www.FourthMolar.

com
 MAXILLARY AIR SINUS:
Introduction
Function of air sinus
Anatomy & Histology of maxillary air sinus
Clinical importance of maxillary air sinus
Disease of the maxillary sinus
Infection- 1. Acute maxillary
sinusitis 2. subacute
maxillary sinusitis 3.
Chronic maxillary sinusiti communication- 1.
Acute oroantral fistula
2. Chronic oroantral fistula
- Etiology
- clinical features
- Investigation
- management
www.FourthMolar.com
 AIR SINUS
These are air filled hollow space present within the
bone around the nasal cavity called as paranasal
air sinuses.
The sinuses are – (1) Frontal air sinus
(2) Maxillary air sinus
(3) Sphenoidal air sinus
(4) Ethmoidal air sinus
These sinus forms various boundaries of the nasal
cavity & all these sinus communicate with each
other and open into the lateral wall of the nasal
cavity.
www.FourthMolar.com
FUNCTION OF AIR SINUS :
The function of air sinus are
(1)Humidification of inspired air
(2) It provides resonance to voice.
(3) It lightens the bone.
(4) It act as thermal insulator to protect organ such
as the eye and cranium from variation in
intranasal temperature.
(5) Sinus increase the surface area of the skull.

www.FourthMolar.com
MAXILLARY AIR SINUS :
Definition: An antrum is a hallow cavity within the
bone called maxillary air sinus.
Maxillary air sinus known as antrum of
Highmore, named after an english antomist
Nathaniel Highmore who was described it.
It is one of the largest paranasal sinus.
ANATOMY OF THE MAXILLARY AIR SINUS :
It is basically pyramidal in shape with the base
of the pyramid forming the lateral nasal wall and
apex at the root of the zygoma.
Capacity : 10-15 ml (in adult antrum)
Size : Dimension of sinus are
www.FourthMolar.com

Height – 3.5 cm
ROOF OF THE ANTRUM :
- Formed by floor of the orbit.
- Thin plate of orbital plate of maxilla.
- It lodges the infraorbital canal and groove
which lodges the infraorbital nerve.
FLOOR OF THE SINUS:
- Alveolar process of the maxilla.
- its level is lower than the level of the floor of the
nose.
- Closely related to root apices of the maxillary
premolar and molar.
www.FourthMolar.com
ANTERIOR WALL:
-Formed by the facial surface of the maxilla.
- Canine fossa is an important structure of this
wall.
POSTERIOR WALL:
- Formed by sphenomaxillary wall.
- A thin plate of bone separate the antral cavity
from the infratemporal fossa.
MEDIAL WALL :
- Lateral wall of the nasal cavity.
- the opening of the antrum in the middle meatus
at the lower part of the hitus semilunaris.
www.FourthMolar.com

- The opening of the sinus is closer to the roof and

HISTOLOGY OF THE MAXILLARY AIR SINUS:
- the sinus is lined by respiratory mucosa which is
lined by ciliated columnar epithelium.
-The ciliated movement help in removal of mucus
secretion towards the osteum.
BLOOD AND NERVE SUPPLY:
Arterial supply : - Facial artery
- Infraorbital artery
- Greater palatine artery
Venous drainage: - Facial vein
- pterygoid venous plexus
www.FourthMolar.com
Lymphatic Drainage : - sumbmandibular lymph
node.
Nerve supply: - Infraorbital nerve
- Anterior superior alveolar nerve
- Middle superior alveolar nerve
- posterior superior alveolar nerve

www.FourthMolar.com
EMBRYLOGY:
 The sinus are rudimentary or even absent at
birth.
 They enlarge rapidly at the age of 6 to 7 months.
 The maxillary air sinus formed first among the
other paranasal sinus.
 It start as a shallow groove on the medial surface
of the maxilla during the fourth month of
intrauterian life.
 Present as small cavity at birth.
 From birth to adult life the growth of sinus due
to enlargment of bone.
 It reach maximum size by around 18 years of age.
www.FourthMolar.com
CLINICAL IMPOTANCE ;
 Dental infection: Infection from the maxillary
premolar and molars can easily communicate and
infect the maxillary antrum.
 Oroantral Communication: Traumatic extraction
of maxillaryteeth can cause oroantral
communication.
 Root Pieces: Root pieces of maxillary teeth may
sometimes be accidentally forced into the maxillary
antrum.
 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.
www.FourthMolar.com

