Conservative treatment and preparation
Treatment tactics directly depend on the form of the disease. For acute odontogenic maxillary sinusitis, a conservative approach is used. The main task is to stop the inflammation and establish the outflow of purulent exudate.
- Local manipulations: Puncture of the maxillary sinus is performed, followed by irrigation of the cavity with antiseptic solutions.
- Drug therapy: The patient is prescribed systemic antibacterial drugs (antibiotics, sulfonamides), desensitizing agents, and vasoconstrictive nasal drops (decongestants) to relieve edema in the region of the natural ostium.
In chronic diffuse sinusitis, treatment begins with mandatory sanitization of the primary focus of infection. Either endodontic treatment of the causal tooth or its extraction is performed. Important: tooth extraction is carried out before starting a radical antrostomy to reduce the risk of unexpected changes in the incision pattern in case of accidental socket perforation.
Radical Caldwell-Luc antrostomy
If conservative measures are ineffective or persistent chronic inflammation is diagnosed, classic radical antrostomy is indicated.
- Trepanation (access): A window is formed in the anterior wall of the sinus in the canine fossa area. A trephine or bur is used. Using a chisel is not recommended, as it leaves rough bone fractures. During the incision, the surgeon must avoid trauma to the neurovascular bundle emerging from the infraorbital foramen (foramen infraorbitale).
- Sinus revision: Curettage is performed through the window. Granulations, polyps, foreign bodies (e.g., filling material), and thickened altered mucosa are thoroughly removed. Healthy areas of the mucous membrane must not be removed.
- Creation of an artificial ostium: For continuous aeration and outflow of exudate, the nasal wall is trepanated in the region of the inferior nasal meatus.
- Tamponade and suturing: The sinus is filled with an iodoform gauze strip, the end of which is brought out into the nose. The wound from the oral vestibule side is tightly sutured with interrupted stitches. The gauze strip is removed the next day.
Surgical closure of oroantral communication
If tooth extraction led to perforation of the floor of the maxillary sinus, the communication must be closed. Before plasty, it is advisable to fill the socket with osteoplastic material (bone autograft or xenograft). Several types of flaps are used for soft tissue plasty:
- Buccal trapezoidal flap: The most popular method. The flap is carefully mobilized over the socket without tension (to achieve this, the periosteum is incised at the base). The main disadvantage is the flattening of the upper vault of the oral vestibule, which can create problems with removable dentures.
- Full-thickness palatal flap: Crafted on the hard palate (with the base facing the soft palate). Used mainly for recurrent fistulous tracts. When raising the flap, it is important not to damage the bundle from the greater palatine foramen (foramen palatinum majus). Disadvantage of the method: bare bone is left in the donor site, healing by secondary intention (requires wearing a protective plate).
- Vascularized subepithelial palatal flap (A.V. Schipsky's method): The most modern and physiological option. The elevated palatal flap is split into two layers: the deep (subepithelial) layer is advanced to close the perforation and fixed with a mattress suture, while the superficial (mucosal) layer is returned to the donor site of the palate. This ensures healing by primary intention and eliminates the need to wear a plate.
Briefly: answers to topical questions
What intraoperative complications can occur during a radical antrostomy?
During a radical antrostomy, intraoperative complications such as injury to the neurovascular bundle and bleeding may occur.
When creating surgical access in the canine fossa area, it is critically important not to damage the structures emerging from the infraorbital foramen (foramen infraorbitale). Damage to this bundle leads to bleeding and subsequent neurological disorders (paresthesia or hypesthesia). In addition, with concomitant extraction of premolars or molars, there is a risk of sinus floor perforation, which will require modifying the incision pattern.
What specific types of osteoplastic materials are used to fill the socket prior to oroantral communication plasty?
Before performing oroantral communication plasty, it is advisable to fill the extracted tooth socket with osteoplastic material. Bone autografts, allografts, as well as materials of xenogenic or synthetic origin are used. In the case of a sclerotic structure type of the maxillary sinus, this creates conditions for subsequent dental implant placement.
What are the radiological signs of chronic odontogenic maxillary sinusitis?
On a direct skull radiograph in chronic odontogenic maxillary sinusitis, homogeneous opacification of the affected maxillary sinus is determined. Orthopantomography may visualize signs of chronic periodontitis of the maxillary teeth, periapical bone destruction foci around the roots of premolars and molars, as well as foreign bodies in the sinus projection.
Class and exam questions
Which teeth most frequently cause odontogenic sinusitis?
The primary source of infection is the maxillary premolars and molars, whose roots are anatomically close to the sinus floor.
Is it necessary to curette the entire sinus mucosa during an antrostomy?
No, only polypoid-altered tissues, granulations, and foreign objects are subject to removal. Unaltered areas of the mucous membrane must be preserved.
Where and why is an ostium created during radical surgery?
An artificial ostium is formed in the region of the inferior nasal meatus. It is necessary for continuous sinus aeration, fluid drainage, and prevention of relapses.
What is the disadvantage of using a buccal flap for perforation closure?
Mobilization of the buccal flap leads to a reduction in the depth of the upper vestibule vault, which in the future seriously complicates the retention of removable dentures on an edentulous jaw.
What else to study on this topic
- Clinical presentation of chronic odontogenic sinusitis (anosmia, nature of discharge)
- Radiological diagnostic methods: OPG and targeted radiographs
- Performing the nose-blow test to confirm sinus floor perforation
- Potentially lethal complications: orbital phlegmon and sinus thrombophlebitis
- Principles of using osteoplastic materials in the extracted tooth socket
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