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•Treacher Collin’s syndrome
•Fracture of maxilla, tuberosity, nasal bone, zygoma and
•Hematoma due to traumatic injury
•Foreign bodies displace into the sinus- fractured tooth/root
•Oral antral fistula
Acute and chronic sinusitis
Inflammation of the mucosa of the paranasal sinuses
is referred to as sinusitis.when maxillary sinus is
involved, it is called as maxillary sinusitis.when all
the sinuses are involved it is called as pansinusitis.
•Periapical infection from the teeth: it may follow dental infection
particularly from upper molars and premolars teeth
•Oroantral fistula: the accidental opening in the floor of the maxillary
sinus during dental extraction is called as oroantral opening.
•Periodontitis: it may spread from a deep pocket of marginal
•Traumatic: injury of facial bones especially nasal bones and malar
•Dental material in the antrum: perforation of endodontic filling
substance. If root canal is overfilled then there are more changes of gutta
purcha points to be inserted into the maxillary sinus.
•Implant: implants are used in upper edentulous jaw to aid the retention
of dentures or bridges or replace missing teeth.implants are also used
when there is insufficiency of bone to support the denture.in these cases
as bone is thin,implant can penetrate the nose or sinus.
•this is a complication of common cold and is accompanied by clear nasal
discharge or pharyngeal drainage,which may eventually become green or
•After a few days the stuffiness increases and the patient complaints of pain and
tenderness to pressure or swelling over the involved sinus
•There will be signs of sepsis;fever,chills,malaise and an elevated leukocyte
•Pain may be referred to the premolars and molar teeth on the affected side and
these teeth may also be sensitive to percussion
•This is a sequel of the former two,which has failed to resolve by 3 months.
•There are no external signs, except in case of an acute exaceberation when
increased pain and discomfort is apparent.
•This type is usually associated with anatomical derangements that inhibit the
outflow of mucous,like;deviation of the nasal septam and presence of concha
•Radiodensity: radiographically,the thickening of the mucous membrane and
the accumulation of secreations that accompany sinusitis reduce the air content
and it will appear as radiopaque.
•Allergic sinusitis: in the case of allergy,mucosa will be more lobulated in
contrast to that in infection where it is straighter and parallel to the sinus wall.
•Transillumination test: affected sinus will be
•Radiograph: water’s view and OPG can be taken
•Anti-histamines for allergy
•Phenylephrine 2-4 times/day
•Amoxicillin 500 mg tid for 10-14 days
•Topical nasal spray (unlimited daily use)
•Nasal steroid spray
The normal mucosal lining of the para nasal sinus is composed of
respiratory epithelium and is approximately 1mm thick, and is not
visualized on the radiograph. When the mucosa becomes inflamed from
either an infectious or allergic process, it may increase in thickness
10 to 15 times and is then seen on the radiograph. This thickening is
called mucositis. Any thickening greater than 3mm is most likely to
•It is usually asymptomatic and is discovered on a routine radiograph.
•It is seen as a non-corticated band noticeably more radiopaque than the
air filled sinus, paralleling the bony wall of sinus.
Mucosal thickening seen distinctly on denta scan images
•Removal of the cause.
The thickened mucosa of chronically inflamed sinus frequently form
irregular folds called as ‘polyps’.polypoid atrophy of mucosa may
develop into an isolated area or number of ares throughout the sinus.
Antrochoanal polyps, are solitary polyps arising from the maxillary
antrum. They were first described by Killian in 1906. Although their
etiology remains unknown, allergy has been implicated
•Age: it usually occurs in young persons.
•Site: maxillary sinus is more involved as compared to other sinus.in
maxillary sinus they may arise from any part of the sinus wall and
occasionally pass through the ostium to appear in the nose as
Symptoms: patients present with nasal obstruction,pain is very mild on
pressure as mass present inside the nose.
•Appearance: it appear as homogenous soft mass with
smooth,outwardly convex borders.single or multiple lesions may be
present.if polyp occurs in the roof of the maxillary sinus in a patient with
a history of trauma,the plain film examination may simulate a blow out
•Destruction of walls of sinus: polyps may cause destruction or
displacement of bone. They can displace or destroy medial or lateral
•CT features: have mucoid attenuation with mucosal enhancement seen
at polyps surface. It appears as smooth homogenous mass.
