Patterns of innervation of the anterior maxilla: a cadaver study with relevance to canine fossa puncture of the maxillary sinus

Assessment of canalis sinuosus, rare anatomical structure using cone-beam computed tomography: A prospective study

Objectives

This prospective study was performed with cone-beam computed tomography (CBCT) images for evaluating canalis sinuosus (CS), determine its location and diameter in relation to gender, age, and distances from important structures, including floor of nasal cavity, incisive foramen, edge of buccal cortical bone, and palatal cortical bone.

Material and Methods

The scans of 650 patients in total were included in this prospective analysis. Gender, age, the position of the CS, its presence or absence, diameter, and its location in reference to the adjacent teeth were the factors that were noted.

Results

The study had 301 female participants and 349 male participants, with a mean age of 42.19. Compared to females, males had a statistically higher frequency of CS. Higher age groups showed a higher presence of CS in comparison to the other age groups. The mean distances of these parameters on the left and right side did not differ significantly. Nonetheless, the distance on both sides between CS and nasal cavity floor for males and females, as well as the diameter and border of buccal-palatal cortical bone on the right side, were statistically significant different. On the left side, both genders demonstrated significance in buccal cortical margin and nasal cavity floor. IIn addition, in females, the diameter of the CS on the right and left sides differed on average. The associations between age and number of CS, CS diameter, and number of CS versus sex were all extremely weak. Overall, the study findings showed that CS is a typical anatomical feature in anterior maxillary region, irrespective of age, or gender.

Conclusion

The bony canal, CS is an obscure feature located in the frontal region of the maxilla. Surgeons can avoid complications by being aware of the auxiliary canals derived from this structure. With the use of CBCT, it is now feasible to examine the course of CS as it passes through the maxillary sinus's anterolateral wall with better radiological accuracy has already been documented.

Neurovascular territories of the canine fossa: Analysis of a South African population

BACKGROUND

The canine fossa, a depression on the surface of the maxillary bone, is important clinically due to the nexus of the neurovascular elements which occur in this region and supply the superficial and deep structures of the face. While it is known that there is much variation in the neurovascular structures of this region, little is known about sex differences. The aim of this study was to investigate and map the neurovascular branching within the region of the canine fossa of a South African population, with particular reference to any sex differences.

METHODS

Sixty hemifaces (n=30 female; n=30 male) of individuals between the ages of 40 and 100years were dissected. The origin, number of branches, connections between branches, origin of connecting branches and the distribution of the neurovascular structures associated with the mid-facial and canine fossa regions were documented. The data obtained was qualitative and was statistically analysed with SPSS v26 statistical analysis software. Frequency and contingency tables, along with Chi-squared analysis and Fischer's Exact test, were used for quantitative data analysis.

RESULTS

While high levels of variation in the neurovascular elements were documented, there was no statistically significant variation between the sexes. A sex variation was only observed for the terminal branches of CN VII with females displaying a lower number of buccal nerve terminal branches than males.

CONCLUSION

While only one sex difference of significance was found in the highly variable neurovascular structures resident in the region of the canine fossa, the variability of the neurovascular elements is of importance to surgeons.

Cone beam computed tomographic evaluation of infraorbital canal protrusion into the maxillary sinus and its importance for endoscopic surgery

OBJECTIVE

The aim of this retrospective study is to investigate the prevalence of Infraorbital Canal Protrusion (ICP) degree into the maxillary sinus and its relationship with variations in adjacent structures on Cone Beam Computed Tomography (CBCT) images.

METHODS

350 CBCT images (700 Infraorbital Canal [IC]) were evaluated retrospectively. ICP was divided into 3 subtypes according to the protrusion degree. The correlation between IC types and variations in adjacent anatomical structures (Haller cell, middle nasal concha pneumatization, maxillary sinus mucosal thickening and septa) was evaluated. The distance between Infraorbital Canal and Cnine Root (IC-CR) was also measured. For type 3, measurements were performed on IC as the length of the bony septum from the IC to the Mxillary Sinus Wall (IC-MSW), the distance from the inferior orbital rim, where the IC begins to protrude into the maxillary sinus (IOR-ICP), the vertical distance from the IC to the Maxillary Sinus Roof (IC-MSR) and Floor (IC-MSF).

RESULTS

The prevalence of type 1, 2 and 3 was 62.9%, 29.1%, and 8% respectively. IC-CR was 10.2, 10.7 and 11.4 mm in type 1, 2 and 3, respectively. IC-MSW, IOR-ICP, IC-MSR and floor IC-MSF was 3.8, 10.9, 7.4 and 27.7 mm, respectively. On the right and left side, statistically significant correlation was found between IC types and the presence of the Haller cell and sinus septa. But there was no significant correlation between IC types and middle concha pneumatization.

CONCLUSION

Accurate diagnosis of ICP is very important in preventing infraorbital nerve damage in surgical procedures to be performed in the maxillary region. The results of this study could be a guide for surgical planning in this region.

LEVEL OF EVIDENCE

Retrospective study.

Assessment of the anterior superior alveolar nerve and its impact on surgery of the lateral nasal wall

BACKGROUND

The anterior superior alveolar nerve (ASAN) plays a major role in innervation of the lateral nasal wall. Its damage during nasal surgery can cause dental paraesthesia and numbness around the upper lip.

METHODOLOGY

Retrospective evaluation of the computed tomographic (CT) scans of 50 consecutive patients analysing 100 sides. We measured the mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve, to the anterior superior alveolar canal and the anterior-posterior distance between the 'shoulder' of the inferior turbinate and the pyriform aperture.

RESULTS

The mean distance from the shoulder of the inferior turbinate to the descending portion of the anterior superior alveolar nerve was 6.4 ± 2.33 mm, with no difference between sides The mean relative height of the shoulder in relation to the anterior superior alveolar nerve canal was 4.78 ± 2.31mm with no significant difference between the two sides. The anterior-posterior distance between the 'shoulder' of inferior turbinate and the pyriform aperture was 6.96± 2.28mm, with no significant difference between the two sides.

