Teeth and Maxillary Sinus

Teeth and Maxillary Sinus

1. Introduction :                                                                                                 

The pathological relationships between the teeth and the maxillary sinus are explained by the anatomical relationships by the fact that the lower wall of the maxillary sinus is centered by the apices of the so-called “antral” teeth. 

Maxillary sinusitis corresponds to an  inflammation of the sinuses with various etiologies . Of which approximately 10% of cases, the etiology is presumed to be dental. 

The clinical manifestations of this pathology are local, locoregional and sometimes general. 

Therapy adapted to each etiology helps avoid complications and after-effects.

 Goals  :  

• Acquire the information needed to diagnose maxillary sinusitis, particularly those of dental origin 
• Identify situations at risk of oral-sinus communication and be able to diagnose it.
• Mastering the management of this pathology     

Problematic   

– Patients consult or are referred by colleagues for etiological research following symptoms of maxillary sinusitis.

 – Cases of oro-sinus communication occurring after dental extraction.

2- Reminders:

• The maxillary sinuses are  bony cavities connected to the nasal fossae  via a drainage canal,  the middle nasal meatus . They are located above the roots of the first molar and second premolar (or even the other molars, the first molar and the canine if they are large), and  separated by a bony floor  whose thickness varies from one individual to another. 
•  The dimensions of the maxillary sinus: the average volume between 12 -13 cm ³ . 
• Anatomical proximity of the apex of the roots of the upper premolars and molars (in order of frequency: 6, 5, 7 then 4)
• The layer of bone separating the dental apices from the sinus mucosa decreases with age and with tooth prolapse (sinus prolapse)
                                                                 

        Prolapse of the sinus Relationship of the teeth to the maxillary sinus                            

• The maxillary sinuses  are narrow cavities connected to the nose, located  at the level of the cheekbones  . Their mucous membrane produces mucus, which plays an important role in preventing ENT infections.

3.Maxillary sinusitis:

 Dental maxillary sinusitis (DMSI) is an inflammatory reaction of the sinus mucosa following a dental infection. During sinus infections,  mucus cannot drain  due to local inflammation induced by the presence of a virus or bacteria. The mucous membrane of the sinuses becomes irritated and swollen. This produces a  thickening of the mucous membrane  that blocks the maxillary sinus and increases the pressure in the sinuses. This is called maxillary sinusitis.

1.  Etiologies  : 

• Dental etiology: An odontogenic source should be suspected in patients with a history of untreated dental or perodontal pain or infection.
• Iatrogenic etiology, including pre-implant surgery, endodontic treatments and this after devitalization, overflowing obturation with a paste (eugenate). The substances put in place can exceed the tip of the root, migrate into the sinus and become superinfected.
• Benign or malignant tumors in development are also responsible for sinusitis.

        Three common clinical situations that can lead us to maxillary sinusitis

• The case of untreated caries → necrosis → granuloma → which can cause a  sinus infection .
• The case of incomplete devitalization → the pulp is not completely blocked → it can become infected and reach the  sinus .
• When a tooth is devitalized → excess filling paste with zinc oxide paste → this paste becomes a favorable site for the development of aspergillosis due  to a fungus of the aspergillus genus.

3.2. Pathophysiological mechanisms  :

The anatomical proximity of the apex of the roots of the upper premolars and molars to the maxillary sinus provides a route for the spread of any infectious focus located in the region. These are complications of dental caries, with pulp necrosis and formation of an apical granuloma (Figure 3a). More rarely, it may be a periodontal infection

Teeth and Maxillary Sinus

 Periapical or periodontal infection Sinusitis following pulp overflow

3.3 . Microbiology  : 

The collection and analysis of a microbiological sample revealed the presence of bacterial flora generally composed of Streptococcus viridans , beta-hemolytic streptococci, group A streptococci, Streptococcus  pneumoniae ,  Staphylococcus aureus ,  Haemophilus parainfluenzae , enterobacteria, anaerobes and other gram-positive and gram-negative cocci. There is also a correlation between dental care and the development of intra-sinus mycotic infections with aspergillus (zinc oxide, corticosteroids). 

