Surgery Part 1

8/13/2019 Surgery Part 1

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Today we will talk about odontogenic diseases of

the maxillary sinus . its a very important lecture

because the maxillary sinus can be involved in

surgical procedure or can be infected .

Introduction

- Maxillary sinus is an air filled space located within

the maxillary bone . other sinuses are : Ethmoid ,

sphenoid and frontal air sinuses .


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The sinuses serve as ( the function of the air

sinuses ) :

Air conditioning-

Reduce of skull weight-

-Resonance of voice

heat insulation-

-Humidification of inspired air

-Shock absorption . for example when the patient

subjected to a trauma to the orbit , the orbital

floor (the superior wall of the maxillary sinus)

might be fractured and the glob won't be rupture .

)look to the picture below(yAnatom

The anatomy of the maxillary sinus :

-its Pyramidal in shape

-Base;(medial side of the maxillary sinus) on

lateral Nasal wall

-Apex; extend laterally within zygomaticprocess of the maxillary bone

-Roof(superior) orbital floor


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maxillary tuberosity anderiorlyPost-posterior to that is ptyregomaxillary space

-Inferiorlyalveolar process of the maxillawith PreMolars & Molars inside

-AnteriorlyCheek bone (Canine Fossa).

Size around 15 ml ( dimensions : 34*33*24)mm,*

And it drains into the middle meatus .


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sDiagnosis of maxillary sinus disease

- As for other diseases we start bytaking fullhistory ( medical , dental , social and habits ). * Medical history is very important , we askthe patient if he had a previous sinusitis or he

receives medication for sinus problems .

* Dental history also is very important , weshould ask the patient about previous dental

surgeries on the upper molar areas .

* Social history by asking the patient about

occupation as if he works in dusty area it may

cause allergy to the sinus .

Also habits are important like blowing habit .*

Middle

meatus


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lextra ora, always we start byClinical Examination

:examination

* Inspection ; looking at the patient if there is

any asymmetry , redness(in the cheek it

indicate sinus problem) , swilling .

* Palpation ; we asses if there is tenderness ,crepitation

* Percussion/Tapping ; to the cheek or frontal

bone if the patient feels heaviness it may

indicate sinus problems .

; we canexaminationintra oralThen we move to

do full intra oral and dental examination to assess

the oral mucosa and the teeth , and we can do

transillumination test ( we subject a light in the

root area on the palatal mucosa and look labialy ,if there is difference between right and left in the

light transmittion it will indicate fullness in the

sinus . for example we direct the light palataly

then its shining from the right and not shining

from left then it indicate that the sinus is full . )


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Then After clinical examination we move to

, sometimes the periapical orradiographpanorama x-ray may show some abnormalities, in

the picture below we can see an apical x ray and

we can look here and find a small piece of root

that displaced into the sinus.

Now if we cant see the piece or we cant do a

proper diagnosis by these x rays we can move to

.s view'aterW

is the best plain x ray to show the:s view'aterW

sinus walls . we can use it in case of sinusitis or

displaced roots .

(waters view angled at 37 degree to orbito-

meatal line )


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But the best view for diagnosis and treatment plan

is CT scan. ( the Dr said I will talk a little bit about

CT scan because there are many students dont

know about it !!! :p)

the cuts of ct scan are : axial , coronal , sagital and

3D .


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For example , a patient came to me and

complaining from a bulge in his upper left six area ,

I took the history started by dental history and he

told me that he underwent extraction for upper

left six before one month and he complained from

epistaxis for 1 to 2 days and after one month thereis a bulge in the soft tissue at the area of extracted

six . after that I asked him to do a CT scan and this

the picfrom the skull(cutaxiala horizontalis the

, we can see)from up to downwarditsbelow


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there is a defect in the left side (upper left six area)

, its asmall piece of remaining root .

-

Now if we move to this cut , it shows both sinuses

and we can see here the difference between the

left and right one ( the left is full of mucus , the

right is full of air (empty) ) .

And the following axial cuts show this again

Left right


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-

we can seecuts ,coronalThe other cuts are the

that the left is full and the right is empty . this cut

shows the oro-antral communication at the area ofextraction

Oro-antral

communication


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-

cuts (sagitalNow the following cuts are the

) . it shows the samefrom anterior to posterior

this is the defect .


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and this is the 3D view , it shows all thecommunication between the oral cavity and the

sinus in the area of upper six .

These are the views of CT scan .


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:the causes of sinus diseasesSo now we move to

1maxillary sinusitis : its the most common

problem . it might be caused by:

- Inflammation ; as acute , subacute and

chronic sinusitis .

- Odontogenic sinusitis ; which we will talk

about in this lecture .

2oro-antral communication

- Acute

- Chronic ; if its chronic we call it fistula.

