PARANASAL SINUSES

MODERATOR: PRESENTER:
Dr. RAMU REDDY VEENA.T

PG 1st year 1
CONTENS
 INTRODUCTION
 DEVELOPMENT
 FRONTAL SINUS
 SPHENOIDAL SINUS
 ETHMOIDAL SINUS
 MAXILLARY SINUS
 DIAGNOSTIC EVALUATION
 DEVELOPMENTAL ANOMALIES
 PATHOLOGIC CONDITIONS OF MAXILLARY SINUS
 PROSTHODONTIC IMPLICATIONS
 CONCLUSION
 REFERENCES

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 INTRODUCTION
DEFINITION OF SINUS:
A cavity within a bone or other tissue,
especially one in the bones of the face or skull
connecting with the nasal cavities.

PARANASAL SINUSES:

Air filled extension of the respiratory

Part of the nasal cavity into the
frontal, Ethmoidal, sphenoidal &
maxillary cranial bone.

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 DEVELOPMENT:

Sinuses begin their The early paranasal sinuses

development at the third month expand into the walls and roof of
of IUL as outpouchings of the the nasal fossae by growth of
mucous membrane of the nasal mucous membrane sacs into the
meatuses and the maxillary, sphenoid, frontal and
sphenoethmoidal recesses. ethmoid bones.

The sinuses enlarge variably

and greatly from their initial
small outpocketings but always
retain their original
communication with the nasal
fossa through ostia.
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 FUNCTIONS:

 Resonance of voice
 Lightening of the skull weight
 Production of lysosome to the nasal
cavity
 Humidification and warming of
inspired air.
• Absorbing shock.
• Increasing surface area for olfaction.
• Regulation of intranasal pressure.

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There are four sets of paranasal sinuses namely;
• Frontal sinus
• Sphenoidal sinus
• Ethmoidal sinus
• Maxillary sinus

Which are present in the respective bones

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Frontal Sinus : Height- 3.15cms
Breadth- 2.5cms
Depth- 1.8cms

• lies in frontal bone deep to superciliary

arch.
• The right and left sinuses are usually
unequal in size.

• It extends upwards above the medial end

of eyebrow and backwards into the medial
part of the roof of the Orbit.

• opening: into the middle meatus of nose(at

the end of hiatus semilunaris)

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DEVELOPMENT

Invades the bone at 2nd year of life. More developed in

males. Radiographically visible at 6 years of age. 

 They grow upward at an extremely variable rate until

puberty. Even after puberty all the sinuses appear to
increase slowly in size into old age.

 Two sinuses are separated from each other by a thin

bony septum which is often deflected to one or the other
side.

Each sinus communicates with the middle meatus of the

nose by a passage called the frontonasal canal.

Subsequent enlargement is the result of atrophic changes

in the bone.

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 BLOOD SUPPLY:
ARTERIAL SUPPLY:
 Supra orbital artery and
Anterior ethmoidal arteries

Venous Drainage:

 Into the anastomotic vein

between supraorbital and
superior ophthalmic veins

Lymphatics:
 To the submandibular
nodes 
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Sphenoidal Sinus : Height- 2cms
Breadth- 1.8cms
Depth- 2cms

• Two large irregular cavities

enclosed in the body of
sphenoid bone.

• Right and left sinuses are

separated from each other by a
deflected bony septum.

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 DEVELOPMENT:
• The two sinuses therefore are
usually asymmetrical and often

partialy subdivided by
additional bony septa.

• Commence at 4th month of IUL

by invading posterior part of
nasal capsule into the body of
the sphenoidal bone.

• It continues growing into early

adulthood and may invade the
wings and rarely the pterygoid
plates of the sphenoid bone
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• Sinus opens into the
sphenoethmoidal recess of the
lateral wall of the nose.

• Radiographically visible at
four years of age only.
• By 8th year it extends to the
hypophyseal fossa.

Relations:
• Above - optic chiasma and
hypophysis cerebri.
• Each side – Internal Carotid
Artery and Cavernous sinus.

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• Blood supply:
Posterior ethmoidal
arteries

• Lymphatics:
To the
retropharyngeal
nodes.

• Nerve supply:
Posterior ethmoidal
nerve and orbital
branches of the
pterygoid ganglion.
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Ethmoidal sinus:

• Occupy the labrynth of

ethmoidal bone.

