General Dentistry

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"DISPLACED ROOT TIPS
and
SINUS PERFORATIONS"

By:  LCDR Lena Hartzell

Maxillary Sinus = Antrum of Highmore

 Maxillary sinus is divided into:

1. The Schneiderian membrane
2. The antrum

• Air-containing spaces occupying the maxillary bone bilaterally
• First of the paranasal sinuses (frontal, ethmoid, sphenoid) to develop
• Begins as an invagination growing laterally from the middle meatus of the nasal cavity at the 70^th day of gestation
• At birth, it expands by pneumatization into the developing alveolar process
• Its growth rate matches that of the maxilla and development of the dentition

Anatomy of the maxillary sinus:

Resembles a four-sided pyramid consisting of:

• The base lies vertically on the medial surface and forms the lateral nasal wall
• The apex extends laterally into the zygomatic process of the maxilla
• The roof of the sinus is also the floor of the orbit
• The posterior wall extends the length of the maxilla

• Posterior wall: Extends the length of the maxilla and dips into the maxillary tuberosity
• Anteriorly and laterally: Extends to the region of the first bicuspid or cuspid
• Medially: The nose
• Superiorly: The floor of the orbit
• Inferiorly: The base of the alveolar process

Physiology of the maxillary sinus:

The sinus membrane acts as a sort of immunologic barrier. It consists of:

• Top layer of ciliated and non-ciliated cells: responsible for transporting mucous and small particles such as dust
• Basal cells
• Muciparous Beaker cells: responsible for producing mucous, and keeping moisture levels appropriate
• Underlying Basal membrane and tunica propria

• Anterior-Posterior: 34 mm
• Height: 33 mm
• Width: 23 mm
• Thickness: 0.8 mm
• Volume: 15 cc

• Periapical
• Occlusal
• Panoramic (most commonly used)
• Water’s (most recommended)
• Linear Tomography

• Computed Axial Tomography (recommended for chronic cases)

Normal Sinus:

Should appear radiolucent and outlined by a well-demarcated layer of cortical bone.

Abnormal Sinus:

 Odontogenic infections of the maxillary sinus:

• If the ostium becomes obstructed, the mucus produced by the secretory cells lining the walls is collected over long periods. Bacterial overgrowth may then produce an infection.
• Odontogenic infections comprise 10-15 % of sinus infections
• Sinusitis: infection of the maxillary sinus
• Pansinusitis: infection of all the paranasal sinuses

ORAL COMMUNICATION:

• Extractions
• Result of trauma
• Periapical lesions
• Perforation of the floor and sinus membrane with injudicious use of instruments
• Forcing a root or tooth into the sinus during removal
• Removal of large cystic lesions that encroach on the sinus cavity
• Pneumatized sinus (forcing apices of teeth to be closer)

• Pain
• Pressure
• Fullness in the vicinity
• Facial swelling
• Erythema
• Malaise
• Fever
• Drainage of foul-smelling mucopurulent material into the nasal cavity and pharynx

• Immediate: After the opening is created
• Later: Long-standing fistula (failure of attempted primary closure)

REMOVAL OF BROKEN ROOTS:

* If tooth was healthy and root tip < 3mm, and unretrievable, it can be left in sinus.

• Good lighting and constant suction
• Adequate exposure by wide reflection of tissue
• Localize the broken root by further radiographs

** Whether in antrum or on Schneiderian membrane

• Utilize fine elevators that force the root down by either direct pull or a wedging effect
• Carefully remove bone in order to allow for maximum mobilization of the root prior to attempting to deliver it

• Suction can be applied immediately after displacement
• Sinus can be irrigated via oral opening and suction reapplied
• Iodoform gauze technique
• Flaps
• Caldwell-Luc procedure

• Do not confirm by having the patient blow with occluded nostrils.
• Do not probe the area
• Do establish a blood clot
• Do place pressure if needed
• Do place gelfoam or other clot stabilizer (collagen plug, collaplug,…)
• Suture
• Flaps are not always necessary

Large communication:

Treatment options:

• Buccal flap advancement (most commonly performed)
• Palatal flap advancement
• Palatal and facial flap advancement over metallic foil plate
• Caldwell-Luc procedure

 CALDWELL-LUC PROCEDURE:

Creates an opening into the nose at the level of the sinus

Allows for drainage of secretions into the nose

Allows for good visualization

Technique:

Anesthetic best suited for the patient

Upper lip is elevated with retractors

U-shaped incision is made through the mucoperiosteum to the bone

Tissue is elevated from the bone with periosteal elevators going superiorly as high as the infraorbital canal

An opening is made into the facial wall of the antrum above the bicuspid roots by means of chisels, gouges, or dental drills

The opening is enlarged by means of bonecutting forceps

The opening should be made high enough to avoid the roots of the teeth in that area

The cavity is cleansed with saline solution

The soft tissue flap is replaced

The flap is sutured over the bone with multiple, interrupted black silk sutures

** If it is a chronic case, an antrostomy needs to be performed to allow for drainage through the nasal cavity.

*** Regardless of the technique, it must be remembered that the osseous defect surrounding the fistula is always larger than the clinically apparent soft tissue. Surgical planning of closure technique should be adjusted accordingly.

 Indications:

Removal of teeth and root fragments in the sinus

Trauma of the maxilla

Management of hematomas of the antrum with active bleeding through the nose

Chronic maxillary sinusitis with polypoid degeneration of the mucosa

Cysts in the maxillary sinus

Neoplasms of the maxillary sinus

Complications:

Recurrent sinusitis

Anesthesia of the cheek and teeth

Persistent cheek swelling

Dental complications

 Prevention:

Treatment planning

Careful observation

Evaluation of radiographs for divergent roots and proximity of roots to the sinus

Use of correct surgical technique

Knowing when to refer

 Post-operative care:

No forceful blowing of the nose

No use of straws

No smoking

Keeping mouth open when sneezing

Soft diet for several days

Antibiotics (PCN, Amoxicillin, or Clindamycin)

Nasal decongestants: Systemic: Sudafed Local: Neosynephrine

** One can combine Augmentin and Amoxicillin for antibiotic therapy.