 The Maxillary Artery can be approached through

 MAXILLRY SINUSITIS
maxillary sinusitis: It is the inflammation of the
maxillary sinus.
Maxillary sinusits

Acute Subacute Chronic

ACUTE SINUSITIS:
 It may be supurrative or non supurrative
inflammation of the antral mucosa.
 It is the most freqently infected of the paranasal
sinus. www.FourthMolar.com
ETIOLOGY:
(1)Nasal Infection (most common) : Viral rhinitis
and influenza are the common infection.
(2) Dental Infection:
Infection from the maxillary posterior teeth can
easily spread to the maxillary sinus as the plate of
bone dividing the root apices from the sinus .
(3)Contaminated Swimming water :
Diving in such water forcibly directs water into the
nasal cavity and then into the sinus.
(4) Trauma:
Fracture of the maxilla or zygoma, gun shot
wound or penitrsting injuries
www.FourthMolar.com can lead to sinusits.
PATHOGENESIE:
During early phase of inflammation, intial
vasodilation leads to increases production of
mucosa from the mucosa gland.
The mucosa concequently exert pressure within
the lumen of the antrum.

www.FourthMolar.com
CLINICAL FEATURES:
The patient gives history of `catching cold’ 3 to 4
days earlier.
Nasal block secondary to rhinitis.
Increase in purulent, thick, discoloured and foul
smelling nasal discharge is prominenant features.
A sense of fullness and pain on cheek on bending
forward.
Patient producing cough secondary to the nasal
discharge with onset of pharyngitis.
The related maxillary teeth are tender on
percussion.
Nasal resonance- change in the voice due to
www.FourthMolar.com

blocking of sinus.
DIAGNOSIS;
(1) Water view radiograph.
(2) Transillumination test: Shows opacity involved
sinus.
(3) Culture: Nasal secretion may be for culture
sensitivity test to see the organisam involved.
MANAGEMENT:

MEDICACAL SURGICAL
MANAGEMENT MANAGEMENT

www.FourthMolar.com
 MEDICAL MANAGEMENT:
1) Antibiotics: Broad spectrum antibiotics.
2) Decongestant: Decreases the congestion and
edema of the nasal sinus. Help in the drainage of
the sinus.
3) Analgesics: Paracetamol provide symptomatic
relief.
4)Steam inhalation: Steam+ Menthol+ Tincture.
After Decongestion for
15 to 20 minutes. Helps in
drainage.
5) Hot Fomentation: Local heat application is
soothing to the inflamed sinus.
www.FourthMolar.com
 SURGICAL MANAGEMENT:
Antral levage:
Acute maxillary sinusitis usually responds well
to medication.
It is basically involves inserting a canula into
the maxillary sinus trough the inferior meat us.
Luke warm water is irrigated through the sinus
and this drains out through the osteum along
with the sinus exudates.
COMPLICATION
- Chronic sinusitis
- Osteomylelitis of the maxilla
- Orbital www.FourthMolar.com
cellulites
 SUBACUTE MAXILLARY SINUSITIS:
It is the intermediate stage between acute and
chronic sinusitis.
There is pain only in the form of the local
discomfort.
patient has persistent discharge.
The voice is nasal, throat is sore with constant
irritating cough.
Patient can not sleep well.
The disease may take a long course over week or
months.

www.FourthMolar.com
 CHRONIC SINUSITIS
Infection of the that last for months or year is
called chronic sinusitis.
It is most commonly is an extension of an acute
sinusitis which failed to resolve completely.
CAUSATIVE ORGANISM: - Aerobic organism
- Anaerobic organism.

www.FourthMolar.com
 PATHOPHISIOLOGY:
After infection
Ciliated epithelium gets destroyed
Prevent drainage of secretion from the maxilla
pooling and stangnation of mucopurulent in sinus
Progression of infection
Mucosa changes
Cilliary damaged and edema
Mucosa may become thick and polypoidal.