• Ethmoidal labyrinths are two

very light cubical masses which
enclose a large number of air
cells arranged in three groups,
1. Anterior,
2. middle and
3. posterior ethmoidal sinuses

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 DEVELOPMENT
 Invade the ethmoid bone from the 5th month of IUL and may also be of a
clinically significant size at birth.

 Grow variably into irregular contour until puberty.

 • The most anterior of the ethmoidal cells grow upward into the frontal
bone and may form the frontal sinuses retaining their origin from the
middle meatus of the nose as the fronto-nasal duct.

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 Anterior ethmoidal sinus:
• consists of around 11-12 air cells.
• Opens into the middle meatus at the anterior part

of hiatus -semilunaris.

Middle ethmoidal sinus:

• Consists of around 1-7 air cells.
• Opens to middle meatus by 1 or more opening
above ethmoidal bulla.

Posterior ethmoidal sinus:

• Consists of around 1-7 air cells.
• Opens to superior meatus of nasal cavity.

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Lymphatic drainage and blood supply:

• Anterior ethmoidal sinus :

Anterior ethmoidal nerve and vessels.

Submandibular nodes.

• Middle ethmoidal sinus :

Posterior ethmoidal nerve and vessels and the orbital
branches of the pterygopalatine ganglion.

Submandibular nodes.

• Posterior ethmoidal sinus :

Posterior ethmoidal nerve and vessels and the orbital

branches of the pterygopalatine ganglion.

Retropharyngeal nodes 17
MAXILLARY SINUS

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 Height - 3.5cms
Maxillary Sinus: Breadth – 2.5cms
Depth – 3.2cms
• First sinus to develop

Definition
• The maxillary sinus is the pneumatic space
that is lodged inside the body of maxilla and
that communicates with the environment by
way of middle nasal meatus.

•Anatomy of maxillary sinus was first

described by Highmore in 1651,

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 DEVELOPMENT:

• In the 4th week I.U.L. – dorsal portion of 1st Pharyngeal arch forms

the Maxillary process, which extends forward and beneath the

developing eye to give rise to the maxilla
• It reaches to maximum size around 18years of age.
Tubular - at birth
Ovoid - in childhood
Pyramidal - in adulthood

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21
AGE CHANGES:

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 Anatomy:
 Pyramidal in shape

 The base of the pyramid

forming the lateral nasal
wall and apex at the root of
the zygoma.

• 4 walls:
• anterior
• posterior
• Roof, and
• floor
• Base and
• Apex

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 ROOF OF THE ANTRUM:
• Formed by floor of orbit and is transversed
by the infraorbital nerves. It is flat and
slopes slightly anteriorly and laterally.
• Imp structures
1. Infraorbital canal
2. Infraorbital foramen
3. Infraorbital nerve and vessels.

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 FLOOR OF SINUS:
 Its mainly curved than flat in structure.
 Formed by junction of anterior sinus wall and lateral nasal wall
 Lies 1-1.2 cm below nasal floor

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 ANTERIOR WALL:

• Formed by the facial surface of the maxilla.

• Extends from pyriform aperture anteriorly
& Inferior orbital rim superiorly to alveolar
process inferiorly.
• Imp structures:
1. Infraorbital foramen
2. ASA, MSA nerves
3. Canine fossa

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 POSTERIOR WALL:

 Formed by sphenomaxillary wall

 A thin plate of bone separate the
antral cavity from the
infratemporal fossa. Made of
zygomatic and greater wing of
sphenoid bone.
 Thick laterally, thin medially.
 Important structures
1. PSA nerve
2. Maxillary artery
3. Pterygopalatine ganglion
4. Nerve of pterygoid canal

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 MEDIAL WALL:
• Formed by lateral nasal wall
• Below- inferior nasal conchae
• Behind- palatine bone
• Above- uncinate process of
ethmoid, lacrimal bone
• Contains double layer of
mucous membrane(pars
membranacea)

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• Imp structures
I. Sinus ostium
II. Hiatus semilunaris
III. Ethmoidal bulla
IV. Uncinate process
V. Infundibulum

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Osteum:
 Opening of the maxillary sinus is called osteum.
 It opens in middle meatus at the lower part of the hiatus
semilunaris.
 Lies above the level of nasal floor.
The ostium lies approximately 2/3rd of the medial wall of the
sinus, making drainage of the sinus inherently difficult.

