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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.

Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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Page 1: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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.

Page 2: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,
Page 3: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

CLINICAL SYMPTOMS

ACUTE SINUSITIS < 3 weeks

SUBACUTE SINUSITIS 3 weeks-3 months

CHRONIC SINUSITIS > 3 months

Page 4: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

SYMPTOMSBloked 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

Page 5: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

MAXILLARY SINUSITIS

FROM DENTAL ORIGIN

1.Periapical abscess

2.Periodontal diseases

3.Infected dental cyst

4.Dental material in antrum

5.Oroantral communication

Page 6: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

1.Periapical abscessAcute sinusitis

Anaerobic organisms

2.Periodontal diseases

Lane & O’Neal

Chronic sinusitis

5 years irrigation + antibiotics

examination communication with the maxillary

sinus via a periodontal pocket

Page 7: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

3.Infected dental cystPeriapical cyst

Most common of all cysts of the oral region

Epithelium rest of Malassez

The cyst enlarges in to the maxillary sinus

Page 8: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

4.Dental material in antrum

1.Displacement of root

extraction

third molar > second molar > canine

Pa or occlusal film loss of lamina dura

2.Implant

3.Root canal overfilling

Page 9: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

CASE REPORTS

Page 10: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

CASE REPORTS

Page 11: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

1.Antral puncture and sinus irrigation

Page 12: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

2.Intranasal antrostomy or Nasoantral Window

Page 13: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

3.Caldwell – luc operation

Page 14: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

3.Caldwell – luc operation

Page 15: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Mandibular condyle (head)Glenoid fossaArticular

tubercle (eminence)

Page 16: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Lateral pterygoid muscle raphe Lower head of lateral pterygoid muscle

Anterior band of articular disc

Mandibular condyle (head)

Posterior band of articular disc

Posterior disc attachment

Page 17: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Mandibular condyle (head)

Articular disc

Page 18: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

MRI and autopsy sections: upper row oblique sagittal MRI, asymptomatic volunteer: left lateral, middle medial, rightopened mouth

Page 19: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

lateral sectionscentral sections open-mouth

Partial anterior disc displacement at baseline

Page 20: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Complete anterior disc displacement

Open-mouth MRI

medial section Autopsy

Page 21: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Lateral disc displacement and normal bone

Page 22: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Medial disc displacement

Oblique coronal MRIcoronal MRI

Page 23: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Posterior disc displacement

Page 24: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Definition 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 Crepitation sounds from joint(s) Restricted or normal mouth opening capacity Pain or no pain from joint areas and/or of

mastication muscles Occasionally, joints may show inflammatory

signs Women more frequent than men

Page 25: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

anteriorly displaced and deformed, degenerated disc and irregular cortical outline with osteophytosis and sclerosis of condyle .

Page 26: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Advanced osteoarthritis and anterior disc displacement, with joint effusion

Page 27: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Imaging Features•Abnormal signal on T2-weighted image fromcondyle 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 advancedosteoarthritis without osteonecrosis, or osteonecrosis

Page 28: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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 Pain (in active disease) from joints Restricted mouth opening capacity Morning stiffness, in particular stiff neck Dental occlusion problems; “my bite doesn’t fit” Crepitation due to secondary osteoarthritis

Page 29: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

After 1 year

Page 30: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Rheumatoid arthritis. A MRI shows completely destroyed disc, replaced by fibrous or vascular pannus and cortical punched-out erosion (arrow) with sclerosis in condyle.

Page 31: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Psoriatic arthropathy. Oblique coronal and oblique sagittal CT images show punched-out erosion in lateral part of condyle (arrow).

Psoriatic arthropathy. MRI shows contrast enhancementwithin bone erosion and in joint space, consistent with thickened synovium/pannus formation. OpenmouthMRI shows reduced condylar translation but normallylocated disc (and normal bone in this section)

Page 32: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Inflammatory arthritis

Page 33: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

DefinitionFibrous or bony union between joint components.

Page 34: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

DefinitionAbnormal growth of mandibular condyle; overgrowth, undergrowth, or bifid appearance.

Page 35: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Normal TMJ

Condylar Hypoplas

ia

Condylar hypoplasia and facial asymmetry

Page 36: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Bifid condyle.

Page 37: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Calcium Pyrophosphate Dehydrate CrystalDeposition Disease (Pseudogout)

Page 38: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Synovial Chondromatosis 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.

Page 39: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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

Page 40: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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

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

Page 41: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Osseous Anatomy 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.

Page 42: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Working together: Dentists Orthodontists Psychologists Physical Therapists Ear, Nose, Throat Doctor Physicians Alternative Medicine

Page 43: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

MRI X-Ray Dental examination for bite alignment

Page 44: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Physical Therapy is an important aspect in the treatment for TMD to: Relieve

musculoskeletal pain Decrease

inflammation Restore normal

joint/muscular movements for oral motor function

Correct poor posture

Page 45: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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

Page 46: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Therapeutic Exercises

Manual Therapy Modalities Electromyographic

(EMG) Biofeedback Dental Splint

Page 47: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Improve muscular coordination

Increase muscular strength

Postural exercises Active ROM

exercises

Muscles of mastication

Cervical spine muscles

General mobility

Page 48: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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.

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.

Page 49: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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.

Page 50: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Long Axis Distraction: 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

2-3x/session Bilaterally

Anterior Glide Same hand

placement Slightly distract

using DIP of thumb while gliding anteriorly

Oscillate for 30 seconds

Page 51: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Lateral Glide Thumb on tongue side of last molar Use whole hand to oscillate laterally

Medial Glide Stand on affected side Thumb on lateral side of last molar Glide medially

Page 52: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Avoid: Large bites Excessive chewing Removing food from

teeth with tongue Gum chewing Chewy foods: bagels,

sandwiches, steak, ice, crunchy fruits/vegetables, caramel, nuts etc.

Relaxation techniques to reduce stress/muscle tension

Maintain good posture

Page 53: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,
Page 54: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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

Page 55: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Patient Factors Outpatient H& P, Blood chemistries, CBC, PT, PTT, U/A,

serum HCG, Chest x-ray or ECG as appropriate Room Set-up

X-rays in room

Page 56: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Position during procedure Supine w/head donut pillow, tuck arms to side

Supplies and equipment Arm sleds, headring pillow

Special considerations: high risk areas Elbows—ulnar nerves

Prep 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

Page 57: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Special considerations Nasal intubation Prophylactic antibiotics & steriods

State/Describe incision Small stab incision w/# 11 before trocar is

introduced at superior joint space

Page 58: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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)

Page 59: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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

Page 60: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

General: suction, Lactated Ringer’s IV bag for irrigation, marking pen

Specific TMJ instrument set

0 degree arthroscope 30-degree arthroscope 70-degree arthroscope Cannulas Sharp & dull obturators

Light cord, camera & cord, small joint rotary shaver

Page 61: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

General: suction system Specific

Monitor/light source/camera tower, shaver control unit, IV pole for irrigant

Fluid infusion system Bipolar ESU Holmium laser

Page 62: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Irrigation solution is injected into the joint space to distend the capsule 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. #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.

Page 63: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

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 Pass skin knife. Prepare additional equipment

(probe, shaver, grasper) Final visual inspection is performed

Additional photos may be taken

Page 64: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Cannuale are removed and excess fluid removed Prepare for closure; count

Wound is closed and dressing placed Pass suture; prepare dressings, reorganize

equipment & supplies if procedure is bilateral Steps may be repeated contralaterally

Repeat steps

Page 65: Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagnosis, treatment, complications, prevention. arthritis,

Thank you