3.4. Clinical forms:

3.4.1. Acute sinusitis  : this is often confused with apical periodontitis of the causative tooth. Acute sinusitis of dental origin is manifested by:

• A vestibular swelling opposite the causative tooth.
• A  discharge of pus from one nostril only.
• A  permanent bad smell in the nose (subjective cacosmia).
• A  throbbing maxillary pain radiating  towards the dental arch , under the eye and/or the forehead.
• Possibly a  fever .

Diagnosis  : It is based on clinical examination and additional tests.

1. Clinical examination  :

• Facial examination: The facial examination looks for elective pain on pressure of the anterior wall of the maxillary sinus, below the emergence of the infraorbital nerve.
• Rhinological examination: The rhinological examination (after blowing the nose) is divided into two rhinoscopies:

Anterior rhinoscopy shows congestion of the mucosa and purulent secretions and posterior rhinoscopy finds pus in the cavum.

• Dental examination: A search is made for an infectious focus (caries, periodontal disease) at the level of the sinus teeth, with especially signs of  mortification . In practice, only intact teeth that react to vitality tests are considered to be out of the question.

Sometimes only a bucco-sinus communication persists after old avulsion.

2. Paraclinical examination: They are dominated by the radiographic examination, which explores the teeth and the sinus. We distinguish: Standard extra-oral sinus images (Blondeau, Hirtz), which are currently replaced by sinus scanography or even (cone beam).  

For the sinus focus: Sinusitis is manifested radiographically by:

• A more or less clear opacity, total or limited to the sinus floor;
• opacity in the frame due to mucosal hyperplasia;
• an opacity with liquid level, visible only on the Blondeau;
• a dense intrasinus radiopaque body (protrusion of canal filling paste or aspergillosis);

Teeth and Maxillary Sinus

                                           X-ray images of sinusitis

For the dental focus  : We use the orthopantomogram or retroalveolar images). The image is translated by radiolucencies:

• A coronal radiolucency of a cavity;
• A periradicular radiolucency of an apical periodontitis (granuloma or cyst)

3.4.2. Chronic maxillary sinusitis  :

This is the most common form, it mainly affects adults over 30 years old. 

The functional symptomatology is limited to unilateral, purulent and fetid rhinorrhea, which evolves cyclically with bouts of warming without returning to normal.

   3.4.3 Alleviated sinusitis:

• It poses difficult diagnostic and therapeutic problems because the causal dental lesions have been attenuated by antibiotic and/or endodontic treatment. 
• The symptomatology is poor (slight and non-fetid rhinorrhea, discrete functional signs). The signs are essentially radiographic and discovered during an inflammatory flare-up or suspected focal infection and the radiological symptomatology is generally limited to an opacity of the sinus floor suggesting a polypoid or cystic thickening of the mucosa.

3.5. Treatment  : The management of dental sinusitis requires treatment of the sinus and the causative tooth, so it is a medical-surgical therapy. It first focuses on the sinusitis (symptomatic treatment), then the therapy of the dental cause.

 Symptomatic treatment of dental sinusitis (bacterial sinusitis):  

In acute forms, it is based on oral antibiotic therapy with amoxicillin (6-10 days) as first-line treatment. In case of allergy, the use of a macrolide or a second-generation cephalosporin (3-5 days) is possible. 

In case of resistance to treatment, targeted antibiotic therapy based on the results of microbiological samples taken (ANTIBIOGRAM).

 An alternative to this method is trial treatment with a broad-spectrum fluoroquinolone or high doses of amoxicillin combined with clavulanic acid (4 g/day).

Sinus washes with antiseptic solutions may also be considered.

Dental treatment (if the tooth is the cause) consists of extracting the offending tooth or carrying out conservative treatment (devitalization of the tooth). 

Surgical treatment  : 

In chronic forms with the formation of intra-sinus granulomatous tissue and once the sinus infection has been treated and the dental cause removed, surgical intervention may be necessary in order to restore the drainage and ventilation functions of the sinus cavity. An endoscopic approach with reopening of the ostium by middle meatotomy is the intervention of first choice.

The management of mycotic sinusitis of dental origin is similar, combining surgery with possible oral antifungal treatment.

