The close anatomical relationship of the maxillary sinus with theroots of maxillary molars, premo-lars and, occasionally, canines ren-ders this… [607431]

B-ENT , 2006, 2, 167-175
Introduction
The close anatomical relationship
of the maxillary sinus with theroots of maxillary molars, premo-lars and, occasionally, canines ren-ders this anatomical region suscep-tible to morbid situations resultingfrom damage to, and therapeuticintervention in, the dento-alveolarenvironment (Figure 1). Stafne
1
estimated that 15-75% of sinusitiscases have a dental cause, althoughthe true incidence is difficult todetermine accurately. The dental
literature contains several references
to the extension of periapicalinflammation to the maxillarysinus.
2-7Several reports have also
been published describing seriouscomplications resulting from theextension of these inflammations,including periorbital cellulitis,
blindness, and even life-threatening
cavernous sinus thrombosis.8-9
The introduction of bacteria
and their products into the pulpchamber can result in inflamma-tion of the pulp tissue and subse-quently, in its devitalisation. Thenecrotic and infected pulp affectsthe periapical tissue. The purposeof root canal or endodontic treat-ment is to maintain the healthystatus of the tissues that surrounda tooth’s root, despite the fact thatthe tooth’s pulp has undergonedegenerative changes. Specifi-cally, our goal is to protect the tis-sues surrounding a tooth’s rootfrom bacterial infection and/orirritating substances leaking fromthose inner surfaces of the toothoriginally occupied by the tooth’snerve tissue. To accomplish thistask during endodontic treatment,the infected pulp tissue should beremoved, together with part of thedentin surrounding the root canal,with the help of mechanicalinstruments and chemicals. Filesand reamers are used to removethe remnants of the pulp tissue andto scrape off the infected dentin,and antiseptics such as sodiumhypochlorite and calcium hydrox-ide are used to maintain an asepticenvironment. Antibiotics have notbeen found useful. In this way, theinfection is eliminated inside theroot canal. The expansion of theroot canal infection to the periapi-cal tissues can lead to a periapicalpathological situation such as aperiapical cyst, a granuloma or anabscess.
Maxillary sinus involvement
may occur during endodontic pro-cedures because of the extensionof periapical infections into thesinus, the introduction of endo-dontic instruments and materialsbeyond the apices of teeth in closeproximity to the sinus and therisks and complications associatedwith endodontic surgery.
The pathological disruption of
both periapical and adjacent antraltissues resulting from endodonticinfection has been well document-ed.
2-5Selden coined the termThe maxillary sinus and its endodontic implications: clinical study and review
V . R. Nimigean *, V . Nimigean **,N . M a ˘ru**, D. Andressakis ***, D. G. Balatsouras **** and V . Danielidis *****
*Oral Rehabilitation Department and **Clinical and Topographical Anatomy Department, Faculty of Dentistry, Carol
Davila University of Medicine and Pharmacy, 5 Calea Plevnei, Sector 5, Bucharest, Romania; ***Dentistry Departmentof Tzanion General Hospital, 1 Afentouli & Zanni, Piraeus, Greece; ****ENT Department of Tzanion General Hospital,1 Afentouli & Zanni, Piraeus, Greece; ****Department of Otorhinolaryngology, School of Medicine, DemocritusUniversity of Thrace, Dragana, Alexandroupolis, Greece
Key-words. Maxillary sinusitis; odontogenic sinusitis; dental disease/complications; endodontics
Abstract. The maxillary sinus and its endodontic implications: clinical study and review. Objectives : Endodontic infec-
tions of posterior maxillary teeth sometimes spread to the maxillary sinus, generating severe complications. The aim ofthis study is to present the various problems encountered during endodontic treatment of these teeth. Methods : The files of 125 cases of odontogenic chronic maxillary sinusitis were reviewed retrospectively.
Results : Chronic apical periodontitis was the cause in 99 cases and traumatising endodontic treatment in 26 cases.
Foreign intrasinusal bodies were occasionally seen as a consequence of different endodontic treatments of posteriormaxillary teeth.Conclusions : A knowledge of dento-antral relationships is particularly important in the prevention of sinal accidents and
complications during various therapeutic manoeuvres, which should be performed according to and depending on theregional morphology.

