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ANATOMY OF THE MAXILLARY SINUS -largest of the paranasal sinuses. -four sided pyramid: Base (mesial): lateral nasal wall Apex (lateral): zygomatic process of the maxilla Upper wall (roof): floor of the orbit Posterior wall: maxillary tuberosity Anterior and lateral: region of cuspid and first bicuspid Frequency of proximity to the maxillary sinus: 1st molars > 3rd molars > 2nd premolars > 1st premolars > canines II. ACCIDENTAL OPENING OF A FOREIGN BODY IN THE ANTRUM A. Cases: There is always a thin wall of bone between the root and the sinus, but it can be very thin indeed. Most of the time, the bone remains intact, but upon occasion, a piece of the bone separating the root from the sinus may break off or be removed. 1. tooth extraction 2. odontectomy 3. apicoectomy 4. surgical cyst treatment In other cases, foreign body may be dislodged into the sinus. 1. Dislocation of a tooth or root into the maxillary sinus Alveolar wall fracture incurred while using a dental elevator used to remove a root, with subsequent dislodgement of the tooth or root into the maxillary sinus 2. Endodontic treatment Gutta percha, files, irrigating solution may be pushed into the sinus Non-treatment of a perforated sinus leads to acute infection which can lead to chronic infection. B. Diagnosis of antral perforation 1. Nose-blowing test The patient is instructed to try to exhale through a blocked nasal airway. Positive test: a. A fine hissing noise can be heard or b. Bubbles develop over the perforation A negative test does not exclude the possibility of antral perforation (valve formation in patients with basal polyps or previous maxillary sinus surgery). It is not always possible to detect small perforations. 2. Cheek-blowing test The patient is instructed to blow air into the cheeks against a closed mouth. Positive test: a. Hissing noise from air escaping through the maxillary sinus and nose. Disadvantage: There is a risk of the spread of germs from the oral cavity into the maxillary sinus. 3. Probing the alveolus most reliable way to diagnose an antral perforation and should always be performed. Cautiously probe with a bulb-head probe C. Treatment for small perforations:

1. Avoid use of irrigations, vigorous mouth washing, frequent and hard blowing of the nose. 2. No probing of the socket so infection will not be introduced into uncontaminated areas. 3. If primary attempt to remove the foreign material fails, a Caldwell-Luc incision must be done to permit adequate visualization of the entire sinus. 4. Prescription: a. antibiotic to prevent infection b. decongestant to keep the sinuses clear during healing 5. Patient Instructions: a. Bite on a big size of gauze for 30 to 60 minutes to form a clot on the socket (If nothing disturbs the clot, it will organize during healing and close the perforation) b. Do not suck on anything for at least a week. This puts pressure on the clot and could dislodge it into the mouth. c. Do not smoke.the longer you wait the better. This will dissolve the clot, or could even suck it out of the socket. d. Do not blow up balloons or anything else. This puts pressure on the clot and could dislodge it into the sinus. e. Avoid sneezing. This explosive event will definitely dislodge the clot. D. Treatment for Large Perforations Timing of treatment: If healthy, a freshly opened maxillary sinus should be closed immediately; otherwise, closure should be performed within 24 hours at the latest. Rationale: A healthy maxillary sinus is germ-free. If communication with the oral cavity is allowed to persist too long, the mucosa will become infected. If the maxillary sinus becomes infected, the perforation will not heal spontaneously, but will develop into a chronic oro-antral fistula. D.1 Attempt to remove a root apex by aspiration It is possible to remove dislodged root apex through an existing perforation using an aspirator with a fine-point tip. The aspirated root apex can then be recovered from the tip of the aspirator or from inside the aspirator (filter). D.2 Trapezoid mucoperiosteal flap with periosteal relief (dentulous areas)

1. The mucoperiosteum is raised both buccally and lingually. The base of the flap, which lies on the fold, is broader than the extraction wound (trapezoidal). Check to ensure the flap is long enough and that it provides adequate cover without stretching 2. Relaxing incisions are made at the base of the flap. Avoid the palatal artery. 3. The height of the alveolar ridge is reduced at the site of the opening substantially. 4. Edges of the soft tissue that is to be approximated are freshened so that raw surfaces will be in contact with each other.

5. Suturing may then be done without tension. Edges are drawn together with mattress sutures and reinforced with multiple, interrupted black silk sutures. Palatal wound is left open. *Must use non-resorbable suture material to remove the possibility of the suture coming out too soon which could possibly limit the success of the closure 6. Suture are left for 5 to 7 days. 7. Prescribe nose drops to shrink the nasal mucosa and promote drainage. D.3 Suture technique -for closure of large accidental sinus opening in edentulous areas (loss of maxillary tuberosity) 1. Reduction of buccal and lingual walls to allow coaptation of buccal ang lingual soft tissue flaps. The soft tissue flaps are trimmed conservatively to form a somewhat even line 2. Flaps are sutured.

