Transcript 08. Odontogenic sinusitis

Odontogenic sinusitis: classification,
etiology, pathogenesis, clinical
features, differential diagnosis,
treatment, complications, prevention.
arthritis, arthrosis temporomandibular
joint (TMJ): classification, clinical
course, diagnosis, treatment,
complications and prevention. TMJ
syndrome of pain disfunction. Surgical
TMJ arthroscopy.
CLINICAL SYMPTOMS
ACUTE SINUSITIS
< 3 weeks
SUBACUTE SINUSITIS
3 weeks-3 months
CHRONIC SINUSITIS
> 3 months
SYMPTOMS
Bloked nose
Headache
Fever
Yellow or green-coloured mucus from the nose
Swelling of the face
Aching teeth in the upper jaw
Loss of the senses of smell and taste
Persistent cough
Generally feeling unwell
MAXILLARY SINUSITIS
FROM DENTAL ORIGIN
1.Periapical abscess
2.Periodontal diseases
3.Infected dental cyst
4.Dental material in antrum
5.Oroantral communication
1.Periapical abscess
Acute sinusitis
Anaerobic organisms
2.Periodontal diseases
Lane & O’Neal
Chronic sinusitis
5 years
examination
irrigation + antibiotics
communication with the maxillary
sinus via a periodontal pocket
3.Infected dental cyst
Periapical cyst
Most common of all cysts of the oral region
Epithelium rest of Malassez
The cyst enlarges in to the maxillary sinus
4.Dental material in antrum
1.Displacement of root
extraction
third molar > second molar > canine
Pa or occlusal film
2.Implant
3.Root canal overfilling
loss of lamina dura
CASE REPORTS
CASE REPORTS
1.Antral puncture and sinus irrigation
2.Intranasal antrostomy or Nasoantral Window
3.Caldwell – luc operation
3.Caldwell – luc operation
Mandibular
condyle
Glenoid
fossa
(head)
Articular
tubercle
(eminence)
Posterior band of articular disc
Anterior band of articular disc
Mandibular condyle (head)
Lateral pterygoid muscle raphe
Lower head of lateral pterygoid muscle
Posterior disc att
Mandibular condyle (head)
Articular disc
MRI and autopsy
sections: upper row
oblique sagittal MRI,
asymptomatic
volunteer: left lateral,
middle medial, right
opened mouth
Partial anterior disc displacement at baseline
lateral sections central sections
open-mouth
Complete anterior disc displacement
medial section
Autopsy
Openmouth
MRI
Lateral disc displacement and normal bone
Medial disc displacement
coronal MRI
Oblique coronal M
Posterior disc displacement
Definition
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Non-inflammatory focal degenerative disorder of
synovial joints, primarily affecting articular cartilage
and sub-condylar bone; initiated by deterioration of
articular soft-tissue cover and exposure of bone.
Clinical Features
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Crepitation sounds from joint(s)
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Restricted or normal mouth opening capacity
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Pain or no pain from joint areas and/or of
mastication muscles
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Occasionally, joints may show inflammatory signs
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Women more frequent than men
anteriorly displaced and deformed, degenerated disc and
irregular cortical outline with osteophytosis and sclerosis of
condyle .
Advanced osteoarthritis
and anterior disc
displacement, with joint
Imaging Features
•Abnormal signal on T2-weighted image
from
condyle marrow: increased signal indicates
marrow edema; reduced signal indicates
marrow sclerosis or fibrosis
•Combination of marrow edema signal and
marrow sclerosis signal in condyle most
reliable sign for histologic diagnosis of
osteonecrosis
•Marrow sclerosis signal may indicate
advanced
osteoarthritis without osteonecrosis, or
osteonecrosis
Definition
 Inflammation of synovial membrane characterized
by edema, cellular accumulation, and synovial
proliferation (villous formation).
Clinical Features
 Swelling of joint area, not frequently seen in TMJ
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Pain (in active disease) from joints
 Restricted mouth opening capacity
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Morning stiffness, in particular stiff neck
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Dental occlusion problems; “my bite doesn’t fit”
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Crepitation due to secondary osteoarthritis
After 1
Rheumatoid arthritis. A MRI shows completely destroyed disc, replaced
by fibrous or vascular pannus and cortical punched-out erosion (arrow)
with sclerosis in condyle.
