Maxilary sinus perforation

The word “Maxilla” is of Latin origin and means upper jaw and thus maxillary sinus is the cavity of the upper jaw. Maxillary sinus perforation is a very common complication of upper teeth extraction. There are numerous anatomical reasons for that. The root tips of teeth 3rd to 8th very often reach almost to the sinus floor being separated by only a thin bone plate or in some cases – by the sinus mucosa. So when a pathology at the tooth tip /granuloma, cyst/ requires its extraction it is very likely that even the most precise dental practitioner breaks the overlying tissue leaving an aperture between the sinus and the oral cavity – sinus perforation. This is why the extraction of the upper teeth mentioned above requires expertise, attention and responsibility. An x-ray is always required to determine the proximity between the root tip and the sinus as well as to check for any pathology. A careless or inattentive approach could bring about fatal results.What happens when the sinus is perforated during tooth extraction? Airflow could be heard passing between the sinus and the nasal cavity with a hissing sound. If the patient drinks water it will pass from the mouth into the sinus and leak though the nostril. The timbre of the voice could also be affected. The dental practitioner needs to perform the so called nasal test – ask the patient to blow air through the nose while pressing it slightly between his thumb and forefinger thus blocking the nostrils. If the nasal test is positive, a loud hissing sound is heard as the air flows from the sinus through the extraction wound and to the oral cavity. This is a certain proof of a maxillary sinus perforation. The nasal test could be negative without hissing air passing through the wound. This is not a certain proof that the sinus is intact. It is possible that there is still a sinus perforation but inflamed sinus mucosa forms a valve or a flap covering the puncture blocking the air passage. In this case a careful examination is performed inserting a specially designed probe into the extraction wound. If there is no perforation the probe would reach to the bottom of the so called alveola /the socket in the jaw at the place of the extracted tooth root / and stop there. On the other hand, in case of sinus perforation, the probe would freely go through the opening and deep into the sinus. This could be verified by an x-rayWould should be done in case of sinus perforation following the extraction of a tooth?First, remain calm and explain to the patient what is happening and why as well as assure the patient that this could be treated. 
Second, swab the extraction wound by filling it tightly from the very bottom to the gingival ridge with specially prepared medication-soaked gauze.  
Third, give the patient specific instructions about the postoperative period. If these steps are ignored, meaning that the dental practitioner does not register the perforation or even worse, if he/she is aware of the problem but does not inform the patient and does not apply the necessary treatment and procedures for closing the perforation, it will eventually epithelize /the puncture edges will become covered by mucosa/ and a significant opening will be formed between the oral cavity and the sinus. This would then lead to numerous complications and difficulties for the patient – poor articulation, penetration of food and drinks from the mouth to the nose, chronic sinusitis, bad odor disturbing social contacts, etc. Moreover, as the maxillary sinus is connected to the other sinuses in the skull they also get infected. A particular surgical intervention is required for closing the sinus perforation. A series of photos below shows the stages of the surgical intervention:
  1. Old epithelized perforation
  2. X-ray, front view, no sinusitis is seen
  3. Immediate post-operative condition – lateral view
  4. The same condition – view from below
  5. One week after the surgery – the sutures are ready to be removed
  6. After the removal of sutures – the incision is healed

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