CONCLUSIONS

We found the anterior superior alveolar nerve to be a constant landmark in the lateral nasal wall. Therefore, the course of the ASAN should be assessed on a CT scan when a surgical approach through the pyriform aperture or anterior medial wall of the maxillary sinus is planned.

Posterior superior alveolar nerves contribute to sensation in the anterior teeth

BACKGROUND

There is no available data on the occurrence rate of a converged alveolar canal, the detailed three-dimensional (3D) courses of alveolar canals/grooves (ACGs), or the contribution of each superior alveolar nerve to each area in the maxilla. This study aimed to clarify the 3D courses of ACGs, the relationship between ACGs and superior alveolar nerves, and the contribution of posterior superior alveolar nerves (PSANs) using computed tomography (CT) with histological analysis.

METHODS

During the gross anatomy course at Niigata University, we investigated nine human cadavers.

RESULTS

All anterior and posterior ACGs converged into the common alveolar canal, which contained blood vessels and several nerve bundles surrounded by perineurium, located at the nasal floor near the pyriform aperture. Histometrical analysis clarified that 16.3% of the nerve bundles in this canal were derived from PSANs, and 67% of the bundles were dispersed while they coursed down to the nasal floor. There seems to be no relationship between the density of nerve bundles in the canal and the number of remaining anterior teeth.

CONCLUSIONS

Data obtained from observing the detailed 3D courses of anterior and posterior ACGs, and their relationship with superior alveolar nerves, suggest that PSANs partially contribute to the nociception of the anterior teeth.

Gender-specific differences in feasibility of pre-lacrimal window approach

The feasibility and surgical effort of a pre-lacrimal window approach (PLWA) depends on the width of the bony window anterior to the nasolacrimal duct. This study aimed to investigate gender-specific differences in feasibility of PLWA. A consecutive series of paranasal computed tomography scans from 50 females (n = 100) and 50 males (n = 100) were retrospectively analyzed. The primary outcome measure was the antero-posterior length of the bony pre-lacrimal window (BPLWA). The secondary outcome measure was the distribution of Simmen’s PLWA feasibility types (major, moderate and minor surgical effort). On average, males had a 1.5 mm (95% CI 0.8–2.2) significantly higher BPLW length in comparison to females [t(198) = 4.4, p < 0.0001]. The requirement of major surgical effort occurred 29% more frequently in females [χ²(1) = 17.7, p < 0.0001], whereas the necessity of moderate surgical effort was 21% more prevalent in males [χ²(1) = 8.8, p = 0.003]. The need of only minor surgical effort was twice as high in males compared to females [χ²(1) = 3, p = 0.081]. Our data indicates that females require more significant surgical effort during a PLWA to gain access to the maxillary sinus. These results are highly informative as a high amount of bone removal and nasolacrimal duct dislocation are associated with a higher likelihood of complications.

A prelacrimal approach technique to overcome the limitation of the narrow lacrimal recess

PURPOSE

The distance between the anterior wall of the maxillary sinus and the nasolacrimal duct has been classified into three types by Simmen, in which type I (< 3 mm) is the least feasible for a prelacrimal approach. The aim of our study is to present a surgical technique which overcomes the anatomical limitation of the narrow lacrimal recess (type I) in the management of inverted papilloma in the maxillary sinus.

METHODS

Case series.

RESULTS

Eight patients with type I lacrimal recess underwent surgical resection for inverted papilloma in the maxillary sinus via a prelacrimal approach. The technique is described in detail in the article and essentially involves exposure of the nasolacrimal duct using a diamond burr. Complete tumor excision was achieved in all cases through this access, with no significant intra-operative complications.

CONCLUSIONS

This prelacrimal approach technique is safe and effective for the management of inverted papilloma in maxillary sinuses with a type I lacrimal recess configuration.

[Surgical anatomy of the maxillary sinus]

BACKGROUND

Improved understanding of the microanatomy of the paranasal sinuses, including its individual variations, makes a substantial contribution to current progress in endonasal endoscopic microsurgery. Microanatomy of the sinuses is an active field of present scientific investitations.

MATERIALS AND METHODS

A comprehensive review on microanatomy of the maxillary sinus is presented from the perspective of contemporary endonasal endoscopic microsurgery.

RESULTS

The range of variation of the individual microanatomy of all sections of the maxillary sinus is presented, in particular to minimize secondary sugical tissue trauma, to avoid complications (e.g. on orbital tissues) and as a basis for the prelacrimal access to the maxillary sinus.

CONCLUSION

Improved understanding of the range of microanatomical variations reduced the burden on the patient while opimizing the effectiveness of the necessary surgical manipulations.

Extended endoscopic approaches to the maxillary sinus

OBJECTIVES

Treatment of inflammatory and neoplastic disease in the maxillary sinus, pterygopalatine and infratemporal fossae requires appropriate surgical exposure. As modern rhinology evolves, so do the techniques available. This paper reviews extended endoscopic approaches to the maxillary sinus and the evidence supporting each technique.

METHODS

A literature search of the Ovid Medline and PubMed databases was performed using appropriate key words relating to endoscopic approaches to the maxillary sinus.

RESULTS

Mega-antrostomy and medial maxillectomy have a role in the surgical treatment of refractory inflammatory disease and sinonasal neoplasms. The pre-lacrimal fossa approach provides excellent access but can be limited because of anatomical variations. Both the transseptal and endoscopic Denker's approaches were reviewed; these appear to be associated with morbidity, without any significant increase in exposure over the afore-described approaches.

CONCLUSION

A range of extended endoscopic approaches to the maxillary sinus exist, each with its own anatomical limitations and potential complications.

Surgery of Inverted Papilloma of the Maxillary Sinus via Translacrimal Approach-Long-Term Outcome and Literature Review

There are several differential diagnoses of unilateral sinus disease. One of these is inverted papilloma (IP) of the maxillary sinus, which is a common benign tumor with a substantial rate of malignant transformation. In general, endoscopic endonasal techniques for addressing the tumor are favored nowadays instead of classical external approaches. The aim of this retrospective study was to investigate the long-term outcome of inverted papilloma treated endoscopically via the prelacrimal approach. We reviewed 17 patients with primary or recurrent IP of the maxillary sinus that were treated via the prelacrimal endoscopic endonasal technique. After a median follow-up period of 45.9 months (3.8 years), none of the 17 included patients showed signs of recurrent disease and no serious complications were reported. Hypoesthesia of the incisors was reported by four patients and was resolved with time in one. All of the maxillary sinuses could be fully visualized with the flexible endoscope. IP is an important differential diagnosis in the clinical finding of unilateral nasal polypoid lesions. The prelacrimal approach is an effective and safe method in the treatment of IP with limited patient morbidity.

