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Maxillary Sinus Disease of Odontogenic Origin

Maxillary Sinus Disease of Odontogenic Origin

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maxillary sinus disease of odontogenic origin.
maxillary sinus disease of odontogenic origin.

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Published by: aka_andres on Feb 20, 2011
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Maxillary sinus disease of odontogenicorigin
Pushkar Mehra, BDS, DMD
*,Haitham Murad, DMD
Department of Oral and Maxillofacial Surgery, Boston University Medical Center,Boston, MA
Department of Oral and Maxillofacial Surgery, Boston University School of Dental Medicine, 100 East Newton Street, Boston, MS 02118, USA
Department of Dentistry, Boston Medical Center, Boston, MA
The maxillary sinus, anatomically lying in an intermediate positionbetween the nasal and oral cavities is vulnerable to invasion by pathogenicorganisms through the nasal ostium or the mouth. Odontogenic sinusitisaccounts for approximately 10% to 12% of maxillary sinusitis cases[1].Sinus disease of odontogenic origin deserves special consideration becauseof some differences in pathophysiology, microbiology, and management ascompared with sinus disease of other origins. Sinusitis related to dentistryand odontogenic causes can occur when the Schneidarian membrane isviolated by conditions such as odontogenic pathology of the maxillary bone,infections arising from the maxillary teeth, maxillary dental trauma, oriatrogenic causes such as dental extractions, placement of dental implants,and maxillary osteotomies in orthognathic surgery. Management of sinusdisease of odontogenic origin often requires treatment of the sinusitis as wellthe odontogenic source.
Anatomy and physiology
The maxillary sinus is part of a series of paranasal sinuses, which includesthe frontal, ethmoid, and sphenoid sinuses. These pneumatic cavitiessurround the nasal cavity and are in close approximation to the orbital wallsand dura mater of the anterior cranial fossa. The maxillary sinus is the first
* Corresponding author. Department of Oral and Maxillofacial Surgery, Boston UniversitySchool of Dental Medicine, 100 East Newton Street, Suite G-407, Boston, MA 02118.
E-mail address:
pushkar.mehra@bmc.org(P. Mehra).0030-6665/04/$ - see front matter
2004 Elsevier Inc. All rights reserved.doi:10.1016/S0030-6665(03)00171-3Otolaryngol Clin N Am37 (2004) 347–364
of the paranasal sinuses to develop in the third month of fetal life. Aprimary pneumatization process occurs as an invagination of nasalepithelium off the ethmoid infundibulum, a recess between two parts of the future ethmoid bone, the uncinate process and ethmoidal bullae. Duringthe fifth month of fetal life, the maxillary sinus begins to grow into theadjacent growing maxilla.Final growth of the maxillary sinus takes place between 12 to 14 years of age and corresponds with the eruption of permanent teeth and growth of thealveolar process of the upper jaw[2]. In children and young teenagers thereis considerable distance between the floor of the sinus and the apices of themaxillary teeth, because the sinus has not reached an adult size. Atcompletion of growth the maxillary sinus is bounded by the orbital floor, thelateral nasal walls, and the dento-alveolar portion of the maxilla and mayextend into the palatine and zygomatic bones. The average volume of a developed sinus at maturity varies between 15 and 20 mL, almost doubleits size at birth. Although these dimensions remain relatively stable once thepermanent maxillary teeth have erupted and growth of the maxilla iscomplete, continued expansion and pneumatization occurs in some patientsthroughout life[3].In the dentate individual, continued expansion causes inferior displace-ment of the sinus floor toward the roots of the maxillary posterior teeth(Fig. 1). The roots of the maxillary teeth may protrude into the sinus cavity,and occasionally the expansion can be so extreme so as to leave only thesinus mucoperiosteum surrounding the apical aspects of the dental roots[4,5].In patients with maxillary tooth loss, the sinus often pneumatizesinferiorly to form a recess between the remaining teeth in the part of thealveolar bone that was previously occupied by the missing tooth (Fig. 2). Inthe completely edentulous person, the sinus may expand further andcontinue to extend into the alveolar bone, sometimes to the point that onlythin alveolar bone remains between sinus and the oral cavity (Fig. 3)[3]. Therefore, there is a significant difference in the height of the sinus floorbetween dentulous and edentulous patients. Many edentulous patients nowrequest implant-supported denture-type dental prostheses. Lack of adequatebone resulting from sinus pneumatization does not permit placement of dental implants, and thus these patients require preprosthetic surgicalprocedures such as alveolar ridge augmentation with bone grafting andsinus membrane elevation procedures (Fig. 4).In general, roots of the central and lateral incisor teeth are not in closeproximity to the maxillary sinus. The roots of the maxillary premolars andmolars, however, are consistently located below the sinus floor. The roots of the second molars are in closest proximity to the sinus floor, followed infrequency by the roots of the first molar, third molar, second premolar, firstpremolar, and canine[1]. One study using CT scanning of the humanmaxilla found that the apex of the mesiobuccal root of the maxillary secondmolar was closest to the sinus floor (mean distance of 1.97 mm), and the
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364
apex of the buccal root of the maxillary first premolar was furthest from thesinus floor (mean distance of 7.5 mm)[6].The lateral wall of the maxilla forms the anterior wall of the sinus. Itsthickness varies from 2 to 5 mm, with the thinnest portion in the center of the canine fossa. The labial levator muscles and the orbicularis oculi muscleare attached to this wall above the infraorbital foramen. The attachments of these muscles usually direct the spread of infection from the maxillary teethto the maxillary sinus once it penetrates the anterior sinus wall.
There has been controversy as to the identities of the normal flora of thesinuses because access for culture is difficult and involves passage through
Fig. 1. (
) A panoramic radiograph showing pneumatization of the left sinus into the furcationof the maxillary molar roots. The roots appear to protrude into the sinus cavity. This patientrequired extraction, and a sinus perforation was expected. (
) The extracted maxillary molar.Notice the cup-shaped area between the roots; this was the actual floor of the maxillary sinus(
solid arrow
) with thin areas of intervening alveolar bone (
open arrow
P. Mehra, H. Murad / Otolaryngol Clin N Am 37 (2004) 347–364

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