•MRI features: mucosa adjacent to polyps will enhance as compared
•Oral and topical nasal steroid
•Endoscopic sinus surgery
Osteomyelitis (osteo- derived from the Greek word osteon, meaning
bone, myelo- meaning marrow, and -itis meaning inflammation) simply
means an infection of the bone or bone marrow. It can be usefully
subclassified on the basis of the causative organism (pyogenic bacteria or
mycobacteria), the route, duration and anatomic location of the infection.
It is a rare type of osteomyelitis seen in infants in few weeks after birth.it
usually involves maxilla.
•Site: it is more common in maxilla due to hematogenous route.
•Symptoms: fever, anorexia, dehydration in some cases, convulsants, and
vomiting may occur.
•Signs: redness and edema of eyelids, alveolar bone and palate of the
•Radiodensity: about 10 days after acute infection, the density of trabeculae will be
decreased, with blurred and fuzzy.
•Trabecular pattern: the earliest radiographic change is that trabeculae in involved
area are thin,of poor density and slightly unsharp or blurred.the trabeculae soon loose
their continuity as well as the little density present.individual trabeculae become fuzzy
•Multiple radiolucency: subsequently, multiple radiolucencies appear which become
apparent on radiograph.
•Lamina dura: there is loss of continuity of lamina dura,which is seen in more than
Clinical diagnosis: fever, pain with maxillary involvement in the infant will give clue
to the diagnosis
•Bacterial sampling and culture
•Vigorous (empirical) antibiotic treatment
•Give specific antibiotics based on culture and sensitivities
•Remove source of infection, if possible
Cyst involving maxillary sinus
Mucous retention cyst (mucocele)
A mucocele is an expanding,destructive lesion that results from a blocked sinus ostium.
The blockage may result from intra-antral or intra nasal inflammation,polyp or
neoplasm.the entire sinus thus becomes the pathologic cavity. As mucous secritions
accumulate and the sinus cavity fills, the increase in intra-antral pressure results in
thinning,displacement,and in some cases destruction of sinus walls. When the cavity is
filled with pus,it is termed an empyema,pyocele or mucopyocele.
•90% of mucoceles occur in the ethmoidal and the frontal sinus and are rare in the
maxillary sphenoidal sinus
•In the maxillary sinus it may exert pressurenon the superior alveolar nerves causing
radiating pain, with a swelling and fullness of the cheek.the swelling may first observed
over the anterioinferior aspect of the antrum where the wall may be thinned or
•If the lesion expands inferiorly,it may cause loosening of the posterior teeth.
•If the medial wall of the sinus is expanded the lateral wall of the nasal cavity will
deform and the nasal airway may be observed.
•If it expands into the orbit,it cause diplopia or proptosis.
•The normal shape of the maxillary sinus is changed into a more circular shape as the
•The scalloped border of the frontal sinus is usually smoothed by expansion, and the
intersinus septum may be displaced.
•In the ethmoidal air cells, displacement of the lamina papyracea may occur, displacing
the contents of the orbit.
•In the sphenoid sinus the expansion may be in the superioe direction, suggesting a
•The sinus cavities appear uniformly radiopaque.
•Any suggestion of a lesion associated with occluded ostium should be a mucocele. A
large odontogenic cyst displacing the maxillary antral floor may mimic a mucocele.
There are usually no complications.
Surgical ciliated cyst
It is a delayed complication arising years after surgery involving maxilla.
•It is usually occurs in the 4th and 5th decades of life
•Mostly seen in males
•The patient may complain of pain,discomfort or swelling of face or intra oral swelling
of the palate or alveolus, with pus discharge
•it is seen as a well defined radiolucency closely related to maxillary sinus.
•There is sclerosis of the surrounding bone.
•As the cyst enlarges it produces pressure effects, with thinning of the sinus walls which
may eventually perforate
•There may be resorption of mallxillary alveolar process.