Direct approach to the anterior and lateral part of the maxillary sinus with an endoscope

OBJECTIVE

The Caldwell-Luc (CL) approach with a sublabial incision is used to manipulate the anterior wall of the maxillary sinus. Paresthesia is one of the major complications associated with the CL approach. We developed a new method, "direct approach to the anterior and lateral part of the maxillary sinus with an endoscope" (DALMA), that negates the need for a sublabial incision and minimizes dental paresthesia by reducing the risk of anterior superior alveolar nerve injury. This study aimed to describe how to perform the DALMA technique, and to review its effectiveness and associated complications.

METHODS

We retrospectively reviewed 10 patients who had received DALMA.

RESULTS

Ten patients underwent DALMA. The anterior superior alveolar nerve was identified in all patients. Access to the lateral side beyond the infraorbital canal and anterior wall of the maxillary sinus was achieved.

CONCLUSIONS

DALMA is a simple, effective, and minimally invasive technique that can be used as an alternative to CL with sublabial incision.

Comparison Between Endoscopic Prelacrimal Medial Maxillectomy and Caldwell-Luc Approach for Benign Maxillary Sinus Tumors

Objectives

Endoscopic prelacrimal medial maxillectomy (EPMM) was previously reported to treat maxillary inverted papilloma. This study aimed to compare prelacrimal recess approach with the conventional Caldwell-Luc approach (CLA) to remove benign maxillary sinus tumors and to evaluate the usefulness of this approach based on our experience.

Methods

Ten patients who underwent EPMM at our hospital from January 2013 to December 2017 were reviewed. We also reviewed 30 patients who underwent benign maxillary sinus tumor resection via CLA during the same period. From medical records, postoperative pathological results, complications due to surgery, and recurrence rate were evaluated.

Results

There were eight inverted papilloma, one ameloblastoma, and one ossifying fibroma in the EPMM group. In the CLA group, all 30 cases were inverted papilloma. There were no cases of failure at gross total removal during surgery, and no recurrences were observed during follow-up in either groups. Mean follow-up period was 13.0 months in CLA group and 10.8 months in EPMM group. Regarding postoperative complications, 11 patients of the CLA group (37%) and three patients of the EPMM group (30%) had numbness around the cheek and upper lip area after surgery (P=0.715). In the CLA group, there were eight patients who had numbness lasting more than 3 months after surgery, and two patients had numbness for more than 1 year. However, facial numbness disappeared within 3 months in all patients in the EPMM group, in which epiphora was not observed.

Conclusion

EPMM is the effective surgical approach for resecting benign maxillary sinus tumor compared with CLA. Although facial numbness was reported in EPMM, the duration of numbness was shorter than CLA.

Resection of Inverted Papilloma of the Maxillary Sinus via a Prelacrimal Recess Approach: A Multicenter Retrospective Analysis of Surgical Efficacy

BACKGROUND

The intranasal endoscopic prelacrimal recess approach (PLRA) access to all aspects of the maxillary sinus while preserving the inferior turbinate and nasolacrimal duct and its use have been reported in the treatment of many maxillary sinus and lateral skull base diseases.

OBJECTIVE

To retrospectively assess the effectiveness of a 10-year multicenter follow-up for the resection of inverted papilloma of the maxillary sinus (IPMS) via a PLRA.

METHODS

A total of 71 patients were admitted and underwent IPMS excision via an intranasal endoscopic PLRA from 2003 to 2013. All patients underwent high-resolution computed tomography scanning of the nasal sinus, and some also underwent magnetic resonance imaging examination.

RESULTS

Based on the Krouse staging system, all 71 patients belong to T3 staging. The PLRA was employed to remove IPMS in 71 patients. The postoperative pathological examination of the excised tissue revealed inverted papilloma, and cancerization was identified in 3 patients. The median follow-up time was 37.3 months (range: 13-134 months). Of the 71 patients, reoccurrence was seen in 5 patients (7.04%); 5 patients (7.04%) experienced numbness of the upper lid and the ala of the nose and 4 (5.63%) experienced mild collapse of the ala of the nose.

CONCLUSIONS

These multicenter follow-up results demonstrated that the PLRA is a safe and effective method for the excision of primary or recurrent IPMS with lower postoperative complications and recurrent rate.

Application of the endoscopic prelacrimal recess approach to the maxillary sinus in unilateral maxillary diseases

BACKGROUND

The endoscopic endonasal prelacrimal recess approach to the maxillary sinus provides wide access to the walls and recesses of the maxillary sinus, and its use has been reported in many maxillary sinus and skull base diseases. The objective of this study was to determine the indication and feasibility of endoscopic sinus surgery using the prelacrimal recess approach in unilateral maxillary sinus diseases.

METHODS

We reviewed 192 cases of unilateral maxillary sinus diseases; over 2 years, 15 cases underwent endoscopic surgery via the prelacrimal recess approach. Data regarding preoperative computed tomography scans, operative findings, postoperative pathological diagnoses, postoperative complications, and disease recurrences were obtained from medical records.

RESULTS

Patients who underwent surgery via the prelacrimal recess approach did so mostly because tumors were present in the maxillary sinuses (12/15; 80%), while most of the patients in this study underwent surgery because of chronic inflammation (122/177; 68.9%) and fungal infections (40/177; 22.6%). Among 15 patients undergoing surgery via the prelacrimal recess approach, 9 were cases of inverted papilloma. The mean follow-up period was 16.5 months (range, 6 to 28 months). No postoperative complications occurred after the prelacrimal recess approach. One out of the 15 cases undergoing the prelacrimal recess approach had tumor recurrence CONCLUSION: Most chronic inflammation and fungal infections of the unilateral maxillary sinuses can be managed through a middle meatal antrostomy. The endoscopic prelacrimal recess approach is a reliable and effective method used to approach maxillary sinus diseases.