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VASCULAR SUPPLY:-

Arterial blood supply:-

• Greater palatine
arteries
• Infraorbital artery
• Facial artery

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 Venous drainage

Venous drainage:

• Pterygoid plexus-

Posteriorly

•Facial vein-

Anteriorly

Watzek et al. 1997

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Infection from the maxillary sinus may spread to involve
cavernous sinus via any of its draining veins as the pterygoid
plexus communicates with the cavernous sinus by EMISSARY
VEIN.

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 Nerve supply

Maxillary division of the

trigeminal nerve, i.e.
• the posterior, middle
and anterior superior
alveolar nerves,
• the infraorbital nerve
and
• the anterior palatine
nerve.

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 Lymphatic drainage:

1. Submandibular lymph
nodes
2. Deep cervical lymph
node
3. Retro pharyngeal
lymph nodes

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 Histology:
• Maxillary sinus is lined by three layers:
epithelial layer,
basal lamina and
sub epithelial layer with periostium.

• Epithelium is pseudo stratified, columnar and ciliated.

• As cilia beats, the mucous on epithelial surface moves from sinus interior towards
nasal cavity.

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 CLINICAL EXAMINATION
 INSPECTION :
Middle third of the face should be inspected for the presence of
asymmetry, deformity, swelling, erythema , ecchymosis or
hematoma

 EXTRAORAL PALPATION :

Include palpation of the facial wall of the sinus above the premolar
where the bone is thinnest.

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 INTRAORAL EXAMINATION:
Examination should be
performed for tenderness, or
paresthesia of upper molar
and premolar region.

TRANSILLUMINATI
ON TEST:
It is performed in a darkened room by
inserting an electrically safe light into the
mouth ( with the lip closed).

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RADIOGRAPHIC EVALUATION

INTRA ORAL • Peri apical

• occlusal
• Lateral occlusal

• OPG
EXTRA ORAL • WATERS VIEW
• SUBMENTO VERTEX VIEW
• PA VIEW

OTHERS • CT SCAN
• MRI

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 Periapical radiograph
• Borders of the maxillary sinus appear as a thin,
delicate radiopaque line .
• In the absence of disease it appears continuous, but
on close
examination it has small interruptions in its
smoothness or density.
• The roots of maxillary molars usually lie in close apposition to
the maxillary sinus and may project into the floor of the sinus,
causing small elevations or prominences.

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OCCLUSAL VIEW LATERAL VIEW

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 ORTHOPANTAMOGRAM
• Provides an extensive overview of the
sinus floor and its relationship with the
tooth roots.

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PA VIEW

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Computerized tomography (CT) &
Magnetic resonance imaging (MRI)

 These modalities provide

multiple sections through
the sinuses at different CT

planes and therefore

contribute to the final
diagnosis and the
determination of
extent of the disease.
MRI

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 ULTRASOUND
 Ultrasound is becoming the diagnostic tool of choice for more and more physicians
in detecting sinusitis.

 It offers a fast, reliable and radiation free method for diagnosing sinusitis and has
been used successfully in Finland for around 15 years.
(Landman 1986)

 Ultrasound beam sent out by the sinus ultra is reflected from the posterior wall of
the sinus when the sinus contains fluid and from the anterior wall when sinus
contains air.

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 DIAGNOSTIC ENDOSCOPY

It is an optimal
method especially for
the assessment of
foreign bodies (such as
root filling materials
and root tips) that have
penetrated into the
maxillary sinus.

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DEVELOPMENTAL ANOMALIES
AND PATHOLOGIC CONDITIONS OF
MAXILLARY SINUS

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 Developmental anomalies

1. Aplasia
2. Agenesis
3. Hypoplasia

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 DEVELOPMENTAL ANOMALIES

• Crouzan syndrome : Early synostosis(fusion) of

sutures produces hypoplasia of the maxilla and therefore
the maxillary sinus together with the high arched palate.
• Treacher Collins syndrome : Associated with grossly and
symmetrically underdeveloped maxillary sinuses and Malar
bones.
• Binder syndrome : Hypoplasia of middle third of the face
with smaller maxillary length and maxillary sinus hypoplasia.

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PATHOLOGIC CONDITIONS OF MAXILLARY SINUS

1.Inflammatory: Maxillary sinusitis

2.Traumatic: •Fractured root Sinus

• contusion
• Blow out fracture
• Zygomatic complex fracture

3.Calcification: • Antroliths

• Radicular cyst, Dentigerous cyst

4.Cyst:
• Mucous retention cyst , Antral Polyps

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 Maxillary sinusitis

Types: depending upon duration

 a. Acute : sudden onset, duration 4weeks or

or less.

 b.Subacute : duration 4-12 weeks.

 c.Chronic: duration 12 weeks.

