MAXILLARY SINUS (PART 3)

MAXILLARY FRACTURES

involves fractures of the midface (part of the facial skeleton from the cranial base of the skull extending to the maxillary occlusal plane)

there are several modifications & classification of maxillary fractures that are being used at present

I. LE FORT FRACTURES/LE FORT CLASSIFICATION

II. MAXILLARY SINUS FRACTURE

III. PALATAL FRACTURES

IV. ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURES

LE FORT FRACTURES / LE FORT CLASSIFICATION

• LE FORT I

• LE FORT II

• LE FORT III

LE FORT FRACTURES / LE FORT CLASSIFICATION

• fractures of the midface, which collectively involve the separation of all or a portion of the midface from the skull base (pterygoid plates are involved as these connect the midface to the sphenoid bone dorsally)

• fractures are distinguished according to the plane of injury

• one of the most commonly used classifications that was introduced by Dr. Rene Le Fort

LE FORT I

• refers to a horizontal maxillary fracture where only the maxilla is affected

LE FORT I

when the upper teeth are pulled → movement is only visible in the maxilla

LE FORT I

fracture line: passes through the alveolar ridge, lateral aspect of the nose, and the
inferior wall of the maxillary sinus

LE FORT I

• clinical appearance: floating palate

LE FORT I

• characteristic feature: GUERIN'S SIGN (presence of ecchymosis or bruising in the region of the palatine vessels)

LE FORT I

• also known as LOW LEVEL FRACTURE or GUERIN / GUERIN'S FRACTURE

LE FORT II

• pertains to a pyramidal fracture where the maxilla & nasal septum are affected

  
  

LE FORT II

• when the upper teeth are pulled → movement is seen on the maxilla & base of the nose

  
  

LE FORT II

• fracture arch: passes through the posterior alveolar ridge, lateral wall of the maxillary sinus, inferior orbital rim, and the nasal bones

  
  

LE FORT II

• clinical appearance: floating maxilla

  
  

LE FORT II

• characteristic feature: MOON FACE / DISH FACE DEFORMITY (edema of the mid-face)

  
  

LE FORT II

• also known as MIDLEVEL FRACTURE

LE FORT III

a craniofacial fracture wherein the fracture goes through the lateral orbital rims & includes the entire zygoma

LE FORT III

• when the upper teeth are pulled → entire facial movement is evident

  
  

LE FORT III

• fracture line: passes throuch the nasofrontal suture, maxilla-frontal suture, orbital wall, and zygomatic arch or zygomaticofrontal suture

  
  

LE FORT III

• clinical appearance: floating face

  
  

LE FORT III

• characteristic features: RACOON EYES (bilateral ecchymosis & subconjunctival
  hemorrhage) and PANDA FACE (edema of the face)

  
  

LE FORT III

• also known as HIGH LEVEL FRACTURE / CRANIOFACIAL DYSJUNCTION

MAXILLARY SINUS FRACTURE

fracture is located below the zygoma without affecting the zygoma which is still intact, and it is caused by a direct blow to either the left or right side of the midface

MAXILLARY SINUS FRACTURE

• It is the fracture of the maxilla in the sagittal plane that involves the anterior-lateral wall of the maxillary sinus (Le Fort fractures are bilateral maxillary fractures)

  
  

MAXILLARY SINUS FRACTURE

• appears as an opacified maxillary sinus on a radiograph

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MAXILLARY SINUS FRACTURE

• fracture pieces are moved back into normal position & left to heal by itself

MAXILLARY SINUS FRACTURE

• if it is not a massive injury, surgical intervention is rarely required (but it will need repair or correction)

  
  

MAXILLARY SINUS FRACTURE

• repair or correction is essential due to nerve compression (intraoral approach)

  
  

MAXILLARY SINUS FRACTURE

• plates or screws are not used due to eggshell thin bones (insertion of the screws will only worsen the condition)

MAXILLARY SINUS FRACTURE

• also known as MAXILLARY SAGITTAL FRACTURE

MAXILLARY SINUS FRACTURE may be classified as the following:

SINGLE, COMPLEX, TRANSFACIAL FRACTURE

SINGLE

isolated wall fracture of the MS

COMPLEX

more than one wall of the MS is involved in the fracture

TRANSFACIAL FRACTURE

involving the maxillary bone & surrounding structures (Le Fort fractures)

*SINUS CONTUSION

• occurs when a blow to the face damages the lining of the paranasal sinuses without fracturing the facial bone since the mucosal lining has absorbed the traumatic blow

*SINUS CONTUSION

• can cause greenstick fracture of the sinus with a tearing injury to the mucosal lining

  
  

*SINUS CONTUSION

• bloody nasal discharge with extreme tenderness of the sinus on pressure (symptom that differentiates a sinus contusion from sinusitis)

PALATAL FRACTURES

• refers isolated fracture/s of the palate (but its occurrence is rare)

  
  