Cone-beam tomographic analysis of canalis sinuosus accessory intraosseous canals in the maxilla

The aim of this study was to assess the frequency, location and width of accessory canals (AC) of canalis sinuosus (CS) using cone beam computed tomography and compare our findings with recent literature. Additionally, intraosseous canals (IOC) in the sinus wall other than the CS were noted. A retrospective analysis of 219 scans from our university department was conducted. The registered parameters were age, sex, location and width of canals. Group A consisted of 201 (85 males and 116 females) adults ranged from 19 to 99 years of age (mean age = 47.5 years). A total of 136 patients (67.6%) presented at least 1 AC, of which 55 cases showed a foramen width greater than 1 mm (27.4%). Group B had a sample size of 18 adolescents (7 males and 11 females) with a range of age from 7 to 18 years (mean age = 15.8 years). Eight cases (44.4%) presented at least one AC, of which only 3 had a foramen width greater than 1 mm (3.6%). ACs were found to occur predominantly at central incisors region (Group A) and the left lateral incisor and canine as well as the central incisors regions (Group B). Adolescents showed a lower prevalence of accessory canals compared to adults. These findings supplement earlier reports on the anatomical variations of the intraosseous vessel and nerve conduits of the maxilla. Surgical interventions in this area can be planned more precisely, taking into account the three-dimensional imaging, thus possibly protecting these sensitive structures.

Anterior superior alveolar nerve injury after extended endoscopic medial maxillectomy: a preclinical study to predict neurological morbidity

BACKGROUND

Endoscopic medial maxillectomies (EMMs) are used to optimize exposure of the maxillary sinus and retromaxillary areas. Although in type D EMM (Sturmann-Canfield procedure) the anterior superior alveolar nerve (ASAN) is always at risk of injury, only 29% of patients complained of alveolar process and dental anesthesia. The purpose of this anatomical study is to assess the neural anastomotic network of the ASAN (ASAN-NAN) and describe different extensions of type D EMMs in a preclinical setting.

METHODS

The ASAN and its medial anastomotic branches (MABs) and lateral anastomotic branches (LABs) were evaluated by cone-beam computerized tomography (CBCT). Five different extensions of type D (D1 to D5) EMMs were identified and nerves at risk of injury in each type were assessed by CBCT. Moreover, quantification of surgical corridors was performed on cadaver heads with a neuronavigation system.

RESULTS

Fifty-seven CBCT scans were analyzed. The ASAN would be spared in 16.3% of cases with a type D1 EMM, while it would be injured in the majority of type D2 to D5 resections. At least 1 nerve of the ASAN-NAN was spared in 96.6%, 93%, 74.6%, 0%, and 65.8% of type D1 to D5 EMMs, respectively. Two cadaver heads were dissected and the incremental volume and number of maxillary subsites exposed was assessed in type D1 to D5 EMMs.

CONCLUSION

ASAN function impairment is probably compensated by LABs and MABs. If this hypothesis will be validated in a prospective study on patients, preoperative CBCT evaluation could predict neurological morbidity after type D EMM, and allow tailoring the procedure to minimize impairment of the ASAN-NAN.

Evaluation of the morphology of the canalis sinuosus using cone-beam computed tomography in patients with maxillary impacted canines

Purpose

The nasopalatine canal is a well-known, important anatomical structure in the anterior maxilla, but this region contains many accessory canals. The canalis sinuosus (CS) is one of these canals; it contains the anterior superior alveolar nerve, along with veins and arteries. The purpose of this study was to evaluate the CS using conebeam computed tomography (CBCT) in patients with maxillary impacted canines.

Materials and Methods

A total of 111 patients admitted to the Istanbul Medipol University School of Dentistry for the exposure, orthodontic treatment, and/or extraction of an impacted canine were included in this study. CBCT images were obtained for these patients under standard conditions. Axial, coronal, and sagittal sections were evaluated to assess the prevalence of CS, the direction and diameter of the canal, its relation with the impacted canine, and its distance from the alveolar crest. Further, possible correlations with patient gender and age were analyzed.

Results

The CS could be detected bilaterally in all the evaluated tomography images. The mean canal diameter was significantly larger in males than in females (P=.001). The CS ran significantly closer to the impacted canine when the canal was located horizontally (P=.03). Variations of the canal, such as accessory canals, were identified in 6 patients.

Conclusion

CS is an anatomical entity that may resemble periapical lesions and other anatomical structures. Evaluation with CBCT prior to surgical procedures in the anterior maxilla will help to prevent overlooking such anatomical structures and to decrease possible surgical complications.

Isolated unilateral upper alveolar numbness in silent sinus syndrome

We present a case of a 59-year-old man with left upper alveolar numbness of 2 years’ duration in the absence of sinonasal symptoms. On physical examination, he demonstrated mild left facial asymmetry and diminished sensation of his left upper alveolus from the left second upper incisor to first canine. CT imaging revealed chronic sinusitis changes of the left maxillary sinus, with reduced volume and depressed anterior wall. The patient underwent functional endoscopic sinus surgery to re-establish maxillary sinus ventilation. He was noted to have some improvement of his upper alveolar paraesthesia postoperatively. Silent sinus syndrome is part of the spectrum of chronic maxillary atelectasis. In the presented case, chronic osteitic bony sclerosis, as opposed to osteopenic change of the maxillary sinus, was seen. We postulate that bony encasement of the anterior superior alveolar nerve resulted in chronic nerve compression and the patient’s unusual symptom of upper alveolar paraesthesia.

Orbital decompression for thyroid eye disease

The literature regarding orbital decompression for thyroid eye disease is vast, spanning multiple specialty areas including neurosurgery, head and neck, maxillofacial, and ophthalmic plastic surgery. Although techniques have advanced considerably over the more than 100 years during which this procedure has been performed, the 4 major approaches remain: transorbital, transcranial, transantral, and transnasal. The explosion in literature related to orbital decompression has mostly involved minor technical variations on broader surgical themes. The purpose of this review is to organize the major approaches in terms of bony anatomy and to contextualize variation in transdisciplinary techniques within a common conceptualization.

