Odontogenic sinusitis: classification, etiology, pathogenesis, clinical features, differential diagn...
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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.



SUBACUTE SINUSITIS 3 weeks-3 months



Bloked nose



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




1.Periapical abscess

2.Periodontal diseases

3.Infected dental cyst

4.Dental material in antrum

5.Oroantral communication

1.Periapical abscess

Acute sinusitis

Anaerobic organisms

2.Periodontal diseases

Lane & O’Neal

Chronic sinusitis

5 years 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


third molar > second molar > canine

Pa or occlusal film loss of lamina dura


3.Root canal overfilling



  • 1.Antral puncture and sinus irrigation

2.Intranasal antrostomy or Nasoantral Window

3.Caldwell – luc operation

3.Caldwell – luc operation

Normal Anatomy

Mandibularcondyle (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 attachment

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


Complete anterior disc displacement

medial section


Open-mouth MRI

Lateral disc displacement and normal bone

Medial disc displacement

coronal MRI

Oblique coronal MRI

Posterior disc displacement



  • 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 effusion

  • 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



  • 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

Rheumatoid arthritis.

After 1 year

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. Obliquecoronal 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



Fibrous or bony union between joint components.

Growth Disturbances (Anomalies)


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

Condylar hypoplasia and facial asymmetry

Condylar Hypoplasia

Normal TMJ

Bifid condyle.

Inflammatory or Tumor-like Conditions

Calcium Pyrophosphate Dehydrate Crystal

Deposition Disease (Pseudogout)

Benign Tumors

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.

Temporomandibular Disorders(TMDs)

  • 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 muscles of mastication and joint

Joint sounds (popping, clicking)

Limited jaw motion

Jaw locking open or closed


Teeth grinding

Abnormal swallowing

Uncomfortable “off” bite

Inability to comfortably open/close mouth


Ringing in the ears

Visual disturbances


Tingling in hands/fingers

Deviation of jaw to one side


TMJ Anatomy

  • 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.

TMD Treatment

  • Working together:

    • Dentists

    • Orthodontists

    • Psychologists

    • Physical Therapists

    • Ear, Nose, Throat Doctor

    • Physicians

    • Alternative Medicine

TMD Examination

  • MRI

  • X-Ray

  • Dental examination for bite alignment

Physical Therapy Treatment

  • 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

TMJ Evaluation

  • 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


Electromyographic (EMG) Biofeedback

Dental Splint

Types of Treatment

Improve muscular coordination

Increase muscular strength

Postural exercises

Active ROM exercises

Muscles of mastication

Cervical spine muscles

General mobility

Therapeutic Exercise

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.

Techniques: Tongue Proprioception and Control

Techniques: Control ofJaw Muscles

  • 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:


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


Anterior Glide

Same hand placement

Slightly distract using DIP of thumb while gliding anteriorly

Oscillate for 30 seconds

Joint Mobilizations

Joint Mobilizations

  • 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


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

Preventing TMD

A & P : TMJ


  • 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

Surgical Intervention:Special Considerations

  • 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

Surgical Intervention: Positioning

  • 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

Surgical Intervention: Special Considerations/Incision

  • Special considerations

    • Nasal intubation

    • Prophylactic antibiotics & steriods

  • State/Describe incision

    • Small stab incision w/# 11 before trocar is introduced at superior joint space

Surgical Intervention: Supplies

  • 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)

Surgical Intervention: Supplies cont’d

  • 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

Surgical Intervention: Instruments

  • 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

Surgical Intervention: Equipment

  • General: suction system

  • Specific

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

    • Fluid infusion system

    • Bipolar ESU

    • Holmium laser

Surgical Intervention: Procedure Steps

  • 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.

Surgical Intervention: Procedure Steps

  • 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

Surgical Intervention: Procedure Steps

  • 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

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