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 Etiology

Infectious causes
a) Bacterial
b) Viral
c) Fungal Non infectious
causes
a) Allergic
b) Non allergic
c) Pharmocologic
d) Irritants Disruption of
mucociliary
drainage
a) Surgery
c) Trauma

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Signs and symptoms associated with maxillary sinusitis
Major signs and symptoms Minor signs and symptoms

Facial pain/pressure Headache

Facial congestion/fullness Fever

Nasal obstruction/blockage Halitosis

Nasal discharge/purgulence/discolored Fatigue

postnasal discharge

Hyposmia/anosmia Dental pain

Purulence in nasal cavity on examination Cough

Ear pain

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 Maxillary sinusitis of Dental origin

•Dental abscess
•Infected dental cyst
•Dental material
•Oro- antral communication: It is a pathologic tract that
connects the oral cavity to the maxillary sinus.

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PROSTHODONTIC
IMPLICATIONS

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SPREAD OF PERIAPICAL INFECTION FROM TEETH

• The spread of pulpal disease

beyond the confines of the
dental supporting tissues into
the maxillary sinus was termed
Endo – antral syndrome (EAS)
by Selden (1974).

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ORO-ANTRAL COMMUNICATION/ ORO ANTRAL FISTULA

•Maxillary sinus perforation occurs occasionally during the

extraction of a maxillary tooth, and it may lead to maxillary
sinusitis or Oro- antral fistula.

•Palatal root of maxillary 2nd molar is most close to the sinus.

Followed by 1st molar, 3rd molar, 2nd premolar, 1st premolar,
canine.

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ORO ANTRAL FISTULA

Symptoms of Oro- antral Symptoms of established

communication: Oro- antral fistula:

 Escape of fluids  Pain

 Epistaxis  Persistent purulent
 Escape of air unilateral nasal
 Enhanced column of discharge
air  Post nasal drip
 Excruciating pain  Popping out of antral
polyp
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Operative Procedures for Oro-antral fistula

Surgical Management:

 Buccal advancement flap procedure

 Palatal pedical flap or Ashley’s operation
 Caldwell Luc operation
 Intra nasal antrostomy

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 BUCCAL ADVANCEMENT FLAP PROCEDURE
•Buccal flap has been elevated.
•The epithelium lining the fistula has
•Tension free flap has been closed across
the defect .
•Suture placed.

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 COMPLICATIONS

• Postoperative maxillary sinusitis.

• formation of chronic Oro-antral

fistula.

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 BUCCAL PEDICLE FAT FLAP
 Buccal pedicle fat pad flaps have been recommended for
the closure of fistulas and communications.

 when fat tissue is exposed to the oral environment, it

becomes epithelialized and is gradually replaced by fibrous
connective tissue within a 30-40-day postoperative period,
without any functional damage to the treated site.

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 Procedure

A larger buccal flap is elevated and

defect is covered by pedicled
portion of the buccal fat pad with
closure of mucoperiosteal flap

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A. Late bucco-sinusal
fistula in the 15-16 tooth
area.

B. Circular incision around

the fistula and mucosa
displacement on the
fistulous path.

C. Absorbable 4-0 catgut

suture on the right
maxillary sinus mucosa.

D. Buccal fat pad dragging

into the fistula site.

E. 4-0 silk suture in isolated

places around the fat
tissue.

F. Tissue repair in the 30-

day postoperative
follow-up. 65
 Advantages

•Low morbidity rate

•Maintenance of the vestibular

sulcus depth

• Low incidence of failure

and the good flap vascularization

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 PALATAL FLAP

Procedure:
•Soft tissue surrounding the
oroantral opening is excised,
exposing underlying alveolar
bone around the osseous defect

•The full thickness palatal flap is

outlined and elevated

•Flap is rotated to ensure that

there is no tension on the flap
when positioned to cover the
osseous defect

•Flap rotation and closure

•Suture placed.

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 Advantages

•Insured vascularity (greater palatine vessels)&

thickness of tissue more like crest of ridge.

•Allows the maintenance of vestibular sulcus depth.