•There is no communication between the cyst and maxillary sinus which may be
demonstated by injecting the sinus with radiopaque material.
Pseudocysts are like cysts, but lack epithelial or endothelial cells.
Initial management consists of general supportive care. Symptoms and complications
caused by pseudocysts require surgery. Computed tomography (CT) scans are used for
initial imaging of cysts, and endoscopic ultrasounds are used in differentiating between
cysts and pseudocysts. Endoscopic drainage is a popular and effective method of
This has not to be confused with the so-called 'pseudocystic appearance', mainly
radiographically, of other lesions, such as Stafne static bone cyst and aneurysmal bone
cyst of the jaws.
Pseudocysts are often asymptomatic. Symptoms are more common in larger
pseudocysts, though the size and time present usually are poor indicators of potential
•it is mainly seen in 2nd and 3rd decades of life.
•Males are most commonly effected than female.
•Mostly involved sites are the antral floor and lateral wall of maxillary sinus.
•There may be localized dull pain in the antral region or fullness and numbness of
•There may be pain in the teeth and over the face over or near the sinus.
•Sometimes antral swelling may also occur.
•it is homogenous mass that is more radiopaque than the surrounding sinus
•It appears as a soft tissue mass rather than a calcified area so that medial and
lateral landmarks can generally be visualized through the lesion.
•It is found projecting from the floor of the sinus, although some may form on
the lateral walls.
•The cyst appers as spherical ,ovoid,or dome shaped
•It has a uniform and a smooth outline.
•They may have narrow or broad base
•They vary in size from minute to very large.
•There is no resorption of adjacent bone.
•Mucous type will associated with thickened mucosa while serous type is
A radicular cyst is a cyst that most likely results when rests of epithelial cells
(Malassez) in the periodontal ligament are stimulated to proliferate and
undergo cystic degeneration by inflammatory products from a non-vital
•Most common type of cyst of the jaws.
•Rarely seen before the age of 10.
•Most frequent between 20 and 60 years.
•More common in males than females 3 to 2.
•Maxilla affected more than 3 times the mandible.
•Cause slowly progressive painless swelling.
The main factors in the pathogenesis of cyst formation are:
•Proliferation of epithelial lining
and fibrous capsule
•Hydrostatic pressure of cyst fluid
•Resorption of Surrounding bone
•Infection from the pulp chamber induces
inflammation and proliferation of the
epithelial rest of Malassez.
•Radicular cyst expand in balloon-like fashion, wherever the local anatomy permits, indicates
that internal pressure is a factor in their growth
•Consistent with the inflammation usually present in cyst walls, cyst fluid may contain
cholesterol, breakdown products of blood cells, exfoliated epithelial cells, and fibrin.
•Collagenases are present in the walls of keratocysts, but their contribution to cyst growth is
•All stages can be seen from a periapical granuloma containing a few strands of proliferation
epithelium derived from the epithelial rest of Malassez, to an enlarging cyst with a hyperplastic
epithelial lining and dense inflammatory infiltrate.
•Epithelial proliferation results from irritant products leaking from an infected root canal to
cause periapical inflammation.
•The epithelial lining consists of stratified squamous epithelium of variable thickness
•In most cases the epicenter of a radicular cyst is located approximately at the apex of a
•Occasionally it appears on the mesial or distal surface of a tooth root, at the opening of
an accessory canal or infrequently in a deep periodontal pocket
•Most radicular cysts (60%) are found in the Maxilla, especially
around incisors and canines
Treatment of a tooth with a radicular cyst may include:
•Apical surgery (Enucleation/Marsupilisation)
Adenoameloblastoma is a lesion that is often found in the upper jaw.
Some consider it a non-cancerous tumor, others a hamartoma (tumor-like growth) or cyst.
Often, an early sign of the lesion is painless swelling. These tumors are rarely found
outside of the jaw.
