Surgery Part 1
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Transcript of 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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