DR.
NEETI TATIYA
MASTERCLASS
MAXILLARY SINUS
CONTENTS
• Introduction
• Functions of Maxillary Sinus
• Development & Age changes
• Developmental Anomalies
• Anatomy of Maxillary Sinus
• Microscopy of Maxillary Sinus
• Diagnostic Evaluation
• Applied aspects & Dental implications
• Conclusion
Maxillary sinus - Part of a series of
pneumatic cavities, called the paranasal
sinuses, that surround the nasal chamber
and lie immediately adjacent to the orbit
and dura of the anterior cranial fossa.
DEFINITION
The Maxillary sinus is the pneumatic space that is
lodged inside the body of the maxilla and that
communicates with the environment by way of the
middle nasal meatus and nasal vestibule.
• Largest PNS
HISTOR
•
Y
Maxillary sinus was first illustrated by
Leonardo
da Vinci & later the significance was given by
Nathaniel Highmore.
• Highmore - the first to describe in detail the
morphology of the maxillary sinus and to advance
the idea of pneumatization by the sinuses.
• Antrum of Highmore. (Greek- Antron- cave)
Functional Importance
• Humidifying and warming inspired air
• Increasing surface area for olfaction
• Lightening the skull
• Resonance of voice
• Absorbing shock
• Contribute to facial growth
• Production of bactericidal lysozyme to the nasal
cavity.
EMBRYOLOGICAL DEVELOPMENT
• First to develop in 2nd month of IU life.
• 32mm CRL in an embryo
Horizontal shift of palatal shelves
Fusion of palatal shelves
Nasal septum separate the secondary oral
cavity from 2 nasal chambers
Expansion of lateral nasal wall– wall
begins to fold
3 nasal conchae & 3 meatuses
Middle meatus expands into lateral nasal wall in
an inferior direction (cartilagenous skeleton
of
lateral nasal capsule)
Occupies future maxillary body
50mm CRL fetus- 1mm MS- First glandular primordia appears
AGE CHANGES
BIRTH 1 YEAR 15 YEAR
• 7-16mm • 15 • 31.5
(AP) •6 • 19
• 2-13mm • 5.5 • 19.5
(SI)
• 1-7mm
(ML)
AGE CHANGES
ADULT OLD AGE
• 34mm (AP) • Resorption of
• 33mm (SI) ridge- thinning of
• 23mm (ML) sinus wall
• Extension of sinus
till crest
SHAPE OF MAXILLARY SINUS
• At birth- tubular
• At childhood- oval
• Atadult-
pyramidal in shape
ANATOMY OF THE MAXILLARY SINUS
• Lies primarily in the maxilla
• The sinus is found to vary widely in shape and
accordingly classified into four types -
– Semi-ellipsoid
– Paraboloid
– Hyperbolic
– Cone shaped
Thickness of the bony walls -2 to 5 mm
Structure and Variations
• It is four-sided pyramid
• The base is facing
medially toward the
nasal cavity and apex of
which is pointed
laterally toward the
body of the zygomatic
bone.
4 SIDED PYRAMID
• Base
(facing
medially)- lateral
wall of nose
• Apex- pointed
laterall
y body toward
zygomatic bone s
of
4 sides
• Anterior -Facial surface
of body of maxilla
• Inferior- alveolar &
zygomatic
process
• Superior- orbital
surface
• Posterior- infratemporal
• Base- thinnest wall
• Presents perforation-
osteum, at the level of
middle meatus,
within hiatus
semilunaris (Crescent-
groove in the lateral
shaped
wall of the nasal
cavity)
• In course of development MS often pneumatizes the
maxilla beyond the boundaries of the body
• Some of the processes of the maxilla become
invaded by the air spaces-these expansions are ref to
as recesses
– Alveolar process-50%
– Zygomatic process-41.5%
– Frontal process-40.5%
– Palatine process-1.75%
• Occurence zygomatic recess- brings the superior
alveolar
of neurovascular bundles into proximity with
the space of the sinus
• The alveopalatine recess pneumatizes the floor of the
sinus adjacent to roots of first molar & less often second
premolar, first premolar & second molar, in the order of
frequency.
• Height and width of the maxillary sinus in edentulous
cadavers are significantly greater than those of dentate
cadavers
• Alveopalatine recesses reduce the amount of
bone between the dental apices and sinus
space- char. by 3 depressions separated by 2
incomplete bony septa
RADIOGRAPHIC APPEARANCE OF MAXILLARY SINUS
Blood supply
• Facial artery and Branch of third part of maxillary
artery (pterygopalatine part)
• Posterior superior alveolar artery
• Infra-orbital artery
• Greater palatine artery.
• Venous - to the anterior facial
sphenopalatine
drainage vein and pterygoid plexus.
vein,
Nerve supply
Maxillary division of
trigeminal nerve
√ Infraorbital nerve.
√ Posterior, middle & anterior
superior alveolar nerves.
√ Greater and lesser palatine
nerves.
Lymphatic
drain
The lymphatic drain of the sinus is through the
networks serving nasopharynx or the
submandibular lymph nodes.
MICROSCOPIC FEATURES OF THE MAXILLARY SINUS
• Lining consists of three layers:
– an epithelial covering
– a lamina propria
– the periosteum.
• Thickness of combined layers is generally less
than 1 mm
• Sinus lining- Rapid regenerative capability
• Mainly by ingrowth from margins of
mucosal defect, from islands of mucosa left
behind
Microscopic Features
• Epithelial layer
• The basal lamina
• Subepithelial layer including the
periosteum
• The epithelium- pseudo-stratified,
columnar and ciliated
• Derived from- olfactory epithelium of
middle nasal meatus.