www.FourthMolar.com
Clinical Features:
Symptoms are non specific unlike acute sinusitis.
patient not having pain or tenderness.
Purulent nasal discharge may be foul smelling.
Block of nasal and change in voice due to loss of
resonance.
Ansomia.
INVESTIGATION
Water’s view radiograph.
Culture of the discharge from the sinus.
Transillumination test.
www.FourthMolar.com
 MANAGEMENT:
Medical management:
1) Antibiotics: Broad spectrum antibiotics.
2) Analgesics: Paracetamol providing relief.
3) Decongestant .
4) Steam inhalation.
5) Hot fomentatiom.

www.FourthMolar.com
SURGICAL MANAGEMENT:
I. Treat any dental infection if present.
II. Antral leavage: If more than three successive
punture have purulent fluid than the treatment
should be more radical.
III. Intra nasal Antrostomy : A window or opening is
created in the inferior meatus of facilltates
drainage of the sinus.
IV. Cold Well luck Operation.

www.FourthMolar.com
CALDWELL LUC OPERATION:
This is the procedure by which the antrum is
entered intraorlly through the anterior wall and
all irreversible disease is removed.
This is followed by an antrostomy to promote
permanent cure.
INDICATION:
Chronic maxillary sinusitis.
Removal of foreign bodies in the antrum such as
root pieces.
Treatment of oroantral fistula that fails to heal.
treatment of benign dental cyst tumor.
Biopsy procedure for a suspected malignancy in
the antrum.
Recurrent antrachoanal polyp.
www.FourthMolar.com
CONTRAINDICATION:
Age- Not performed in patient below 17 years as
there may be damage to devloping tooth bud in
that region.
Acute infecion.
Other systemic cause contraindicating surgery.
PROCEDURE:
1) procedure is usually under general anesthesia.
2) Patient is placed supine with head end of the
table raised. Head is turned slightly to the
opposite side.
3) Incision: A semilunar incision is placed in the
mucobuccal fold.

www.FourthMolar.com
4) Exposure: A full thickness mucoperiostel flap is
reflected upto the infraorbital nerve.
Care is taken to
protect the infraorbital nerve.
5) Approach to the antrum: A micromotor with the
large round burr is used to create a window
about 1.5 to 2 cm in the anteroir wall of the
antrum.
The sinus mucosa is seen below the bone.
6) Antral lesion: The lesion may be delt with. A
biopsy may be done or sinus mucosa is removed
with the help of the curette as the case demand.
7) Antrostomy: A opening is made in the medial
wall in the lower most and anterior aspect of the
inferior meatus.
www.FourthMolar.com
(8) Packing: The sinus cavity may be packed with
the ribbon gauze impregnated with vaseline.
The gauze is packed in layer and the free end is
brought out through the created antrostomy
opening.
(9)Sutures: The bone margin is smoothened and
the flap is replaced. The flap may be sutured
using resorbable suture material.

www.FourthMolar.com
POST OPERATIVE CARE:
- Ice pack over the cheek for first few hour after
surgery. Sinus pack is removed after 24 to 48
hours.
- Avoid blowing of the nose for at least 2 week
after surgery.
COMPLICATION:
Intraoperative complication:
 Bleeding
 Damaged to infraorbital nerve.
 Damaged to orbital content- Due to perforation
into the thin orbital floor during curettage of the
superior wall of the trauma.
Postoperative complication;
 Reactionary Heamorrhage.
 Infection.
 Numbness in the infraorbital region.
www.FourthMolar.com
 Recurrence of the lesion.
OROANTRAL FISTULA:
Definition: It is the pathological communication
between oral cavity and maxillary antrum.
- Fresh communication will lake the epithelium
lining while long standing ones known as chronic
oroantral fistula have epithelized fistulous tract.
OROANTRAL FISTULA