III. SURGICAL CLOSURE OF THE ORO-ANTRAL COMMUNICATION (FISTULA) A. Palatal Flap Method -A pedicle flap raised from the palate is thick and has good supply so the chances for success are raised. -The design of the flap can be determined by a trial prior to surgery: A cast is made then covered by soft acrylic or wax. The flap is outlined on the acrylic or wax, the incision is mad, and the flap turned, covering the defect. This provides a preview of results. This trial session will ensure that the flap to be made will adequately cover the opening. 1. With a no.15 blade, the tissue is incised and the flap is raised. A V-shaped section of the tissue may be excised at the region of greatest bend to prevent folding and wrinkling. 2. The pedicle is raised with the periosteum and this must contain a branch of the palatal artery. 3. The margins of the fistula defect are freshened and the edges undermined. 4. The flap is tucked under the undermined edge of the buccal flap. This procedure permits two fresh bleeding surfaces to be in contact. 5. With mattress sutures, the tissues are drawn in good contact, and margins are sutured with multiple interrupted sutures. Sutures are removed after 5 to 7 days. 6. The exposed bone at the donor site on the palate may be covered with surgical cement or a gauze strip saturated with compound tincture of benzoin.

B. Berger Method -obtains tissue from the buccal or cheek area. 1. The tissues that form the rim of the fistula are incised. 2. From the extreme edges, diagonal incisions are made through the mucoperiosteum to the bone. The incisions are carried upward into the muccobuccal fold. 3. The flap is elevated, exposing the bone defect. 4. In the undersurface of the flap, the periosteum is incised horizontally at different points, care being taken to incise the periosteum only so that there will be no interference with the blood supply. The incision in the periosteum lengthens the flap so that it may slide down over the opening. 5. Margins are sutured with multiple interrupted sutures. Sutures are removed after 5 to 7 days.

C. Proctor Method -placement of a cone-shaped piece of preserved cartilage into the defect. The tooth socket is curetted and the cartilage with a proper size is wedged into place. Too small size may be dislodged and drop-out before the membrane grows over it or it may be lodged into the sinus and become a foreign object inside it. D. 1. 2. 3. Other methods: Placement of gold implant Placement of autogenous bone disks Transplant obtained from the opposite side of the palate

*Causes of failure of surgical closure

1. Incomplete elimination of infection prior to closure: Use antibiotics or lavage 2. Patients general physical condition was overlooked: diseases like diabetes and syphilis adversely affects healing 3. Too much tension on the flaps 4. Failure to provide a fresh bleeding surface that will promote healing. *There must be good drainage from the sinus to the nose. This is ensured by intranasal antrostomy. IV. CALDWELL-LUC OPERATION (CLO) Indications include the following: 1. Removal of teeth and root fragments in the sinus. CLO eliminates blind procedures and facilitates recovery of the foreign body. 2. Trauma of the maxilla when the walls of the maxillary sinus are crushed or when the floor of the orbit has dropped. Management of hematomas of the antrum with active bleeding through the nose. Blood may be evacuated and the cause is located. Hemorrhage is arrested with epinephrine packs or hemostatis packs. 3. Chronic maxillary sinusitis with polypoid degeneration of the mucosa. 4. Cysts in the maxillary sinus 5. Neoplasms of the maxillary sinus

Procedure: 1. Prepare patient. Anesthetize. 2. Upper lip is elevated with retractors. 3. U-shaped incision is made through the mucoperiosteum to the bone. 4. Vertical incisions are made in the cuspid and second molar areas from the points just above the mucobuccal fold. 5. A horizontal line connecting the vertical incisions is made in the alveolar mucosa several millimetres above the gingival attachments of the teeth. 6. The tissue is elevated from the bone with periosteal elevators, going superiorly as high as the infraorbital canal. Care is exercised here to prevent injury to the nerve. 7. An opening is made into the facial wall of the antrum above the bicuspid roots by means of chisels, gouges, or dental drills, and this is enlarged by means of rongeurs to a size that permits inspection of the cavity. The size ultimately obtained is about the size of the end of an average index finger. 8. The opening should be made high enough to avoid the roots of the teeth in that area. 9. The purpose of the operation is readily accomplished (e.g. removal of root ends). 10.The cavity is cleansed. A resorbable collagen wall may be placed to aid bone healing. 11.The soft tissue flap is replaced and sutured over the bone with multiple, interrupted black silk sutures which are removed after 5 to 7 days. Post-operative care after repair of antral perforation

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No nose-blowing for 10 days No smoking Prescribe nose drops to reduce swelling on the affected side: 3 times daily Chamomile steam inhalation: 3 days after surgery Remove sutures 7 to 10 days after surgery Antibiotic treatment: 7 to 10 days Diet: Soft food is recommended, however, if the wound is not painful and patient is able to chew, regular diet is allowed. 8. Patients with Dentures: continuous wearing for seven days to prevent gums from swelling 9. Elevate the head at all times to reduce bleeding and swelling. 10.For 6 hours after the operation, apply ice packs to the face between the eye and the lip. This reduces the bruising and swelling. 11.Nasal bleeding is expected for two to three days after surgery. If this occurs, just change the drip pad as needed and keep the nostril clean. Clean the dried blood and secretions from the nostrils with hydrogen peroxide 3% and Q-tips.