3traumatic ; ex if the patient subjected to

fracture in the zygomatic bone the blood will

accumulate in the sinus ; we call it haemo-sinus

and it might develop into infection.

4iatrogenic causes ; ex if tooth or root displaced

into the sinus .5rare cases of tumor within the sinus or moving

from the oral cavity to the sinus .

6antral rhinolithis ; sometimes we find

radiopaque material within the sinus ; it might be

rhinolithwhich is a stone or calcification .


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causes of sinusitis :Odontogenic

1 - Infections; it came from :

- Acute or Chronic PeriApical infections

- Acute or Chronic Periodontal infections2 - Iatrogenic ; such as

-Complications after endodontic

treatment

-Complications after Extraction

Iatrogenic and dental complication

In endodontics , some endodontic material might

extrude through the apex such as the gutta percha

and the sealers , or broken files it might extrude

and displaced through the sinus and this might

cause an infection to the sinus .

Displaced tooth or root within extraction into the

most common Upper 6 Palatal(sinusillarymax

) .Root


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Any other causes of oro-antral communicationmight cause sinus problems, such as post

alveolectomy or any surgery or trauma to theposterior maxillary area .

Complication after trauma or sinus lift

procedures or orthognathic surgery ( these

are the surgerys that we do to maxilla and

might cause sinus problems ).

After trauma the blood may accumulate into the

sinus and we call this haemosinus as we said . this

haematoma might develop to infection and cause

sinusitis .

The orthognathic procedure is the surgerys that

involve cutting the maxilla and moving it toimprove the esthitatic and function of the jaws .

we cut the lateral and the medial walls of the sinus

, so we open into the sinus during this surgery . so

it might happen that the mucosa might be

traumatized and a retention cyst might develop .


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In cases of orthognathic and trauma , fixation

screws might cause a foreign body reaction and

develop into infection .In sinus lift procedures we might put a bone to

increase the vertical width of the sinus to be able

to put an implant , this bone might cause a foreign

body reaction .

Acute sinusitis

Now we will talk about Acute sinusitis, which is

the most common sinus infection .

but,aerobic bacteriaUsually sinusitis is caused byits usually mixedcausesodontogenicin case of

and most commonly caused by anaerobic

.bacteria

of acute sinusitis :signsThe

The patient start to Feel a dull pain , fullness

in his head, headache, foul smell purulent

nasal discharge.

May include fever, malaise,facial swelling.this


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:Chronic sinusitis

Its less common.

Might be caused by foreign body reaction .

Some times caused by fungal infections (someroot canal sealers implicated in fungal

sinusitis)

And most of the time its Asymptomatic orcausing recurrent obstructions and acute

episodes .

so most of the time its acute sinusitis butsometime it might be chronic sinusitis in a

form of foreign body reaction .

now if sinusitis isnt treated , is this a problem ?

or it might be complicated in a serious thing ?

the answer is yes , in some cases itmight developinto :

superiorlyPeriorbital cellulitis ; if it extend-

Intraorbital abscess--Intracranial abscess; when it spread to the

brain


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is topCavernus sinus thrombosis ; which-emergency

The following figure will show us orbital

complication of sinusitis ;

A: preseptal (periorbiatl) cellulitis

B: intra orbital cellulitis

C: subperiosteal abscess

D: orbital abscess

E: cavernous sinus thrombosis


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of sinusitis :treatmentThe

* Local measures; we always start by local

measurements like :

Humidification of inspired air-

-Topical decongestant/steroids; Nasal Spraysor Nasal Gel

Nasal warm washes-

*Systemic therapy; Then we give the patient

systemic therapy like :

-Antibiotic ; usually because its mixed

infection we prescribe augmentin or

clarithromycin for sinusitis patient . most

commonly its clarithromycin 500 mg 1 by 2

daily

Decongestants; as Psudoephidrine

-Antihistamine ; as loratidine 10 mg 1 by 1daily for 2-3 weeks

Analgesics; as profens 400 mg 1 by 3-

End of part 1 .. best wishes

Done by : yahya al Omary


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Some cases needs surgical treatment

A] surgical treatment to do drainage of the sinus, obstructive cases

and foreign bodies

(Caldwell-Luc procedure , FESS)

B] Surgical closure of oro-antral communications/ fistulae

[1] - Caldwell-Luc procedure

In Caldwellluc procedure the labial mucosa is incised superior to the

canine to reach the upper 6 , and reflected , then a window is openedthrough the maxillary bone to expose the sinus membrane which is

Schneiderian Membranecalled

Surgical treatment


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do we do this procedure ?Why

, so once a segment ofTo retrieve a displaced root or tooth-1

the root is displaced into the sinus this is the treatment to do

Caldwell-Luc procedure , if it cannot be retrieved through out thesocket .

