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 & ONeal
Chronic sinusitis
5 years irrigation + antibiotics
examination 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 loss of lamina dura
2.Implant
3.Root canal overfilling
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 Open-

mouth
MRI
Lateral disc displacement and normal bone
Medial disc displacement

coronal MRI Oblique coronal M

Posterior disc displacement
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
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

Pain (in active disease) from joints

Restricted mouth opening capacity

Morning stiffness, in particular stiff neck

Dental occlusion problems; my bite doesnt fit
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
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.
 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
 Facial pains/Muscle
spasms
Pain/tenderness in the Uncomfortable off bite
muscles of mastication Inability to comfortably
and joint
open/close mouth
Joint sounds (popping,
clicking) Dizziness/vertigo
Limited jaw motion Ringing in the ears
Jaw locking open or Visual disturbances
closed Insomnia
Headaches Tingling in
Teeth grinding hands/fingers
Abnormal swallowing Deviation of jaw to one
side
 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.
 Working together:
Dentists
Orthodontists
Psychologists
Physical Therapists
Ear, Nose, Throat Doctor
Physicians
Alternative Medicine
 MRI
X-Ray
Dental examination for bite alignment
 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
 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
 Therapeutic Exercises
Manual Therapy
Modalities
Electromyographic
(EMG) Biofeedback
Dental Splint
 Improve muscular Muscles of
coordination mastication
Increase muscular Cervical spine
strength muscles
Postural exercises General mobility
Active ROM exercises
 Make a clicking Place tip of tongue on
sound with the tongue palate behind teeth and
on the roof of the draw small circles.
mouth. This slightly
opens the jaw with the Place tip of tongue on
tongue on the palate hard palate and blow
behind the front teeth, air out, rolling the
which is the resting tongue, or making a r r
position of the jaw and r r sound.
the first portion of
relaxation exercises.
 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.
 Long Axis Distraction: Anterior Glide
Sitting/Supine
Same hand placement
PT positioned opposite of
affected side Slightly distract using
Use hand opposite of DIP of thumb while
affected jt. side gliding anteriorly
Thumb in mouth on last
molar Oscillate for 30
Apply gentle downward seconds
pressure with thumb
Hold for ~30 seconds 2-
3x/session
Bilaterally
 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
 Avoid: Relaxation techniques
Large bites to reduce
Excessive chewing stress/muscle tension
Removing food from teeth
with tongue Maintain good
Gum chewing posture
Chewy foods: bagels,
sandwiches, steak, ice,
crunchy fruits/vegetables,
caramel, nuts etc.
 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
 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
 Position during procedure
Supine w/head donut pillow, tuck arms to side
Supplies and equipment
Arm sleds, headring pillow
Special considerations: high risk areas
Elbowsulnar 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
 Special considerations
Nasal intubation
Prophylactic antibiotics & steriods
State/Describe incision
Small stab incision w/# 11 before trocar is
introduced at superior joint space
 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 pts face; moistened
cotton in external auditory canals, irrigation collection
pouch at base of ear and TMJ)
 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
 General: suction, Lactated Ringers 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
 General: suction system
Specific
Monitor/light source/camera tower, shaver control
unit, IV pole for irrigant
Fluid infusion system
Bipolar ESU
Holmium laser
 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.
 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
 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
Thank you