Removal of Long-Term Broken Roots Displaced Into the Maxillary Sinus by Endoscopic Assistant

PURPOSE

This report presented a patient with 2 long-term broken roots displaced in left maxillary sinus. The residual root fragments made the patient uncomfortable in both mind and body and interfered with prosthodontics work. The application of endoscope combined with piezoelectric device both helps in removing the broken roots successfully with minimally surgical injury and preserves the residual alveolar bone.

METHODS

Computed tomography scans and 3-dimensional reconstructions located the broken roots. A 1.0 cm × 1.5  cm rectangle bone window on anterolateral sinus wall was opened by a piezoelectric device to place the endoscope and forcep into sinus. Two broken roots could be observed clearly via a endoscopic screen. They were removed by a mini goblet forcep completely and efficiently. A whole bone lid was replaced with a biological membrane to help repair bone defect after removing procedure.

RESULTS

The operation is about 20 minutes with endoscope and piezoelectric device helped to save a lot of time and provided excellent visual surgical field. Main postoperative adverse effects were swelling, numbness, and temporal no-vitality for the first premolar (24). Three months later, computed tomography shows the Schneiderian membrane thinned to around 0.8  mm. The bone lid is on its position and starts to perform synostosis. The 24 tooth is still dysesthetic and needs time to recover.

CONCLUSIONS

Endoscopic surgery combined with a piezoelectric device has obvious advantage of minimizing surgical injury and providing excellent visibility of surgical field when removing long-term foreign bodies in maxillary sinus. It is efficient and protects the residual alveolar bone.

MDCT evaluation of nasopalatine canal morphometry and variations: An analysis of 100 patients

OBJECTIVE

The goal of this study was to investigate the possible variations in morphology of nasopalatine canal (NPC) morphometry depending on age, gender and absence of anterior incisors using multidetector row computed tomography (MDCT).

MATERIALS AND METHODS

A total of 100 patients (50 men, 50 women) with a mean age of 43.29±18.81 (SD) years (range: 18-90 years) who have undergone head MDTC were included into the study. Foramen nasalis diameter (P1), foramen incisivum diameter (P2), NPC length (P3), distance between buccal wall of incisive foramen and facial side of the buccal bone (P4), distances between buccal bone wall of NPC and facial side of buccal bone (P5), distance between mid-NPC buccal wall and facial side of buccal bone (P6), distance between buccal wall of NPC and the apex of anterior central incisors (P7) and NPC angle (P8) were measured. Formal variations in NPC were searched for. Differences in morphometric data were searched using Student t-test or Mann-Whitney test. Gender-based analysis of the variations was done with the χ² test. Pearson's test was used to search for correlation between morphometric data and age.

RESULTS

P1 was larger in men (3.72±1.41mm) than in women (3.07±1.34mm) (P<0.001). Similarly, P3 was larger in men (13.68±2.73mm) than in women (11.43±2.78mm) (P<0.001). No differences in the other NPC measurements (P2, P4, P5, P6, P7, P8) were found between men and women. Morphological variations in NPC (cylindrical, hourglass, banana shape, funnel shape, single canal, Y-type canal, parallel canal and others) were detected with frequencies ranging from 8 to 65.3%. A significant negative correlation was found between NCP measurements and patient age for P3 (r=-0.311; P=0.002), P4 (r=-0.267; P=0.007) and P8 (r=-0.318; P<0.001). New NPC variations, which were not reported before were found in 19% of our patients.

CONCLUSION

NPC shows myriad potential variations that have various prevalences. It is assumed that familiarity with these variations may help decrease the incidence of complications during facial or dental surgery.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Early Practice: External Sinus Surgery and Procedures and Complications

External approaches to the paranasal sinuses are rarely used in the endoscopic era. However, their indications for use have not changed, and in every surgeon's career those indications may present themselves. For residents training in the endoscopic era, these procedures are also very rarely seen. In this article, the external approaches to the maxillary, ethmoid, and frontal sinuses are described: their original descriptions, modern use, and potential complications. It is hoped that this article will serve to instruct residents and practitioners alike in these techniques.

Unexpected rare complication of the facial paralysis in a patient with an antrochoanal polyp following canine fossa puncture

Canine fossa puncture (CFP) combined with endoscopic sinus surgery is a simple and effective method for treating antrochoanal polyps, particularly those that originate in the anterior, inferior or medial aspect of the antrum. Several complications can occur following CFP, including facial paraesthesia and dental numbness. However, facial palsy is extremely rare after CFP. We postulated that a possible mechanism of facial palsy is pressure injury to the soft tissues adjacent to the puncture site, which can damage the buccal branch of the facial nerve during CFP.

[Recovery of maxillary tooth sensibility after Le Fort I osteotomy]

INTRODUCTION

Upper alveolar nerves, when injured during Le Fort I osteotomies, alter maxillary tooth sensitivity. We had for aim to analyze post-operative maxillary tooth sensitivity recovery.

MATERIAL AND METHODS

We conducted a prospective study in a series of patients having undergone Le Fort I osteotomy, with, or without mandibular osteotomy or intermaxillary disjunction (IMD). The direction and range of displacement of the maxillary bone were recorded. One tooth in each alveolar sector (incisivocanine, premolar, molar) was tested with an electric stimulator for each patient. The tests were performed before (D-1), and after surgery (D2 or day+2, D+15, M2 (or month +2), M3, and M6).

RESULTS

Twenty-two patients were included. Among the tested teeth, 91.9 % were sensitive at D-1. At D2, only 12.7 % of teeth were sensitive. At D15, M2, M3, and M6, the sensitivity was respectively 33.3 %, 43.1 %, 50 %, and 61.8 %. The recovery of sensitivity was faster in young patients (under 35 years of age) and for upper middle and superior alveolar nerves. There was no difference regarding the direction of maxillary movement.

DISCUSSION

Among the teeth that were sensitive before surgery, 87.3 % had not regained sensitivity at D2. The recovery of sensitivity increased at D15. A great displacement of the maxillary bone was an aggravating factor for loss of tooth sensitivity.