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ODONTOGENIC CYSTIC LESIONS
AFFECTING THE MAXILLARY SINUS

•Radicular cyst
•Dentigerous cyst
•Mucous retention cyst

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TUMORS OF MAXILLARY SINUS

•Ameloblastoma
• benign tumor affecting maxillary sinus.

•Squamous cell carcinoma

• malignant tumor
•It Invade and destruct the surrounding tissues

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 Maxillary sinus Fracture

•Fractures of the maxillary sinuses are

usually coupled with cheekbone fractures.

•In maxillary sinus fractures, may notice

air under the skin of the cheek or notice
bleeding during nose blowing.

•However, isolated maxillary sinus

fractures can easily go undiagnosed.

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 Treatment of Fracture
•Maxillary sinus fractures may not require repair
if fractured pieces of bone are not displaced.

•In cases of severe displacement, repair can be

performed through a small incision on the inside
of the gum line.

•The fractured bones are then placed back into

their original locations and secured with thin
titanium plates.

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 Maxillary sinus Pneumatization
The expansion of the sinus is larger following extraction of
several adjacent posterior teeth.

If dental implant placement is planned in these cases,

immediate implantation and/or immediate bone grafting should
be considered to assist in preserving the 3-dimensional bony
architecture of the sinus floor at the extraction site.

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 IMPLANTS IN THE MAXILLA
Lack of sufficient bone height along maxillary sinus causes significant
difficulty for placement of implants in edentulous maxillary jaw.
In these cases, we go for sinus lift, which is a surgical procedure which
aims to increase the amount of bone in the posterior maxilla.

• The use of 7–10 mm long

implants is a greater concern in
the maxilla than the mandible
because the implant failure rate
is higher in the maxilla.
• Therefore, 13 mm is the
recommended minimum
occlusocervical bone
dimension in the maxilla
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 SINUS LIFT
There are many techniques to lift the maxillary
sinus:

1. The Lateral Window Technique/ Direct (Caldwell- Luc)

2. The Osteotome Technique/ Indirect (Summers Tech.)
3. The Crestal Core Elevation
4. Balloon Sinus Elevation

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 DIRECT SINUS LIFT

Advantages
• It has clear view
• Easy access
• More efficient work is
done
Disadvantages
• painful
• post operative discomfort
• time consuming
• Needs highly efficient
practitioner
• susceptible to infection

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 INDIRECT TECHNIQUE
•Advantages
1. Minimally invasive surgical procedure
2. Requires less time and expertise than direct
technique
•Disadvantages
1. Blind procedure
2. More chances of errors to occur

invented by SUMMER IN 1994

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 Complications of Sinus Lift
A major risk of a sinus augmentation is that the sinus membrane
could be pierced or ripped

Procedure related complications-

• Infection
• Hematoma
• Inflammation
• Pain
• Itching
• Scar formation
• Graft failure
• Oro-antral communication / Oro-antral fistula
• Tilting or loosening of implants

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Bone Grafting

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 Graft Types

•Different types of bone-grafting materials used with

sinus lift surgery.

•Auto graft-the patient's own bone that taken from

iliac crest or tibia.

•Allo graft- Humans prepared bone (frozen bone,

freeze-dried bone, demineralized freeze-dried bone)

•Xeno graft- another species (i.e. bovine)

Synthetic graft- hydroxyapatite.

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 How to differentiate
sinus pain from
odontalgia ?

•History of cold, allergy, congestion or nasal discharge

•Dull aching pain that is difficult to localized
•Feel pressure in the cheek and below the eyes
•Position change like bending forward produces pain
•Dental local anesthetic blockade will not relief sinus

pain
•Normal pulp vitality test

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 CONLUSION

Due to close proximity of maxillary sinus to

the orbits, alveolar ridge and maxillary teeth,
diseases involving these structures may
produce overlapping signs and symptoms.
Hence, a precise information about the surgical
anatomy is essential to the dental surgeons.

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 References
•Textbook of oral and maxillofacialsurgery, Neelima
malik.
• Maxillary sinus and its implication by Killey and Kay.
• Orban’s, Oral histology and embryology, 11th edition.
•James K Avery Essentials of oral histology& Embryology.
• Cate A.R. Ten, Oral Histology: development, structure, and function. 6th
edition.
•ITI Treatment Guide, sinus floor elevation procedures, H.
Katsuyama& S.S. Jensen
•Textbook of general anatomy, B.D. Chaurasia.
•Oral radiology: White and Pharoah
•Textbook of Oral Medicine; anil ghoms.
•e- Medicine and Internet.

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