Psoriatic arthropathy. Oblique coronal and oblique sagittal
CT images show punched-out erosion in lateral part of
condyle (arrow).
Psoriatic arthropathy. MRI shows contrast enhancement
within bone erosion and in joint space, consistent with thickened
synovium/pannus formation. Openmouth
MRI shows reduced condylar translation but normally
located disc (and normal bone in this section)
Inflammatory arthritis
Definition
Fibrous or bony union between joint
components.
Definition
Abnormal growth of mandibular condyle; overgrowth,
undergrowth, or bifid appearance.
Condylar hypoplasia and
facial asymmetry
Condylar
Hypoplasia
Normal TMJ
Bifid condyle.
Calcium Pyrophosphate Dehydrate Crystal
Deposition Disease (Pseudogout)
Synovial Chondromatosis
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Benign tumor characterized by cartilaginous
metaplasia of synovial membrane, usually in knee,
producing small nodules of cartilage, which
essentially separate from membrane to become
loose bodies that may ossify.
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Different pathologies
affecting the
masticatory muscles,
the
temporomandibular
joint (TMJ), and
related structures
Affects more than 25%
of the population
90% of those seeking
treatment are women
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Facial pains/Muscle
spasms
Pain/tenderness in the
muscles of mastication
and joint
Joint sounds (popping,
clicking)
Limited jaw motion
Jaw locking open or
closed
Headaches
Teeth grinding
Abnormal swallowing
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Uncomfortable “off” bite
Inability to comfortably
open/close mouth
Dizziness/vertigo
Ringing in the ears
Visual disturbances
Insomnia
Tingling in
hands/fingers
Deviation of jaw to one
side
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Osseous Anatomy
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The articulation between the condyles of the
mandible and the temporal bone, which is part of the
cranium.
The articular surface of the condyle is convex and
the articular eminence of the temporal bone is
concave.
Working together:
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Dentists
Orthodontists
Psychologists
Physical Therapists
Ear, Nose, Throat Doctor
Physicians
Alternative Medicine
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MRI
X-Ray
Dental examination for bite alignment
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Physical Therapy is an
important aspect in
the treatment for TMD
to:
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Relieve musculoskeletal
pain
Decrease inflammation
Restore normal
joint/muscular
movements for oral
motor function
Correct poor posture
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History
Posture
Watch, feel, listen to jaw with AROM
 Opening between 40-50mm
 Protrusion/retraction between 8-10mm
 Lateral deviation while opening (S or C curve)
 Lateral excursion 8-10mm
Ligamentous Laxity testing
 Transverse Ligament
 Alar Ligament
Cervical ROM testing
Palpate joints/muscles for tenderness
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Therapeutic Exercises
Manual Therapy
Modalities
Electromyographic
(EMG) Biofeedback
Dental Splint
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Improve muscular
coordination
Increase muscular
strength
Postural exercises
Active ROM exercises
Muscles of
mastication
 Cervical spine
muscles
 General mobility
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Make a “clicking”
sound with the tongue
on the roof of the
mouth. This slightly
opens the jaw with the
tongue on the palate
behind the front teeth,
which is the resting
position of the jaw and
the first portion of
relaxation exercises.
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Place tip of tongue on
palate behind teeth and
draw small circles.
Place tip of tongue on
hard palate and blow
air out, rolling the
tongue, or making a “r r
r r” sound.
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Begin with proper resting position of the jaw. Teach
the patient control while elevating and depressing the
mandible throughout the first half of the ROM.
Keeping the tongue on the roof of the mouth, the
patient opens the mouth while trying to keep the chin
in midline. Use a mirror for visual reinforcement.
If the jaw deviates to one side, teach the patient to
practice lateral deviation to the opposite side without
creating pain or excessive motion.