Variable extent of nasoantral window for resection of antrochoanal polyp: selection of the optimum endoscopic approach

The aim of this study is to evaluate the long-term results of endoscopic sinus surgery in the treatment of antrochoanal polyps and the role of extending the middle meatal antrostomy on the expense of the inferior meatus in providing wide exposure and accessibility within the maxillary sinus to ensure complete removal of its antral portion. Thirty-six patients were reviewed. Two groups were identified: Group A including patients with antrochoanal polyps that were resected endoscopically through a classical wide middle meatal antrostomy and Group B which included those who underwent endoscopic removal via an extension of the antrostomy inferiorly through submucosal resection of the lateral bony skeleton of the inferior meatus. There were 13 female and 23 male patients with a mean age of 28 ± 9.4 years. The mean follow-up period was 20.4 ± 6.7 months. Six patients were recurrent after previous endoscopic surgery. Group A included 17 patients and the remaining 19 patients were assigned to Group B. Two patients from Group A developed symptomatic recurrence and were cured with revision extended antrostomy. Three patients showed endoscopic evidence of a developing cystic lesion within the maxillary sinus that was punctured through the wide antrostomy. Endoscopic resection is considered the main treatment modality of antrochoanal polyps. Modification of the technique through removal of the lateral bony skeleton of the inferior meatus with downward displacement of the inferior turbinate provided accessibility to the inferior and prelacrimal recesses of the maxillary sinus.

Presurgical CBCT assessment of maxillary neurovascularization in relation to maxillary sinus augmentation procedures and posterior implant placement

PURPOSE

To provide more information to clinicians planning sinus grafting and maxillofacial surgical interventions, the present study evaluated the prevalence, diameter and location of the superior alveolar canals (SAC) using CBCT images.

METHODS

The maxillary sinus CBCT scans (i-CAT Classic(®), ISI, USA) of 100 adult patients (67 women and 33 men) aged 20-79 years [mean (SD) 40 (15)] were examined. A dentomaxillofacial radiologist observed the SAC based on CBCT image data and more specifically the parasagittal views to assess SAC's diameter and location.

RESULTS

The anterior and posterior SAC, double ASAC, intraosseous anastomoses and the extension of the anterior SAC to the piriform aperture were observed in 100, 73, 24.5, 38.5 and 84 % of the cases, respectively. The anastomosis was located between canine and first premolar in 43 % of the cases. The SAC diameters were in 80 % of the cases ≤1 mm, remaining canals had a diameter between 1 and 2 mm. The distance of the SAC to the alveolar crest ranged between 2.42 and 44.6 mm. The anterior SAC was more prevalent in the upper (53 %) and middle (44 %) thirds of the maxillary sinus, while the posterior SAC was more prevalent in the middle (36 %) and lower thirds (64 %). The distance was significantly bigger in men in some tooth positions.

CONCLUSIONS

Based on the present findings, one-fifth of the patients may have a diameter of the SAC >1 mm, large enough to cause bleeding and/or paraesthesia. CBCT imaging may assist surgeons to plan grafting and osteotomy procedures, while avoiding these neurovascular structures.

Effect of maxillary sinus packing with epinephrine hydrochloride-soaked cotton pledgets on complications after canine fossa puncture

CONCLUSION

Bleeding control with epinephrine hydrochloride-soaked cotton packing in the maxillary sinus after canine fossa puncture (CFP) during operation is a simple method for reducing complications, especially those associated with blood leakage from the maxillary sinus into the subcutaneous tissue.

OBJECTIVE

Although CFP is a useful method for extensive maxillary sinus disease, complications can occur associated with nerve injuries or mucosal bleeding. We evaluated whether maxillary sinus packing with epinephrine hydrochloride-soaked cotton pledgets would reduce complications after CFP.

METHODS

Patients who met the inclusion criteria were randomly allocated to groups 1 (packing) and 2 (no packing). Patients underwent unilateral or bilateral CFP. We compared the disease entities, complication incidence, and average symptom duration between the groups.

RESULTS

A total of 57 patients were included. Group 1 underwent 36 CFPs, and complications occurred in 20 sides of 17 patients. Group 2 had 39 CFPs, and 20 patients experienced complications in 26 sides. The total number of complications was 40 and 73 in groups 1 and 2, respectively. Incidence or duration of facial, dental, or gum numbness did not differ between groups. Tingling sensation, facial pain, facial swelling, and bruising showed significantly lower occurrence rates and shorter duration in group 1.

Five 'nontraditional' techniques for use in patients with recalcitrant sinusitis

PURPOSE OF REVIEW

Although endoscopic sinus surgery remains the mainstay of surgical approaches to treating paranasal sinus disease, some disease may require alternative approaches. We review here five techniques: endoscopic middle turbinectomy, maxillary sinoscopy, the Caldwell-Luc procedure, intranasal inflammatory polyp steroid injection, and frontal sinus trephine.

RECENT FINDINGS

Recent findings suggest that endoscopic sinus surgery is limited in certain cases to access particular anatomic sites that may contain disease. The anterior, inferior maxillary wall and the frontal sinus may be accessed externally with minimal morbidity, and this access may be critical to treating the disease. The middle turbinate can contribute to preoperative and postoperative obstruction of sinus drainage, and resection of it can benefit the patient in many ways. Finally, the management of intranasal inflammatory polyps remains a challenge. In both preoperative and postoperative patients, the polyps may not respond to standard and even aggressive topical therapies. Intrapolyp steroid injection can provide a substantial anti-inflammatory effect and may avoid surgery for some patients.

SUMMARY

This article will review five ancillary procedures that add to the rhinologist's skill set to treat difficult or recalcitrant paranasal sinus disease.