4. Oral-sinus communications (BSC):

    A CBS is defined as an osteo-mucosal discontinuity between the oral cavity and the maxillary sinus. They can be classified according to their size (small; medium and large); but also according to their topography (alveolar, vestibular, palatine).

   They can be recent or old.

Teeth and Maxillary Sinus

                                         Clinical and radiographic view of CBS

4.1 Etiologies: They are classified;

• Iatrogenic:

• In dental extractions of teeth closely related to the sinus (95% )
• During surgery near the sinus.
• In oral implantology.

• Traumatic.
• Tumors.
• General diseases (syphilis, sarcoidosis, etc.).

4.2. Diagnosis: It is easy, it is clinical and radiological.

• The presence of air bubbles in the alveolus after dental extraction.
• The sensation of air escaping or food passing through the nose.
• Maxillary sinusitis may be indicative of CBS
• The VALSALVA maneuver (it must be gentle) or careful exploration with a curette or a cannula 
•  Radiography is more than essential on a preventive and evaluative level, it allows the study of tooth-sinus relationships; the detection of foreign bodies in the sinus, etc.

4.3 Treatment  : It depends on several parameters .

• CBS is recent or old with or without associated sinus infection
• The location of the CBS (alveolar, vestibular or palatine)
• The importance of CBS (small or large)
• For recent CBS  : Management can range from simple surveillance with protection (cases of small CBS less than 3 mm) to flap surgery (cases of large CBS). The flaps can be:

• Local flaps (vestibular or palatine).
• Locoregional flaps (Bichat fat ball, lingual flap);
• Closure can be done with dental autotransplantation, an implant, the use of aluminum plate, bone grafting, biomaterials, etc.

Teeth and Maxillary Sinus

                          Different flaps in sinus surgery

In the presence of a large and recent CBS, it is preferable to attempt immediate closure (95% success rate) unless there is a sinus infection.

• For old CBS (more than 3 weeks):

• No attempt at surgical closure will be made in the presence of sinus infection.
• It is imperative to treat sinusitis first.
• Any inflammation or infection is a poor prognostic factor for the closure of a CBS.

4.4 Causes of failures: mainly are:

–   Closing CBS on an infection not properly treated.

– A lack of vascularization of the flap used.

– Excessive tension of the sutures of the closing flaps. 

Conclusion

• Make sure to maintain a good neighborly relationship between the teeth and the maxillary sinus.
• A dental origin should be suspected in cases of recurrent unilateral sinusitis .
• In the event of acute sinusitis of dental (bacterial) origin, antibiotic therapy is indicated. The appropriate treatment is strictly dental.
• CBS is possible after tooth extraction and sometimes it is unavoidable . Therefore early and adequate treatment will lead to perfect healing.  
• Never forget the importance of the VALSALVA maneuver in the diagnostic process of CBS, provided that it is done well.

Bibliographic references

1. Briche T., Raynal M., Kossowski M., Seigneuric JB. and Denhez F. “Pathological relationships between teeth and maxillary sinuses”, Encyclopédie Médico-Chirurgicale (Editions Scientifiques et Médicales Elsevier SAS, Paris), Stomatology, 22-038-A-10, Odontology, 23-061-F-10, 2003 . 
2. Cavézian R., Pasquet G., Bel G., Baller G. “Dento-maxillary imaging: Radio-clinical approach”, Medical-Diagnostic Imaging Collection, Masson, Paris, 2001 .
3. Eloy P, Nollevaux M.-C., Bertrand B. “Physiology of the paranasal sinuses”, Medical-Surgical Encyclopedia (Scientific and Medical Editions Elsevier SAS, Paris), Oto-rhino-laryngology, 20-416-A-10, 2005 .

Teeth and Maxillary Sinus

  Wisdom teeth can cause infections if not removed.
Dental crowns restore the function and appearance of damaged teeth.
Swollen gums are often a sign of periodontal disease.
Orthodontic treatments can be performed at any age.
Composite fillings are discreet and durable.
Composite fillings are discreet and durable.
Interdental brushes effectively clean tight spaces.
Visiting the dentist every six months prevents dental problems.
 

Teeth and Maxillary Sinus