It is mostly seen in the maxilla
Some of the symptoms of Adenoameloblastoma incude:
It is fairly uncommon, but It is seen more in young people. Two thirds of the cases are
found in females
Clinical features generally focus on complaints regarding a missing tooth. The lesion
usually present as asymptomatic swelling which is slowly growing and often associated
with an unerupted tooth. However, the rare peripheral variant occurs primarily in the
gingival tissue of tooth-bearing areas. Unerupted permanent canine are the theeth
most often involved in adenoameloblastoma
The radiographic findings of AOT frequently resemble other odontogenic lesions such
as dentigerous cysts, calcifying odontogenic cysts, calcifying odontogenic tumors,
globule-maxillary cysts, ameloblastomas, odontogenic keratocysts and periapical
disease . Whereas the follicular variant shows a well-circumscribed unilocular
radiolucency associated with the crown and often part of the root of an unerupted tooth,
the radiolucency of the extrafollicular type is located between, above or superimposed
upon the roots of erupted permanent teeth. Displacement of neighbouring teeth due to
tumor expansion is much more common than root resorptions
Conservative surgical enucleation is the treatment modality of choice. For
periodontal intrabony defects caused by AOT guided tissue regeneration with
membrane technique is suggested after complete removal of the tumor. Recurrence of
AOT is exceptionally rare. Only three cases in Japanese patients are reported in which
the recurrence of this tumor occurred. Therefore, the prognosis is excellent.
An exostosis (plural: exostoses) is the formation of new bone on the surface of a
bone. Exostoses can cause chronic pain ranging from mild to debilitatingly severe, depending on
the shape, size, and location of the lesion.
If an exostosis is thought to be present your podiatrist will most likely have an x-ray taken of
your foot to evaluate it. The underlying cause of forming the exostosis needs to be addressed. An
exostosis can be treated conservatively or surgically depending on location and symptoms. If a
surgery is performed where the exostosis is removed this is termed an exostectomy.
The clinical features of osteochondromata are:
•swelling - usually, at the metaphysis of a long bone
•lesions may be single or multiple
•the lump is bony hard
Radiologically, the osteochondroma is well-defined. Often the lesion may look smaller than it
feels because the cartilage cap is invisible.
There are two main varieties that are seen:
There may be partial calcification of the osteochondroma.
Treatment & Prognosis
A hyperplasia of bone within the jaws. Also referred to as a dense bony island.
•The lesions were all at least 1.5 cm. in diameter.
•Pain, drainage, or localized expansion of the jaw was present
•Womens are mostely effected
Males are more commonly affected than females.
•Location: Anywhere throughout the maxilla and mandible.
•Edge:Well-defined toWell-localized, continuous with the surrounding bone trabeculae.
•Shape: Does not always have a given shape, but may appear round, ovoid or irregular in shape.
•Internal: Radiopaque, radiopacity of cancellous bone.
Diagnosis is made by pain on palpation of the long bones of the
limbs. X-rays may show an increased density in the medullary cavity
of the affected bones, often near the nutrient foramen (where the
blood vessels enter the bone). This evidence may not be present for
up to ten days after lameness begins.
In the vast majority of cases, bone islands have a pathognomonic
appearance. Larger lesions may sometimes pose a diagnostic
dillema, particularly in the setting of known malignancy.
Differential considerations include:
•low grade osteosarcoma
Squamous cell carcinoma
This originates from metaplastic epithelium of the sinus mucosal
•The males are commonly effected.
•The most common symptom is facial pain or swelling, nasal obstruction and lesion in
the oral cavity.
•Lymphnodes are involved in most of the case.
•Erosion of the medial wall causes nasal obstruction, nasal discharge, bleeding and
•Expansion of the alveolar process in the maxillary sinus
•Sinus root and floor of the orbit causes symptoms related to eye diplopia and proptosis,
pain and hyperesthesia or anesthesia and pain over the cheek and upper teeth.
The medial wall of the sinus is best seen on the waters projection
As the lesion enlarges it may destroy the sinus walls and in general cause irregular
radiolucent areas in the surrounding bone
Adjacent alveolar process may show bone destruction around the teeth or irregular
widening of periodontal ligament space.
•The medial wall of the sinus maynbe thinned or destroyed and it may also extend into
the nasal cavity.
•Destruction of the floor and anterior and posterior walls may be dectected.