Endoscopic transmaxillary repair of orbital floor fractures: a minimally invasive treatment

Although endoscopic transmaxillary repair of orbital floor fractures is a minimally invasive treatment, controversy remains regarding the method for supporting the orbital floor after elevation of the orbital contents. To date, a urethral balloon catheter has been widely used. However, it can be difficult to leave the catheter in place for a long time period due to the inconvenience, and prolapse of the orbital contents may recur in the case of its premature removal. This study described the techniques for endoscopic reduction and use of a balloon for orbital floor fractures. From June 2006 through November 2011, 30 of 52 patients (57.7%) with an isolated orbital floor fracture underwent endoscopic transmaxillary repair. A maxillary sinus balloon (#3007, Koken Co., Japan) was inserted into the maxillary sinus to support the orbital floor after endoscopic transmaxillary reduction, and the connecting tube of the balloon was pulled into the nasal cavity through the maxillary ostium. After confirmation of accurate reduction by postoperative CT, the connecting tube was shortened and hidden in the nasal cavity. The balloon was left in place for 4-8 weeks, and then removed via the maxillary ostium on an outpatient basis. Complete resolution of the preoperative diplopia was achieved in 93%, and no late-developing enophthalmos was seen in 97% of the patients. There were no significant complications. This technique is safe and permits prolonged retention of the balloon, without interfering with daily life.

The 'double-barrel' approach to the removal of dental implants from the maxillary sinus

The purpose of this article is to present a new surgical technique - the double-barrel approach - employed for the extraction of dental implants from the maxillary sinus, and to compare it with the classic canine fossa puncture (CFP). The surgical steps in the performance of the double-barrel approach (DBA) are systematically described. In order to compare the two techniques (CFP versus DBA), a prospective, randomized study was carried out between 2004 and 2011, comparing the length of duration of the procedure and the incidence of adverse effects. The average duration was 6.3 ± 5.2 min for the DBA group and 14.8 ± 8.4 min for the CFP group (P=0.0001, Mann-Whitney test). Nevertheless, the incidence of adverse effects within the first postoperative week did not differ between the two groups. We have demonstrated that the double-barrel approach is faster, has the same incidence of adverse effects, provides excellent visualization, and permits a more accurate withdrawal of implants in comparison with the classic CFP. It is minimally invasive, requires no sutures, and minimizes the risks to local vascular and neural structures.

Antral retriever and displaced dental implants in the maxillary sinus

PURPOSE

Removal of antral foreign bodies after implantation is mandatory to avoid infectious processes and may be a troublesome question. Different surgical approaches could be considered, with several limitations and morbidities.

METHODS

We present a new tool (Antral Retriever) conceived to remove antral dental implants or any other migrated material through a minimally invasive canine fossa approach, under continuous endoscopic view and local anesthesia.

RESULTS AND CONCLUSIONS

Antral Retriever enables the surgeon to successfully remove antral foreign bodies through a canine fossa approach under continuous endoscopic visualization and local anesthesia, with minimal discomfort for the patient

The canine fossa puncture technique in chronic odontogenic maxillary sinusitis

BACKGROUND

Endoscopic sinus surgery (ESS) including middle meatus antrostomy (MMA) has been advocated as the technique of choice in the treatment of maxillary chronic odontogenic sinusitis (COS). However, recently the endoscopic canine fossa puncture (CFP) has been proposed as an alternative surgical technique of accessing the entire antrum when pathology is limited only to the maxillary sinus. This study was designed to assess the outcomes of the CFP approach versus ESS (comprising MMA) in the management of COS.

METHODS

A prospective study was performed on patients with COS produced by odontogenic infections (periapical granulomas or small inflammatory cysts of the molars or bicuspids), oroantral fistula (OAF), large odontogenic cysts, and maxillary foreign bodies (dental fillings, teeth roots, and implants). Patients were randomly allocated into two groups: 56 patients underwent CFP and in 54 patients the maxillary sinus was approached through MMA. After a mean follow-up of 18.5 months, recurrence rates were compared between the two groups.

RESULTS

During the follow-up period, OAF recurred in 10 patients: 4 in the MMA group (7.4%) and 6 in the CFP group (10.7%). The difference is not statistically significant (p = 0.39, Fisher exact test).

CONCLUSION

In patients with COS a conservative approach with avoidance of endonasal surgery is suggested: in COS without a fistula, CFP at the time of dental treatment will be sufficient. In OAF cases, CFP yielded similar results with MMA. Nevertheless, additional study with a larger sample and a longer follow-up is required to validate these results.

Canalis sinuosus: a rare anatomical variation

The infraorbital canal issues a small branch on its lateral face close to its midpoint to allow passage of the anterior superior alveolar nerve. This small canal, sometimes called the canalis sinuosus, runs forward and downward to the inferior wall of the orbit, lateral to the infraorbital canal and medially bent to the anterior wall of the maxillary sinus, passing below the infraorbital foramen. Anatomical variations in the maxilla are rarely described in the literature and, in most cases, are related to the nasopalatine canal. This article describes a rare anatomical variation of the presence of a bilateral accessory canal extending from the nasal cavity lateral wall to an accessory foramen located on the hard palate, adjacent to the maxillary lateral incisor observed in cone beam computed tomography (CBCT) images. This case is an anatomical variation of the anterior superior alveolar nerve (canalis sinuosus). Identification of individual anatomical variations, especially on CBCT, may help the surgeon to avoid injuries to nerves during implant placement.

Importance of ENT assessment in stratifying candidates for sinus floor elevation: a prospective clinical study

OBJECTIVES

The aim of this article was to describe our experience in the field of preoperative ear, nose and throat (ENT) assessment in each candidate for (maxillary) sinus floor elevation (SFE) after the introduction of a systematic protocol. The protocol evaluates the sinus compliance by means of ENT preliminary examination with nasal fiberoptic endoscopy to identify all of the situations that may predispose to post-lifting complications, i.e. potentially irreversible (PIECs) and presumably reversible (PRECs) ENT contraindications to SFE, and to evaluate its impact on SFE success.

MATERIAL AND METHODS

Patient candidates for SFE were carefully assessed by means of case-history collection, complete ENT evaluation with nasal fiberoptic endoscopy and imaging to detect PIECs, PRECs, or no ENT contraindications for SFE. In case of PRECs, SFE was postponed until complete clinical recovery. Impact of preoperative ENT assessment on SFE outcome was assessed by means of post-lifting telephonic interview and ENT evaluation.