PALATAL FRACTURES

• about 8 - 13% of Le Fort fractures are complicated by associated palatal fractures

  
  

PALATAL FRACTURES

• clinical manifestations: laceration of the lip, change in occlusion, displacement of the maxillary segment, gingival & palatal lacerations

  
  

PALATAL FRACTURES

• diagnosis: can be confirmed by a maxillofacial computed tomography (CT) scan with axial & coronal cuts

PALATAL FRACTURES may be classified into six types (according to Hendrickson) based on the anatomical location of the fracture:

• TYPE I (alveolar fracture)

• TYPE II (sagittal fracture)

• TYPE III (parasagittal fracture)

• TYPE IV (para-alveolar fracture)

• TYPE V (complex comminuted fracture)

• TYPE VI (transverse fracture)

TYPE Ia

• anterior alveolus; containing only the incisor teeth & the associated alveolus

TYPE Ib

• posterior alveolus; containing premolars, molars, & the associated alveolars

TYPE II (sagittal fractures)

• a split of the palatal midline

  
  

TYPE II (sagittal fractures)

• typically occurs in the 2nd or 3rd decade due to the lack of ossification of the midline palatal suture

TYPE III (parasagittal suture)

• most common palatal fracture in adults (63%) because of thin bone that is parasagittally located

• different fracture pattern from Type Ia by the inclusion of the maxillary canine

TYPE IV (para-alveolar fracture)

occurs palatal to the maxillary alveolus & incisors

TYPE IV (para-alveolar fracture)

occurs palatal to the maxillary alveolus & incisors

TYPE VI (transverse fracture)

rare; involves a division in the coronal plane

IV. ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURES

• pertains to fractures that involve the associated teeth

  
  

ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURES

• can occur in any age group but are most commonly seen during the 1st and 2nd decade after eruption of the permanent incisors

  
  

ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURE

predominant in dentate arches, but can also occur in edentulous arches



COMMON SITES OF ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURE

• anterior maxilla & anterior mandible (posterior areas are more resistant to alveolar fractures due to anatomic shape & high bone density, but can occasionally occur secondary to tooth extraction)

PREDISPOSING FACTORS OF ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURE

• incompetent lips, maxillary incisor overjet & proclination

  
  

CAUSES OF ALVEOLAR PROCESS FRACTURE IN CHILDREN

• bicycle injuries, falls, sports injuries, motor vehicle accidents, and
  child abuse cases

  
  

CAUSES OF ALVEOLAR PROCESS FRACTURE IN ADULTS

fights, falls, motor vehicle crashes, contact sports injuries, industrial trauma

ALVEOLAR PROCESS FRACTURE / DENTOALVEOLAR FRACTURES

• usually compound (open) fractures that are occasionally also comminuted fractures

alveolar process fractures / dentoalveolar fracture may be classified (according to Andreasen) based on the injuries of supporting bone:

• COMMINUTION OF THE ALVEOLAR SOCKET

• FRACTURE OF THE ALVEOLAR SOCKET WALL

• FRACTURE OF THE ALVEOLAR PROCESS

• FRACTURE OF THE MANDIBLE or MAXILLA

COMMINUTION OF THE ALVEOLAR SOCKET

crushing of the alveolar socket is correlated with an intrusive or lateral luxation of an associated tooth or teeth

FRACTURE OF THE ALVEOLAR SOCKET WALL

fracture is usually confined to the facial cortical bone or the lingual cortical bone

FRACTURE OF THE ALVEOLAR PROCESS

• fracture involves both the labial & lingual cortical bone, which may or may not involve the tooth socket

FRACTURE OF THE MANDIBLE or MAXILLA

fracture involves either the base of the mandible or the maxilla & the alveolar process, which may or may not involve the alveolar socket

FRACTURES OF THE MAXILLARY SINUS CAN BE PRESENT IN THE FOLLOWING CASES

• FRACTURED MAXILLARY TUBEROSITY

• ORBITAL BLOWOUT FRACTURE

• ZYGOMATIC COMPLEX FRACTURE

• LE FORT FRACTURES (I, II, III)

FRACTURED MAXILLARY TUBEROSITY

• occurs most frequent on a solitary or lone standing upper molar

FRACTURED MAXILLARY TUBEROSITY

• antibiotics, nasal drops, & inhalation regimen is prescribed to prevent chronic OAF

ORBITAL BLOWOUT FRACTURE

• caused from a blow to the orbit by an object that is too large to enter the orbit

ORBITAL BLOWOUT FRACTURE

• force is dissipated to the surrounding bone & the fracture occurs on the thinnest parts of the orbit

  
  

ORBITAL BLOWOUT FRACTURE

• involves any or all of the orbital bones (e.g., ethmoid, frontal, palatine, maxilla) that may be involved in the trauma

ORBITAL BLOWOUT FRACTURE

It is different from an ORBITAL BLOW-IN FRACTURE where the fracture segments are inwardly displaced into the orbit which then impinges the orbital muscles resulting in decreased orbital volume.