ACUTE CHRONIC

www.FourthMolar.com
ETIOLOGY:
1) Extraction of teeth:
- Occurs as a result of a traumatic extraction
of maxillary posterior teeth whose root may be
inclose proximity to the floor of the maxillary
antrum. -
Tuberosity fracture as a result of upper third
molar extraction. - In advert curettage of
maxillary tooth socket.
2) Facial Trauma: Maxillofacial trauma and
penitrating injury.
3) Surgical removal of the cyst and tumor
associated with the maxillary alveolar region
extending into the antrum.
4) Osteomylities of the maxilla or following
irradication. www.FourthMolar.com
ACUTE OROANTRAL FISTULA:
Clinical features:
Symptoms- History of recurrent surgery in the
vicinity of maxillary sinus.
Escape of air and fluids through the nose and
mouth.
Unilateral epsitaxis.
pain may be severe throbbing ordull aching pain.
Enhanced column of air causing change in the vocal
resonance and consequently change in the voice.
IMIDIATED SIGN-
The part of the bony part of the sinus may be
adhearent to the root tip on extraction.
Maxillary tuberosity fracture.
Root tip in the maxillary antrum.
www.FourthMolar.com
DELAYED SIGN OF OROANTRAL FISTULA:
Discharging of foul smelling pus from the fistula.
Maxillary sinusitis.
Infraobital region is tender on palpation.
Infraorbital edema.
Teeth an affected side will be tender on
percussion.
Nasal congestation around the osteum.
Pus in the posterior wall of the pharynx.
Antral polyp in the oral cavity.

www.FourthMolar.com
DIAGNOSIS OF OROANTRAL FISTULA:
- A large fistula is easily seen on inspection.
- Nose blowing test: The patient is placed to close
his nostril and blow gently down the nose with
nose open.
Whistling sound as air passes down the fistula
in the oral cavity.
- cotton wisp test: The escape of air through the
nose can be tested by placing a wisp of cotton
near the orrifice.
- Mouth mirror fogging test: A mouth mirror
placed at the oroantral fistula causing the
fogging of the mirror.
- Unilateral epistaxis may sometimes be seen
- some time the oroantral fistula can blocked by
the an antral polyp.
www.FourthMolar.com
MANAGEMENT:
Aim: - To prevent nasal regurgitation of fluides.
- To prevent infection of the maxillary antrum
from the oral cavity.
CLOUSURE OF OROANTRAL COMMUNICATION:
Aim: - Primary repair to close the communication.
- Antibiotics to cure the sinus infection
PROCEDURE:
I. Irrigation of the antrum with saline.
II. Simple suturing of the socket.
III. A well fitting denture base may be constructed
with a flenge extention to cover the oppening
completely.
IV. This prevent contamination of the oral cavity
and antral cavity and thus enabled healing.
V. Once a communicate is formed between the oral
and antral cavity, ther are the chance of
www.FourthMolar.com

infection of the maxillary antrum.

SUPPORTIVE MEASURE:
Antibiotics: -For prevent the sinusitis.
- For preventing the infection.
Steam inhalation: Steam inhalation with benzoin
compound helps to thin down the antral section
and helps in the easy drainage of these fluids
through the nose..
Nasal Decongestant: - for reduce nasal secretion.
- Decrease the nasal
inflammation of the nasal mucosa.
Analgesics and Antihistaminics: -For reduction of
the pain
- Decrease the
secretion. www.FourthMolar.com

Antral leavage:-
CHRONIC OROANTRAL FISTULA:
This occur due to the persistence of the
communication between the oral cavity and the
maxillary antrum.
CLINICAL FEATURES:
- Persistent unilatral foul discharge.
- Post nasal drip with the discharge trickle down
the phrynx from the posterior nares resulting in
foul smell and unpleasent test.
- Systemic sequeles due to swallowed pus in the
form of
- -Pyrexia, malaise, Headache,
Ansomnia,Anroxia.
- Pain is diminish consiberabely.
www.FourthMolar.com

- Polyp projecting form the antrum into the oral

INVESTIGATION:
- Intra oral periapical radiograph is taken with the
silver probe placed into the fistula tract to
determine the frequency of the tract.
- Maxillary sinus radiograph of the skull.
- Routine evalution.
MANAGEMENT

SURGICAL SUPPORTIVE
METHOD METHOD

www.FourthMolar.com
 SURGICAL METHOD
If fistulous persist for more than 2 to 3 months the
fistula tract would have been epithelized.
METHOD OF CLOSURE TECHQUINE;
LACAL FLAP
1. Buccal flap – Buccal advancement flap
- Buccal sliding trepezoid flap
- Bipedic flap
2. Palatal Flap- Palatal advancement flap
- Palatal rotational advancement
flap
Submucosal connective tissue
pedicle
- Pedicle island flap
- Anterior based flap
3. Combination of buccal and palatal flap
DISTANT FLAP www.FourthMolar.com
PRINCIPLE :
1. Blood supply should be adequate so that the
flap does not necrose.
2. Suture line is well supported by normal bone.
3. Wound is sutured in tension.
4. All basic requirement should be fullfilled.