• Columnar ciliated cells- numerous cellular type
• Basal cells, columnar nonciliated cells and
mucous producing, secretory cells called as
Goblet cells.
• A ciliated cells encloses nucleus, cytoplasm with numerous
mitochondria and enzyme-containing organelles.
• Goblet cell is a flask shaped secretory cell- golgi apparatus,
zymogen granules
• Secretory mucosubstances released by exocytosis
• Basal bodies serve as the attachment of the ciliary
microtubules to the cells – characteristic of the apical
segment of the cell
• Cilia- composed of 9+1 pairs of microtubules
• Provide motile apparatus to the sinus epithelium
Cilia
• Ciliary beating- mucous blanket moves from
the sinus interior towards the nasal cavity
• Direction- genetically programmed
• Mucous secretion forms a blanket
• Cilia are constantly beating at an
approximate rate of 1000 strokes/min
• Flow rate of the mucous blanket -6 mm/ min.
• Mucous blanket covering the epithelial surface
is necessary to maintain ciliary function.
• Resistance of the sinus mucosa to infection and
easier penetration for micro-organism
• Lamina propria -thin layer of connective tissue
• Thinner than that of nasal mucosa
• Fewer mucous, seromucous, and serous glands
• Secretion from these glands is controlled
by divisions of the autonomic nervous system.
• Numerous nonmyelinated and
fewer myelinated axons
• Subepithelial glands –
• Serous – Ninhydrin Schiff, Sudan black
B
• Mucous – Alcian blue
• Myoepithelial cells
Periosteum-
• Adherent to the overlying lamina propria
• Can be stripped easily from underlying
bone.
• Prone to edematous swelling on
slight irritation
Clinical examination
Inspection
√ Assess asymmetry.
√ Color of overlaying skin.
Palpatio
n
√ Tenderness.
√ Swelling and expansion.
√ Depression.
Examination of nasal passage
√ Nasal patency.
√ Pus discharge.
√ Nasal polyps.
√ Erythema, change in the color of nasal mucosa.
Transillumination
Radiographical examination
INTRA ORAL
Peri apical
occlusal
Lateral occlusal
Radiographical examination
EXTRA ORAL
Orthopantomogram (OPG)
Occipitomental (WATERS VIEW )
SUBMENTO VERTEX VIEW
PA VIEW
Special radiographical investigations
• CT scan
• MRI
• Ultrasound
• Endoscopy
Microbiology & histological examination:
• Culture and sensitivity and biopsy.
Clinical consideration/Pathology
• Proximity with first molar root
• Congenital anomalies
• Inflammatory diseases
• Cysts and odontogenic infection
• Bone tumors
• Neoplasia
• Trauma
• Implants
PROXIMITY WITH FIRST MOLAR ROOT
• Dental infection: Infection from the maxillary
premolar and molars can easily communicate
and infect the maxillary antrum.
• Oroantral Communication:
Traumatic extraction of maxillary teeth can
cause oroantral communication.
• Root Pieces: Root pieces of maxillary teeth
may sometimes be accidentally forced into the
maxillary antrum.
• Maxillary Sinusitis: Thickened and inflamed
sinus lining compresses the nerve supply of the
maxillary posterior teeth causing tenderness of
the maxillary teeth.
– Neuralgia
Congenital anomalies
o Agenesis
o Aplasia/ hypoplasia
o Cleft palate
o Supernumerary sinus
o Congenital syphilis
o Pituitary gigantism
Inflammatory diseases
√ Bacterial infection.
– Syphilis (spirochetes)
– Streptococci
– Staphylococci
– pneumococci
√ Fungal infection.
√ Viral infection.
– Common cold
Cysts and odontogenic tumors
• Odontogenic cysts: • Non-odontogenic
cysts.
√ Radicular cysts. √ Mucocele and
√ Residual cysts. retention cysts.
√ Dentigerous cysts.
√ Premordial cysts.
• Odontogenic
tumors:
√ Ameloblastoma.
√ Myxoma.
Bone tumors
√ Fibrous dysplasia.
√ Ossifying fibroma.
√ Osteoma.
√ Giant cell lesions.
Neoplasia
√ Squamous cell carcinoma.
√ Adenocarcinoma.
√ Sarcoma (osteosarcoma).
√ Ewing’s sarcoma.
Trauma
√ Tuberosity fracture.
√ Dentoalveolar fracture.
√ LeFort’s fractures.
√ Zygomatic complex fracture.
√ Orbital floor fractures.
√ Establishment of oro-antral fistula.
Pneumatization
IMPLANTS
• Implants in the maxilla lack sufficient bone
height along maxillary sinus, produces
significant difficulty for placement of implants
in edentulous maxillary jaw
• In that case, we go for sinus lift, which is a
surgical procedure which aims to increase the
amount of bone in the posterior maxilla.
SINUS LIFT
•Direct
(Caldwell luc)
• Indirect
Conclusion :
• Important and anatomic structure for
interesting surgeon. dental
• Due to close association of sinus and oral cavity, diseases
involving these structures may produce confusing symptoms.
• Knowledge of the anatomical relationship between the
maxillary sinus floor and the maxillary posterior teeth is
important for the preoperative treatment planning of
maxillary posterior teeth. Clinicians must be particularly
cautious when performing dental procedures involving the
maxillary posterior teeth.