ORBITAL BLOW-IN FRACTURE

where the fracture segments are inwardly displaced into the orbit which then impinges the orbital muscles resulting in decreased orbital volume.

ZYGOMATIC COMPLEX FRACTURE

• fractured zygoma is forced into the sinus with tearing of the Schneiderian membrane

  
  

ZYGOMATIC COMPLEX FRACTURE

• occurs at the line of weakness & passes through the orbit (usually medial to the zygomaticomaxillary suture)

LE FORT FRACTURES (I, II, & III)

chronic inflammatory mucosal changes can occur in the maxillary sinus following these fractures

TOOTH DISPLACEMENT INTO THE SINUS

• an iatrogenic disease which is a result of diagnostic & therapeutic procedures undertaken by the patient under the care of a surgeon (or any primary care specialist in charge of the case) wherein the tooth or root fragment was pushed or forced into the sinus

  
  

DIAGNOSIS FOR TOOTH DISPLACEMENT INTO THE SINUS

• confirmed through panoramic, occlusal, and/or periapical radiographs which are essential in its localization (some roots do not penetrate the membrane and are lodged between the membrane & the bony wall)

CAUSES OF TOOTH DISPLACEMENT INTO THE SINUS can be attributed to the following:

1. absence of intervening bone in between the tooth & the antrum

2. aggressive instrumentation to retrieve a fractured maxillary root

3. extraction of a solitary maxillary molar surrounded by dense cortical bone that may lead to an alveolar fracture

4. tooth may simply pop into the maxillary sinus during luxation or extraction

MANAGEMENT OF TOOTH DISPLACEMENT INTO THE SINUS

1. powerful suction is placed at the entrance of the oroantral fistula (OAF) & root fragment

2. may sometimes be retrieved by packing rolled gauze in the area & withdrawing this in a sudden or jerky motion (if the tooth is loose in the antrum)

3. surgical approach requires a Caldwell Luc procedure with continuous irrigation using normal saline solution (NSS) through the created "window" on the anterior wall (formation of a whirlpool effect inside the sinus can displace & retrieve the root or tooth)

ANTROLITHS / ANTRAL RHINOLITH

• rare condition where rhinoliths (calcified nasal concretions formed by salt from lacrimal secretions) are present in the maxillary sinus

  
  

ANTROLITHS / ANTRAL RHINOLITH

• also refers to calcifications that may be long standing mucus, foreign bodies, or tooth fragments

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ANTROLITHS / ANTRAL RHINOLITH

• cause of this condition is undefined

  
  

ANTROLITHS / ANTRAL RHINOLITH

• usually small & asymptomatic (but large antroliths can occur and may present with pain & discharge from the sinus)

  
  

DIAGNOSIS OF ANTROLITHS / ANTRAL RHINOLITH

• must be differentiated from an odontoma (benign tumor with normal dental tissue) and an osteoma (hard tissue with bone-like structures)

  
  

TREATMENT OF ANTROLITHS / ANTRAL RHINOLITHS

• done by buccal antrostomy & a Caldwell Luc procedure (if infection is present)

OTHER INFLAMMATORY DISEASES OF THE MAXILLARY SINUS (EXCLUDING SINUSITIS)

• POLYPS

• MUCOSITIS

• EMPYEMA

• OSTEOMYELITIS

POLYPS

• soft, painless, irregular, non-cancerous folds or growths from the thickened mucosa of a chronically inflamed sinus

• polyps are serious once it causes displacement or bone destruction
  
  

• small polyps →

usually asymptomatic

• large polyps →

can block nasal passages leading to infections

POLYPOSIS

refers to the manifestation of multiple polyps

ANTROCHOANAL POLYPS (ACP)

• benign lesions that arise from the mucosa of the maxillary sinus & reach the choana or posterior nares

  
  

MAIN SYMPTOM OF ANTROCHOANAL POLYPS (ACP)

• nasal obstruction

  
  

IN SEVERE CASES OF ANTROCHOANAL POLYPS (ACP)

it is seen behind the soft palate

TREATMENT OF ANTROCHOANAL POLYPS

FESS & Caldwell Luc procedure

MUCOSITIS

Inflammation of the mucosal lining (resulting in distinct thickness) of the paranasal sinuses

MUCOSITIS

lining thickness is increased by 10-15 times its normal thickness (which is 1 mm)

MUCOSITIS

• mucosal thickness > 3mm indicates a pathologic disease

  
  

MUCOSITIS

• usually asymptomatic (unless infection is present)

  
  

CAUSES OF MUCOSITIS

• infection, allergy, trauma, chemical irritation, or presence of a foreign body

  
  

DIAGNOSIS OF MUCOSITIS

• visible on a radiograph

MANAGEMENT OF MUCOSITIS

Focus is on the underlying cause