2- sinus left procedure:-in case of a resorbed maxillary ridge , the sinus

is lifted to apply a boneSchneiderian Membranemembrane i.a

graft there, by this the bone height will be increased which will

enable us to put an implant for example

s a procedure that is made when the: itAntrostomy-Naso-3

blocked , in which a\normal drainage site of the sinus is closednew hole is opened other than the normal one in the sinus to

drain the mucous into the nasal cavity

this was an old procedure nowadays they

red that this procedure is ineffectivediscovein most of the cases ,because the lining of

the sinus is pseudostratified ciliated columnar

epithelium same as the respiratory epithelium

so the cilia keep vibrating to its original path

ite , so it will keep doingi.a normal drainage s

that even if there is a new hole, so the mucous will

rotate around the new hole and goes to the blocked exist

So this procedure is not regarded for now as a successful

he originalopen t-to reisprocedure , so the treatment nowadays

FESS procedureorifice endoscopically which is called


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FESS functionally endoscopic sinus surgery[2]

it is done by ENT specialist-

the normal orifice wheremedial meatus slide 22 showing the

the mucous should drain

diseased or blocked tissue is removedso in this procedure the

open the original drainage site-to re

B] Surgical closure of oro-antral communications/ fistulae

during the extraction of upper 6 or 7 they might be some

ocket or the patient may feel abubbles come out from the s

antral-nose bleed , when this happened an oro

communication is suspected

what should be done

- we have to evaluate if the whole tooth is removed or part

of it is displaced into the sinus , we have to attempt to

remove any displaced part throughout the socket by any

pickups tweezers or by section tip

- x-rays is needed to confirm if the tooth is removed as awhole or if there is a piece inside the sinus if its displaced

and we failed to retrieve it we should arrange a Caldwell-

Luc procedure to remove that peace or the whole tooth

- we should asses the opening by inspection looking at the

socket if there is bubbles coming out in inspiration


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- we dont recommend to do the blow out test to blow

against the closed nostrils because this might extend the

defect and open it widely

2 mm , we-i.a less than 1smallif the communication is**

-might leave it for normal blood clot closure or we might but 1

2 stiches, and the most important thing is to give the patient

will be mentioned later onnus instructionsthe si

a buccal slidingwe employeelargeif the opening was**

-:flap

we make two releasing incisions on the buccal

the buccal tissue tostretchaspect then we

close the defect and to put the stiches all around

after the communicationan immediate procedurethis is

forthnmoif the communication persist for more than one

so the fistula should,it will be lined by epithelium,example

the communication is , then we elevatebe excised where

the buccal flap and stretch it to be able to stretch it will we

so that theperiosteummight put a horizontal incision in the

flap could be stretched then we suture it, this is called

Buccal Advancement flap


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what is the side effects of this procedure ?

there will be reduction in the vestibular depth , it will be

problem in denture wearer , and in the common oral hygienepractice as when the patient try to brush his posterior teeth

he cant put the brush there .

- if its a very large opening we can employ a palatal

rotational flap

a finger projection on the side of the palate based on thesed , after the excision of thegrater palatine artery is inci

se the defect then we suture it.fistula we rotate the flap to clo


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-what is the problem I in this procedure :

the problem there will be an area of an exposed bone which

is very painful , the area will heal by scar tissue secondary

intention

so to decrease this complain we might get the patient some

creams mentioned in the last lecture , or we might make a

nt for the patient or night guard that he wear until thespli

healing is completed within 3 weeks

- there is others technique in the past the used to put metal foil

below the flap , its mostly from bone or chin foil

- if the lesion is very big we can develop a tongue flap we take

some tissue from the tongue then we close the defect with it ,

and suture the tongue

- we might but a buccal fat pad : - there a fat pad in the buccal

area which make the check fat we might take a pellicle of fat

and close the fistula with it by this we will have a better

closure for the communication

The most important thing in sinus surgery is to give the patient

instructionssinus

- for 2 weeks

- MOS minor oral surgery instructions are given we add

- That the patient should avoid blowing his nose he is allowed

to wipe the nose not to blow

- If the patient want to sneeze he should open his mouth


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All these instructions in order to not make a difference in the

l cavity so thepressure between the oral cavity and the nasa

open if there is a difference in the pressure-surgery will re

The same implies for smoking and using straws because by-using them they might cause a negative pressure in the oral cavity

and might reopen the surgical site

before we prescribe to the patient antibiotic ,as mentioned

Decongestant, Antihistamine

- Those instruction and medication are very important for two

weeks

End of part 2

done by mohammad elwir


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Surgery Part 1

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Transcript of Surgery Part 1