BUCCAL ADVANCEMENT FLAP: (VON REHRMANN

FLAP)
Described by Von Rehrmann in 1936.
Mostly is used method.
TECHQUINE:
1.Excise the tissue lining the oroantral fitula.
2. Two vertical divergent incision are made on
either side of the fistula on the
buccal gingiva. www.FourthMolar.com
4. If the extent of the flap is inadequate the
periosteum and the inner side of the flap may be
incised horizontaly.
the flap now be sutured more easiley.
5. The flap is made to cover the opening and is
sutured to the palatal tissue.
ADVANTAGE:
1. Simple and easily to perform.
2. Flap is usually has a good blood supply due to
broad base.
3. Well tolerated by the most patient.
4. Denture may be placed immediately
DISADVANTAGES:
Reduction in the buccal vestibular depth.

www.FourthMolar.com
PALATAL ADVANCEMENT FLAP:
Procedure:
The palatal tissue surrounding the oroantaral
communication may be advanced and sutured to
the buccal tissue o cover the defect.
The surface marking is midway between the free
gingival margin and midline of the palate.
The palatal mucoperiosteal flap with greater
palatine vessles is raised its bed and roteted
across the fistula with greater palatine foramen
as the center of rotation
Incision is made with the B.P. blade no. 11, the
fistulous tract at least 2mm away from the
epithelized surface.
It is desected and removed out.
Surface line rest on the normal bone.
Flap design and length of the flap are determined.
www.FourthMolar.com
www.FourthMolar.com

Depending on the length of the flap is raised

DISADVANTAGE:
- Palatal tissue is not very elastic and cannot be
streached to cover the defect completely.

www.FourthMolar.com
ROTATIONAL ADVANCEMENT FLAP:
This is posteriorly based flap which gets its blood
supply from greater palatine artery.
It has the advantage greater mobility and bulk.
The flap is reflected and rotated to fit the defect.
Chance of bending of the tissue when it is truned
to cover the oroantral opening.
This may be damaged due to venous congestion.
To prevent the bending a V- shaped excision of the
tissue at the bend may be done.
This prevent the folding of the tissue at the
junction.
Then sutured to the buccal side with minimal
tension.

www.FourthMolar.com
SUBMUCOSAL CONNECTIVE TISSUE PEDICLE:
The submucosa on the palatal is used to cover the
oroantral communication.
The mucosa layer or the epithelial layeris then
packed back on the donor site.
Therefore there is no row surface on the palatal
unlike the previous procedure.
The dissection of the submucosa is however is
difficulty procedure and required great care.

www.FourthMolar.com
COMBINATION PROCEDURE:
A combination has been described where in
alveolar bone based buccal flap is reversed and
sutured with palatal margin.
This replace the living part of the wound.
The palatal flap is rotated and palaced in the usual
manner.
Thus the row surface of both the flaps are placed
against each other.
this is two layerd closure.

www.FourthMolar.com
DISTANT FLAP :
Tongue Flap:
Highly vascular and provide adequate bulk for the
closure of large defects without tension.
Disadvantages:
Mobility of the tongue which can result in failure
of flap.

www.FourthMolar.com
GRAFT PROCEDURE :
1. Buccal fat pad- small to medium sized defect
can be closed with a buccal fat pad graft.
It is simple surgical technique with the donor site
being closed to area of closure.
2. Bone graft
Allopalstic material :
- Gold foil / gold plate : Gold foil can be used to
bridge between the buccal and palatal flap till
the defect heals.
- soft polymethylmethacrylate
- Hydroxyapatite blocks

www.FourthMolar.com
 References

Textbook of oral and maxillofacial surgery - chitra

chakravarty
Text book of oral and maxillofacial surgery - B.shrinivasan
Text book of oral medicine - Anil govindrao
Ghom

www.FourthMolar.com