and sutured to palatal tissue without
any tension.
 Blood supply is from temporal, maxillary and
facial arteries

50. • Buccal pad of Fat

51. Advantages
• Easy mobilization
• Excellent blood supply
• Minimal donor site morbidity
Complications
• Graft necrosis
• New fistula formation

52. Bridge flap
 Commonly employed in edentulous arch.
 Incisions are placed transversely across line of
the arch.
 The bridge is shifted over the fistula and the
raw area is allowed to epithelized.

53. Tongue flaps
• 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

54. 3. Distant flaps
• Tongue flap

56. Grafts
GRAFTS
AUTOGENOUS
Iliac crest
Chin
Retromolar area
Zygoma
ALLOGENOUS
Collagen sheet
Fibrin glue
Gold foil
Tantalum
PMMA
Hydroxyapatite
XENOGRAFTS
Porcine dermis
Bio guide & Bio oss

57. 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

58. • Bone graft for closure are often harvested
from iliac crest, chin , retromolar area and
zygoma, lateral wall of maxillary sinus.
• Autografts are considered a better option than
allograft because of
o Risk of transmission of viral hepatitis
o Expense
o Diffusion of particulate graft into the sinus
can produce foreign body reaction.

59. 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.

60.  Usually the blood, which accumulate in the
maxillary sinus, is eliminated by the activity of
the ciliated epithelium of the antral
membrane promoting normal drainage
through the ostium.
 If the haematoma is not removed infection
might occur.

61. IATROGENIC DISEASE
Teeth Displaced into Sinus
 Foreign body that usually is displaced into
maxillary sinus is a tooth or a tooth root.
Aetiology
Absence of intervening bone in between the
tooth root and antrum.
Aggressive instrumentation to retrieve
fractured maxillary molar root.

62. ANTRAL RHINOLITHS
 Two types of rhinoliths
I. Rhinoliths around an
endogenous nucleus such as
RBCs or pus cells,
II. Those found around
exogenous material such as
root of teeth, or any other
foreign body.
 Sometime they are covered
with granulation tissue.

63. SURGICAL PROCEDURES INVOLVING
MAXILLARY SINUS
Caldwell-Luc Operation
Intra nasal antrostomy
Functional Endoscopic Sinus Surgery
Sinus Lift Procedure
Mid Face fractures

64. Caldwell luc sinusotomy
• By George Caldwell (1893) & Henry Luc (1897)
• Indications
• Fungal sinusitis
• Multiple antral lesions
• Antral polyp
• Excision of tumor
• Closure of OAF
• Removal of antral foreign body
• Antral revision procedures
• surgical approach for transantral sphenoethmoidectomy,
orbital decompression

65. Surgical Procedure
 The surgical procedure can be performed under
LA. Or GA.
 A semilunar incision is placed in the buccal
vestibule from canine to second molar.
 A mucoperiosteal flap is elevated till infraorbital
ridge.
 A round bony cut is marked over the canine fossa
using a round bur( post stamp incision)
 Window is created and bone is removed using
ronger

66.  Then pus is sucked away from
the sinus and thorough
irrigation is carried out.
 Inspection and removal of
foreign body from the sinus
can be done at this stage.
 Antral cavity packed with
iodoform ribbon gauze.
 The incision is closed with 3-0
0 silk.
 Pack removal on 5th day.

67. Caldwell luc sinusotomy

68. Caldwell luc sinusotomy
• Complications
• Bleeding
• Dental sensitivity
• Infraorbital neuralgia
• Osseous defect in anterolateral wall
• Entrapment of inferior rectus muscle

69. Denker’s Approach
• Modification of Caldwell luc surgery
• Along with the Caldwell Luc surgery a slit of
bone is removed from the anterior bony angle
of the antrum right up to the lateral nasal
aperture to render continuous free
unimpeded drainage of sinus from nasal cavity
and canine fossa

71. Functional Endoscopic Sinus Surgery
Purpose
 The purpose of FESS is to restore normal
paranasal air sinuses mucocilliary function.