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Long Axis Distraction:
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Sitting/Supine
PT positioned opposite of
affected side
Use hand opposite of
affected jt. side
Thumb in mouth on last
molar
Apply gentle downward
pressure with thumb
Hold for ~30 seconds 23x/session
Bilaterally
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Anterior Glide
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Same hand placement
Slightly distract using
DIP of thumb while
gliding anteriorly
Oscillate for 30
seconds
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Lateral Glide
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Thumb on tongue side of last molar
Use whole hand to oscillate laterally
Medial Glide
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Stand on affected side
Thumb on lateral side of last molar
Glide medially
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Avoid:
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Large bites
Excessive chewing
Removing food from teeth
with tongue
Gum chewing
Chewy foods: bagels,
sandwiches, steak, ice,
crunchy fruits/vegetables,
caramel, nuts etc.
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Relaxation techniques
to reduce
stress/muscle tension
Maintain good
posture
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5-10 % dx w/TMJ Dysfunction fail to have
relief of medical tx, and require surgery
Antiinflammatories, soft diet, hot
compresses, muscle relaxants
>2 weeks: intraoral occlusion splints, med
tx
Recurrent or chronic: permanent dental
correction
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Patient Factors
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Outpatient
H& P, Blood chemistries, CBC, PT, PTT, U/A, serum
HCG, Chest x-ray or ECG as appropriate
Room Set-up
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X-rays in room
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Position during procedure
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Supplies and equipment
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Arm sleds, headring pillow
Special considerations: high risk areas
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Supine w/head donut pillow, tuck arms to side
Elbows—ulnar nerves
Prep
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Shave preauricular area
Cotton to ears to prevent pooling of povidone-iodine &
caution w/eyes; entire facial area prepped from hairline,
down to shoulder, and laterally to include mouth and chin
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Special considerations
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Nasal intubation
Prophylactic antibiotics & steriods
State/Describe incision
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Small stab incision w/# 11 before trocar is
introduced at superior joint space
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General: basic pack drape and split head sheet,
gowns & gloves, towels, basin set, prep set, sterile
adhesive wound drape, irrigation pouch, skin
marker, raytex,
Specific
 Suture & Blades (# 11)
 Medications on field (name & purpose)
 Catheters & Drains: n/a
 Drapes: head turban for initial drape; pad pt forehead
with a folded towel; plastic adhesive wound drape to cover
ET tube and mouth; split sheet and large sheet for body
drape, (laser: 4 wet towels around pt’s face; moistened
cotton in external auditory canals, irrigation collection
pouch at base of ear and TMJ)
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2 60 mL syringes
4 10 mL syringes
1 1-mL syringe
Needles: 18 g, 21 g, 25 g
Skin stapler
Eye pads
Sterile water and saline
1000 mL Lactated Ringers for irrigation
30 in extension tubing
Stopcock
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General: suction, Lactated Ringer’s IV bag for
irrigation, marking pen
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Specific
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TMJ instrument set
 0 degree arthroscope
 30-degree arthroscope
 70-degree arthroscope
 Cannulas
 Sharp & dull obturators
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Light cord, camera & cord, small joint rotary shaver
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General: suction system
Specific
Monitor/light source/camera tower, shaver control
unit, IV pole for irrigant
 Fluid infusion system
 Bipolar ESU
 Holmium laser
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Irrigation solution is injected into the joint space to
distend the capsule
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LR solution is preloaded in syringe w/needle attached.
After small stab incision is placed, surgeon inserts a
sheath w/sharp obturator into superior joint space.
After space is entered, the sharp is replaced with a
dull obturator to further direct the sheath into the
joint without damaging the intraarticular tissue or
adjacent neurovascular structures.
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#11 blade with # 7 handle will be ready
Trocar/cannula is preassembled. Expect trocor to be
returned. Be prepared to assist with connections of
video/light cord connections.
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Irrigation is infused into the joint
 LR solution is connected to the cannua via
extension tubing
Joint is examined
 Prepare to operate remote control for still photos
If functional surgery is needed, a second stab
wound is made
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Pass skin knife. Prepare additional equipment (probe,
shaver, grasper)
Final visual inspection is performed
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Additional photos may be taken
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Cannuale are removed and excess fluid
removed
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Wound is closed and dressing placed
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Prepare for closure; count
Pass suture; prepare dressings, reorganize
equipment & supplies if procedure is bilateral
Steps may be repeated contralaterally
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Repeat steps
Thank you