• odontogenic cyst
•Large retention cyst
•Debridement of sinus
a) Amphotericin b
Syndromes associated withmaxillary sinus
Crouzon syndrome is a genetic disorder known as a branchial arch syndrome.
Specifically, this syndrome affects the first branchial (or pharyngeal) arch,
which is the precursor of the maxilla and mandible. Since the branchial arches
are important developmental features in a growing embryo, disturbances in
their development create lasting and widespread effects.
Crouzon syndrome is autosomal dominant; children of a patient have a 50%
chance of being affected
As a result of the changes to the developing embryo, the symptoms are very
pronounced features, especially in the face. Low-set ears are a typical
characteristic, as in all of the disorders which are called branchial arch
syndromes. The reason for this abnormality is that ears on a fetus are much
lower than those on an adult. During normal development, the ears "travel"
upward on the head; however, in Crouzon patients, this pattern of
development is disrupted. Ear canal malformations are extremely common,
generally resulting in some hearing loss.
Diagnosis of Crouzon syndrome usually can occur at birth by
assessing the signs and symptoms of the baby. Further analysis,
including radiographs, magnetic resonance imaging (MRI) scans,
genetic testing, X-rays and CT scans can be used to confirm the
diagnosis of Crouzon syndrome.
For dentists, this disorder is important to understand since many of
the physical abnormalities are present in the head, and particularly
the oral cavity. Common features are a narrow/high-arched palate,
posterior bilateral crossbite, hypodontia (missing some teeth), and
crowding of teeth. Due to maxillary hypoplasia, Crouzon patients
generally have a considerable permanent underbite and
subsequently cannot chew using their incisors.
Binder syndrome (maxilla nasal dysplasia)
Binder's Syndrome/Binder Syndrome (Maxillo-Nasal Dysplasia) is a developmental
disorder primarily affecting the anterior part of the maxilla and nasal complex (nose
and jaw). It is a rare disorder and the causes are unclear. Hereditary and vitamin D
deficiency during embryonic growth have been researched as possible causes.
•abnormal position of nasal bones,
•atrophy of nasal mucosa, reduced
• absent anterior nasal spine,
• absence of frontal sinus (not obligatory).
•Naso-maxillo-vertebral syndrome (Binder syndrome).
The prognosis is good if there is no other problem associated.
•osteotomy when the children were older
An antrolith is a calcified mass within the maxillary sinus. The origin of the nidus of
calcification may be extrinsic (foreign body in sinus) or intrinsic (stagnant mucus,
Most antroliths are small and asympotomatic. Larger ones may present as sinusitis with
symptoms like pain and discharge.
•Location: Maxillary sinuses.
•Edge:Well-defined, smooth or irregular outline.
•Shape: Round, ovoid.
•Internal: Radiopaque, may have a ‘laminated’ appearance with radiopaque and
radiolucent bands evident due to continued laying down of calcium salts. (This looks
similar to layers of an onion.)
•Number: May be single of multiple.
endoscopic sinus surgery
Traumatic injuries of maxillary sinuses
Tooth roots may be fractured as a result of various forms, including iatrogenic reasons.
fractured roots may be forced into the sinus during extraction or subsequent attemps to
Excess root canal filling material may be forced through the apex of an upper posterior
tooth during endodontic therapy. Foreign materials may be pushed into the antrum via
an existing oro antral fistula. Metallic objects such as pellets, bullets and fragments of
shells or bombs may be found if patients has been exposed to the same.
•no visible signs and symptoms if the roots is displaced recently.
•Ask the patient to hold the nose while attempting to breathe out through, similar to a
valsalva maneuver, it will cause bubbles to appear within the blood contained within the
•If the patient has the root or tooth in the sinus for a number of days, he may present
•The associated roots are usually of molars and premolars as the sinus is in close
proximity to these teeth.
•The dislodged fragments are usually found near the floor of the sinus because of the
gravity. Sometimes the displaced structure may be mucosal, between the osseous wall
of the sinus and the periosteum. The floor of the sinus and periosteum.
