Written by Idelmo Rangel Garcia-Jr, PhD, et al Monday, 30 June 2008 19:00
Because the anatomic juxtaposition of teeth and the maxillary sinus increases the possibility of buccal-sinus communication, maxillary sinusitis can be of an odontogenic origin. The clinical and anatomic characteristics of the maxillary sinuses were described for the first time by Highmore.1 Since then these anatomic structures have been more seriously considered in certain dental treatments involving the maxillary teeth. The maxillary sinuses are pneumatic cavities situated inside the maxillary bone and appear pyramidal shape. Their base faces toward the midline and the apex toward the zygomatic process of the maxilla. In adults, each sinus occupies a volumetric space of approximately 15.0 mL.2,3
Maxillary sinusitis is an inflammation of the maxillary sinus mucosa that can present as an acute or chronic condition. Its etiology can be of a viral, allergic, or odontogenic origin.4 The anatomic juxtaposition of the maxillary posterior teeth to the maxillary sinuses increases the possibility of buccal-sinus communication. The incidence of odontogenic sinusitis ranges from 5% to 10%, according to William and Simel.5 The dental conditions associated with maxillary sinusitis are pulpitis, periodontal abscess, foreign bodies (filling materials, impression materials., etc), residual roots, endodontic treatment, maxillofacial surgeries, maxillary sinus lifts, maxillary tuberosity reductions, alveolectomies, apicoectomies, root cysts, implants, and particularly first, second, and third maxillary molar extractions.4
Acute sinusitis differs from chronic sinusitis in both intensity and duration. Brook4 characterized acute sinusitis as a condition with symptoms that usually last for less than a month, while symptoms for chronic sinusitis persist for more than a month. The most common symptoms of sinusitis are feelings of pressure and weight in the proximities of the sinus, facial tumefaction, erythema, pain and facial congestion, nasal obstruction, paranasal drainage, reduced sense of smell, fever, headache, odontalgia, halitosis, and fatigue.6
Because dental surgeons repeatedly perform treatments in the proximity of the maxillary sinus, the authors consider it important to review a clinical case report involving maxillary sinusitis caused by a foreign body after improper treatment of a buccal-sinus communication.
|Figure 1. Photo of the maxillary right quadrant. Observe a solid, whitish matter present in the alveolar region of the missing maxillary right first molar.||Figure 2. Panoramic radiograph showing extensive radiopaque material present in the alveolar region and maxillary sinus associated with the maxillary right first molar extraction site.|
A 34-year-old man came to our surgery clinic at the Araçatuba Dentistry School-UNESP complaining of facial pain and fetor oris 2 months after the extraction of his maxillary right first molar. The patient said he had experienced a great deal of pain during the days immediately following his first molar extraction. The dental surgeon who had performed the extraction, in light of the signs and symptoms related to him by the patient at that time, placed a “paste” in the region of the extracted tooth. Clinical and radiographic examination showed a solid, whitish matter, compatible with a zinc oxide eugenol material, inside the right maxillary sinus (Figures 1 and 2). The patient developed maxillary sinusitis caused by the iatrogenic introduction of a foreign body during improper and inadequate treatment of a buccal-sinus communication. In view of the condition diagnosed, the option was to remove the foreign body by means of an antrotomy followed by careful curettage to clean the foreign body out of the maxillary sinus.
Figure 3. Observe the solid, whitish material in the alveolar region after performing the muco-periosteal flap.
Figure 4. Removal and curettage of the material using the Caldwell-Luc technique.
Figure 5. Foreign body has been successfully removed.
|Figure 6. The surgical site is sutured.|
Figure 7. Photo at 2 years postoperatively.
|Figure 8. Panoramic radiograph at 2 years postoperatively.|
The surgical intervention was performed immediately to avoid any further exacerbation or spread of the facial infection, since the patient presented with no systemic contraindications. The patient was anesthetized, and a Caldwell-Luc technique was employed to remove the foreign body and to close the buccal-sinus communication (Figures 3 to 6). This procedure is a proven technique that has been well-studied and indicated for cases of sinus membrane rupture or when an odontogenic maxillary sinusitis has become established.8 Enlargement of the alveolus with the intention of removing the foreign body is a condemnable practice, since this increases the frequency of remaining fistulas and enables the oral-to-sinus passage of liquids and foreign bodies.