74. Indications
 Recurrent sinusitis with stenosis.
 Chronic hyperplastic sinusitis with obstructive
nasal polyps.
 Chronic sinusitis with mucocele formation.
 Fungal sinusitis in patient with diabetes or
immunocompromised status.
 Neoplasms
 Orbital cellulitis or abscess
 Unresponsiveness to medical treatment.

75. Surgical technique
 Performed under GA or LA
 Patient is placed in supine position at 15 degree reverse
trendelenberg position.
 Nose is additionally anaesthetized with 4% cocaine soaked
cotton pledgets placed in middle meatus.
 Additional injections are given at greater palatine foramen
and middle meatus perimeter.
 Endoscopy of maxillary sinus is performed by canine fossa
or through maxillary sinus antrostomy.
 All diseased mucous membrane and polyps if in case are
present is removed.
 Overzealous removal of septa and normal appearing
mucous membrane is not advocated.

76. SINUS LIFT PROCEDURES
• Done in resorbed maxillary posterior ridges.

77. Techniques
Lateral window technique
• Modification of Caldwell Luc technique
• LA administration
PSA nerve block
ASA nerve block
Palatal infiltration
Crestal incision is given from maxillary tuberosity to the point
just anterior to anterior border of sinus along with vertical
releasing incisions
Mucoperiosteal flap reflected, lateral wall of maxilla exposed.
Linear osteotomy performed using #6 or #8 round bur

78. Diagram demonstrating the ideal location of sinus window preparation of the lateral
maxillary wall. The inferior ostectomy should be approximately 1 mm superior to or
level with the floor of the sinus. The posterior ostectomy should be at the corner of the
maxillary buttress. The anterior ostectomy should be adjacent to and parallel with the
lateral wall of the nose, and the superior ostectomy should be at the height of the
intended graft.
(From Block MS. Color atlas of dental implant surgery. 2nd edition. Philadelphia:
Saunders;2007. p. 129)

79. • Once the window is created membrane is
exposed, adherent bone is either removed or
rotated medially.
• Schnederian membrane is elevated using a freer
or currete.
• Bone graft is placed under the membrane in
anterior and inferior direction. Graft should
contact the medial wall of maxillary sinus.
• Mucoperiosteal flap is repositioned and sutured.
• After 6 months implant is placed.

80. Sinus Intrusion Osteotomy
• Indicated when minimal bone height is needed.
• Crestal incision is made and implant drills are
used to create an osteotomy, leaving 1 mm of
bone between site and sinus membrane.
• Sequential osteotomies are done to compact the
bone laterally and apically, which will elevate the
sinus membrane.
• Bone graft is placed.
• Implant is placed with a coverscrew and primary
closure is done.

81. Trephined bone core partially intruded into sinus cavity. (FromFonseca RJ,MarcianiRD,
Turvey TA. Oral and maxillofacial surgery. 2nd edition. Philadelphia: Saunders; 2008. p. 465;

82. Retention cyst
• Caused by blockage and subsequent dilation
of ducts of the seromucinous gland and are
subsequently lined with epithelium.
• Seldom seen on radiographs.

83. Mucoceles
Rarely found in maxillary sinus.
Expansive and potentially destructive lesions,
which differentiate it from the pseudocyst.
Usually formed when sinus ostium is obstructed.
In advanced cases it may cause bony erision and
destruction.

84. Carcinoma of maxillary sinus
Clinical features
• Signs of chronic sinusitis
• Foul smelling nasal discharge
• Nasal stuffiness
• Epistaxis
• Loss of Transillumination

85. 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

89. BIBLIOGRAPHY
• B D Chaurasia , Text book of Anatomy
• Contemprory oral and maxillofacial
surgery, Peterson IV edition
• Fonseca text book of oral and maxillofacial
surgery II edition

90. • Treatment of Oro antral Fistula using Bone press
fit technique. American association of oral and
maxillofacial surgeon 2012
• Sinus Lift Procedure, An overview of current
technique Avichai Stern, James Green. Dent
clinics of N America 2012, 219-233