RESULTS

PRECs were detected and resolved before SFE was performed in 38.2% of our 34 patients; no intra- or post-lifting complications occurred in the patients with no ENT contraindications or PRECs.

CONCLUSIONS

The results of the study suggest that a careful multi-tasking preoperative management, including an ENT assessment with fiberoptic endoscopy and a radiological evaluation extended to the ostio-meatal complex, is very useful in candidates for SFE.

A review of the mandibular and maxillary nerve supplies and their clinical relevance

Mandibular and maxillary nerve supplies are described in most anatomy textbooks. Nevertheless, several anatomical variations can be found and some of them are clinically relevant. Several studies have described the anatomical variations of the branching pattern of the trigeminal nerve in great detail. The aim of this review is to collect data from the literature and gives a detailed description of the innervation of the mandible and maxilla. We carried out a search of studies published in PubMed up to 2011, including clinical, anatomical and radiological studies. This paper gives an overview of the main anatomical variations of the maxillary and mandibular nerve supplies, describing the anatomical variations that should be considered by the clinicians to understand pathological situations better and to avoid complications associated with anaesthesia and surgical procedures.

First clinic experience: patient selection and outcomes for ostial dilation for chronic rhinosinusitis

BACKGROUND

To report outcomes for subjects undergoing balloon dilation in either the operating room (OR) or the clinic and define criteria to identify suitable candidates for local anesthesia procedures.

METHODS

Subjects with medically refractory chronic rhinosinusitis (CRS) underwent de novo surgery via transantral balloon dilation of the maxillary sinus ostium and ethmoid infundibulum. Concomitant nasal or endoscopic sinus surgeries were contraindicated. Technical success, surgical parameters, and long-term outcomes were evaluated through 12-month follow-up.

RESULTS

Seventy-one subjects underwent balloon dilation and 94% completed follow-up through 12 months. A total of 132 maxillary ostia were targeted for treatment and 129 were successfully dilated (98%). Almost one-half (33) of the procedures were performed in the OR under local anesthesia with intravenous sedation. Average balloon procedure times for unilateral and bilateral treatment were 28.3 ± 21.1 and 40.2 ± 17.7 minutes, respectively. Thirty-three ostial dilations in 19 subjects were attempted in the clinic. Each ostium was successfully accessed and ballooned under local anesthesia. Patient tolerance was very good with an average self-reported pain level of 2.7 (2 = hurts a little bit) out of 10. Each subject was discharged within 2 hours of the procedure and there was no postoperative bleeding. Symptomatic improvement of the clinic subgroup at 3, 6, and 12 months postprocedure was statistically significant (p ≤ 0.0012) and clinically meaningful and similar in magnitude to improvement seen across all subjects regardless of site of service.

CONCLUSION

Transantral balloon dilation can be performed safely in the clinic and operative settings with symptom improvement sustained through 1 year.

Cadaveric comparison of canine fossa vs transnasal maxillary sinus access

OBJECTIVE

Anatomic limitations complicate complete eradication of debris from the maxillary sinus using an exclusively transnasal (TN) endoscopic technique. Creation of a canine fossa trephination (CFT) permits a more direct approach than removal via the maxillary ostium.

METHODS

Microdebrider eradication of debris completely filling the maxillary sinus was performed on 5 thawed fresh-frozen cadaver heads (10 sides) using a TN or CFT approach. Postdebridement computed tomography (CT) scanning assessed remaining debris. Additional outcome measures included time of debris removal, number of different angled blades utilized, and clogging.

RESULTS

A significantly greater amount of debris was left after the TN approach compared with CFT (3.88 cm(3) vs 2.88 cm(3), p = 0.015). Median blade utilization was significantly higher with the TN approach vs CFT (4 vs 1, p < 0.002). Time for debris eradication with CFT was similar regardless of expertise (323.4 vs 272.4 seconds, p = 0.21), but the TN approach showed a statistical difference in time-to-completion (698.8 vs 438.51 seconds, p = 1.7 × 10(-5)).

CONCLUSION

Controversy surrounds the appropriate application of CFT due to disease process and approach-related morbidity. Rhinologists should have numerous well-studied options at their disposal. This model suggests that maxillary debris removal is accomplished more thoroughly with fewer microdebrider blades when a CFT approach is employed.

Prevention and management of complications in maxillary sinus surgery

This article is divided into six sections that are related to six commonly used operations for surgery on the maxillary sinus. The authors discuss maxillary sinoscopy, the Caldwell-Luc procedure, extended middle meatus antrostomy, endoscopic maxillary sinus antrostomy, minimally invasive sinus technique, and balloon sinus procedures. In each of these procedures, the authors discuss potential complications and address prevention and management strategies. Maxillary sinus surgery can greatly improve patients' symptoms and disease process. The authors encourage the surgeon to take great care in ensuring sound surgical principles. Understanding the potential areas in which surgery can fail will help tremendously in preventing complications.

Weakness of buccal branch of facial nerve after canine fossa puncture

Objective:

We report a case of weakness of the buccal branch of the facial nerve after a canine fossa puncture procedure.

Method:

A case report and literature review are presented.

Results:

A 52-year-old woman diagnosed with right chronic maxillary sinusitis underwent canine fossa puncture during endoscopic sinus surgery. Immediately after the operation, she complained of motor weakness of the right upper lip and oral commissure, in the area innervated by the buccal branch of the facial nerve. Electroneurography revealed incomplete paralysis of the right buccal branch. However, facial weakness had recovered spontaneously by three months post-operatively, with no permanent disability.

Conclusion:

This is the first reported case of an injury to the buccal branch of the facial nerve following canine fossa puncture. Although the incidence of this complication is very low, surgeons should inform their patients of the possibility, and should take care when choosing the puncture site.

Application of minimally invasive endoscopic sinus surgery techniques

New instrumentation and techniques for endoscopic sinus surgery (ESS) are presently available that offer the potential of successfully treating recalcitrant chronic rhinosinusitis is a manner that minimizes operative times, sinus-mucosal trauma, and operative costs. This content describes current ESS techniques and quality-of-life outcomes, techniques for transnasal and transantral balloon catheter dilatation, and their outcomes. The authors address the changing medical climate that may open new avenues for surgeons to treat patients.