Penicillin, the medication of preference in prophylaxis against oral cavity bacteria, was prescribed for 10 days, as it is very effective against oral anaerobes.9 In addition to the medication prescribed, post surgical instructions (followed for 14 days) were recommended. These included avoidance of blowing the nose, sneezing with the nose obstructed, drinking through a straw, and smoking.
The patient in this case report made good progress without recurrence in the immediate postoperative period. After 2 years of follow-up, the treatment was successful in its outcome (Figures 7 and 8).
Buccal-sinus communications larger than 2.0 mm in diameter can be easily seen and diagnosed. However, if a small communication is questioned, the professional can ask the patient to block the nose and gently force air into it while the professional checks for any air bubbles that may appear in the region of the surgery.7 If the sinus membrane integrity is compromised, this often results in a delay of the repair process due to the direct communication it can provide to contaminants from the oral cavity. It can also increase the chances of developing a chronic buccal-sinus fistula.
When a buccal-sinus communication has been diagnosed after extraction surgery, the professional must approximate the edges of the wound in the best possible manner. If this is not feasible, the professional should create a flap taken from the mucosa to close the oral-sinus communication. It is important to prescribe an antibiotic therapy and a nasal decongestant that is appropriate for the patient. The patient must be duly informed of the occurrence of the buccal-sinus communication and be given proper postoperative instructions for home care.
Due to the anatomic proximities existent between the maxillary molar roots and the maxillary sinus, the dental surgeon must be aware of the possible formation of a buccal-sinus communication. Dental practitioners that extract posterior maxillary teeth will inevitably come across buccal-sinus communications and must be able to diagnose and properly treat this condition. This is also true for acute sinusitis, which can be an occasional postoperative complication. Referral to an oral surgeon for diagnosis, and/or diagnosis and treatment, is sometimes necessary and prudent depending upon the nature of the problem and the skills and experience of the general dentist.
- Highmore N. Corporis Humanii Disquito Anatomica. In: Schaeffer JP, ed. The Nose, Paranasal Sinuses, Nasolacrimal Passageways and Olfactory Organ in Man: A Genetic, Developmental and Anatomico-Physiological Consideration. Philadelphia, PA: P. Blakiston’s Son; 1920:109.
- Graney DO, Rice DH. Anatomy. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology – Head and Neck Surgery. 3rd ed. St Louis, MO: Mosby; 1998:1059-1062.
- Hollinshead WH. The nose and paranasal sinuses. In: Anatomy for Surgeons: the Head and Neck. 2nd ed. New York, NY: Harper & Row; 1968:253-305.
- Brook I. Microbiology of acute and chronic maxillary sinusitis associated with an odontogenic origin. Laryngoscope. 2005;115:823-825.
- Williams JW Jr, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. 1993;270:1242-1246.
- Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am. 1999;83:27-41.
- Laskin DM. Management of oroantral fistula and other sinus-related complications. Oral Maxillofac Surg Clin North Am. 1999;11:155-164.
- Kretzschmar DP, Kretzschmar JL. Rhinosinusi-tis: review from a dental perspective. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:128-135.
- Rabin MA. Pharyngitis, sinusitis, otitis, and other upper respiratory tract infections. In: Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine, 17th ed. New York, NY: McGraw Hill; 2008:206-213.
Dr. Garcia-Jr is a professor in the Department of Surgery, faculty of dentistry of Araçatuba, University of the Sao Paulo State. He can be reached at firstname.lastname@example.org.
Dr. Almeida-Jr is a doctoral student in the Department of Surgery, faculty of dentistry of Araçatuba, University of the Sao Paulo State. He can be reached at email@example.com.
Dr. Cardoso is a doctoral student in the Department of Surgery, faculty of dentistry of Araçatuba, University of the Sao Paulo State. He can be reached at firstname.lastname@example.org.
Dr. Luvizuto is a doctoral student in the Integrated Clinic Department, faculty of dentistry of Araçatuba, University of the Sao Paulo State. She can be reached at email@example.com.
Dr. Magro Filho is a professor in the Department of Surgery, faculty of dentistry of Araçatuba, University of the Sao Paulo State. He can be reached at firstname.lastname@example.org.
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