•The foor of the sinus may break due to the displacement of the tooth fragment into the
Exostoses of the sinus wall or the floor and the septa within the sinus, may mimic
dental root fragments or even whole teeth.
THERE IS A ROOT FRAGMENT LOCATED OBLIQUELY AND APICAL TO
THE APEX LINE
CT finding which showed that the tooth was located close to
mesial wall of the sinus and roots
This occurs due to a blow to the face that damages the lining of
the paranasal sinuses without fracturing the facial bone. There
may be green stick fracture of the sinus with a resultant tearing
injury to the mucosal lining.
•There is a bloody nasal discharge, extreme tenderness of the
involved sinus on pressure.
•There is rapid resolution of the soft tissue changes.
•Haziness of the sinus due to edema.
•An opaque sinus or fluid level resulting from hemorrhage from
the mucosal tear.
This results from sudden increase in the intraorbital pressure, due to may
be a direct blow to the eye.
•The pressure of the blow forces the inferior orbital content through the
•It results in diplopia when the victim look upward and enophthalmus
following reduction of edema and fat atropy.
•Opacification of the sinus with or without a fluid level.
•There will be shadow of soft tissue mass in the upper portion of the
sinus and shadows of the depressed bone fragments into the sinus.
•A tear drop shaped radiopacity is produced in the upper part of the
sinus, due to the herniation of the orbital content downward into the
sinus following the collapse of the antral roof.
•The depression fracture of the orbit may be accompanied by the fracture
of the antrum wall of the maxillary sinus.
•This involves a single wall which may appear as a
bright line on the radiograph.
•The most common sites are the anterolateral wall of the
antrum and the floor of the antrum, during extraction of
the upper posterior teeth whose roots are in close
proximity to the antrall floor.
Zygomatic complex fracture
This fractures occurs at the line of weakness and passes through the orbital floor,
usually medial to the zygomaticomaxillary suture.
•The fractured zygoma is forced into sinus.
•There may be tearing of the lining membrane with subsequent bleeding into
•the antrum appers cloudy or will show a fluid level.
Standard occipitomental showing fracture of the right zygomatic complex with a
break of antral roof
This is a pathological pathway connecting the oral cavity and the maxillary sinus. It
may be caused due to extraction of teeth having chronic periapical infection, extraction
of solitary tooth. Extraction of teeth having apices very close to the antral floor, blind
instrumentation, surgical removal of large lesions in the upper jaws, malignant
tumors,osteomyelitis, syphilis, malignant granulomatous lesion, facial trauma and
inadequate blood clot formation.
•immediate history of recent traumatic extraction or disappearance of the roots during
•Passage of fluid into the nose from the oral cavity
•Inability to blow the cheek or smoke.
•Unilateral epitaxis, due to blood in the antrum escaping through the nasal ostium.
•Alteration in vocal resonance.
•There will be a break in the continuity of the floor of the maxillary sinus, which may
be seen as a disalignment of a small portion of cortical layer of bone
•Radiographic features of acute or chronic sinusitis are present.
•There may be evidence of the displaced root or tooth,and a second view of the sinus
with the head in a different position may be required to asceration the the exact
location of the displace object
Periapical showing a discontinuity of the
•It consist of repair and surgical closure under
Unilateral maxillary sinus opacification is a relatively
common finding. Early identification of inverting papilomas
and mucocele may avoid delay in surgical inervation,whereas
acute/chronic sinusitis and nasal polyps can initially be
managed medically. careful history, endoscopic examination
and radiographic studies can often determine the responsible
•Dental and maxillofacial radiology: freny r kajodkar ,2nd
edition, jaypee 2009 ; page 751 to 773
•Text book of oral medicine: anil govidharao editors, ghom,2nd
edition, jaypee 2010 , page 677 to696
•Text book of oral and maxillo facial surgery: chitra
chakravarthy editor,2nd edition, paras publishers 2011 ,page
246 to 263
•Oral & Maxillofacial Pathology: Neville, B, et al. editors,3rd
Ed. Saunders 2002 ,page 219 to 226
•Text book of medicine; pramod john r editor,2nd
edition,jaypee 2005,page 284 to 288