168 V . R. Nimigean et al.
“endo-antral syndrome” (EAS)
for the spread of pulpal diseasebeyond the confines of the dentalsupporting tissues into the sinus.
4,5
The characteristics of EAS are:(1) pulpal disease in a tooth ofwhich the apex approximates thefloor of the maxillary sinus;(2) periapical radiolucencies onpulpally involved teeth; (3) radio-graphic loss of the lamina duradefining the inferior border of themaxillary sinus over the pulpallyinvolved tooth; (4) a faintlyradiopaque mass bulging into thesinus space above the apex of theinvolved tooth, connected neitherto the tooth nor the lamina dura ofthe tooth socket (representing alocalised swelling and thickeningof the sinus mucosa); and(5) varying degrees of radiopacityof the surrounding sinus space(comparison of the contralateralsinus is often helpful).
4,5The vari-
able presentation of EAS can cre-ate diagnostic and therapeutic dif-ficulties, because all five featuresare not always evident.
The aim of this study was to
examine the relation between theteeth and the maxillary sinuses,and therefore to prevent damageduring the various stages ofendodontic therapy.
Materials and methodsThe study included 309 patients
referred for endodontic treatmentto the Oral Maxillary and FacialSurgery Clinic of the Carol DavilaUniversity of Medicine andPharmacy of Bucharest over aperiod of 2 years. One hundredand twenty-five of them sufferedfrom chronic maxillary sinusitiscaused by various odontogenicproblems and the consequences ofendodontic treatment. The inclu-sion criteria were:
– chronic maxillary sinusitis
diagnosed on clinical and radio-logical grounds;
– lack of response to medical or
surgical treatment;
– presence of various related
problems in posterior maxillaryteeth;
– cure after appropriate endodon-
tic treatment.
The files of these 125 patients
were reviewed retrospectively.Results
The patients ranged in age from
12 to 81 years (mean 46.5 years).The age range of 66 patients was30-60 years. Sixty-nine (55.3%)of them were female and 56(44.7%) were male. In 99 patients(79.2%), the cause of sinusitis waschronic apical periodontitis and,in another 26 cases (20.8%), trau-matising endodontic treatmentwas probably implicated (syn-drome EAS). All patients hadreceived medical treatment,including antibiotics and anticon-gestants, without success. Twelvepatients had been operated withCaldwell-Luc procedures, but thesymptoms of maxillary sinusitisremained unchanged or had slight-ly improved.
Among the 99 cases of chronic
periapical periodontitis (Figure 2),12 patients presented periapicalcysts, which had either graduallydestroyed the alveolo-sinusal boneplate (9 cases) or showed intra-sinusal invasion (3 cases)(Figures 3,4). In the group of26 cases with traumatising endo-dontic treatment, 16 presented
Figure 1
Maxillary molars in close proximity to the sinus. The arrowshows the lamina dura.Figure 2
Thickened sinus mucous membrane as a result of chronicapical periodontitis at 25.

Maxillary sinus and endodontics 169
with foreign intrasinusal bodies
from various endodontic treat-ments of posterior maxillary teeth(Figure 5).
In the present study we found
the presence of Selden endo-
antral syndrome as an endodontic
complication in 35.9% of thepatients.
Mucosal thickening was
observed in 115 patients, fluidaccumulation in 7 patients, andbony wall thickening in 3 patients.Severe symptoms such as pain andnasal obstruction were limited tothe 7 patients who had fluid accu-mulations on CT images.
Figure 3
Large periapical cyst in the left maxillary area with extensioninto the maxillary sinus.
Figure 4a
Large cyst in the periapical area of 16 after failure of endodon-tic treatment (panoramic X-ray).
Figure 4b
CT scan, axial view
Figure 4c
CT scan, coronal view
Figure 4d
CT scan, lateral view

170 V . R. Nimigean et al.
The following causal teeth were
identified: M 2 (32.4%); M 1
(30.6%); PM 2(23.7%); M 3
(6.8%); PM 1(5.6%); C (0.9%).
Conventional endodontic treat-ment was performed in 77 cases,endodontic re-treatment in26 cases and apicectomy in22 cases. After appropriateendodontic treatment, completeremission of the disease occurredin all 7 patients with severe sinusi-tis, and improvement of the symp-toms and the radiological findingswas observed in the other patients.
DiscussionThe maxillary sinus is the first of
the paranasal sinuses to develop inhuman foetal life. During the fifthfoetal month, secondary pneuma-tisation starts as the maxillarysinus grows beyond the nasal cap-sule into the maxilla. At birth, thesinus is approximately 10
/H110033/H11003
4 mm in dimension and continuesto grow slowly until the age of7 years when expansion occursmore rapidly until permanent teethhave erupted. The average dimen-sions of the maxillary sinus of theadult are 40
/H1100326/H1100328 mm with
an average volume of 15 mL.10,11The maxillary sinus is typically
pyramidal in shape, with the baseof the pyramid forming the lateralnasal wall and the apex extendinginto the zygoma.
11The anatomical
relation between the maxillarysinus and maxillary teeth is a com-plex one, owing to the variableextension of the sinus. In about50% of the population, it mayexpand into the process of themaxilla, forming an alveolarrecess. In these cases, the maxil-lary sinus is in close relation to theroots of the maxillary molar andpremolar teeth, particularly thesecond premolar and the first andsecond permanent molars. In rarecases the sinus floor can extend asfar as the region of the canineroot.
12The sinus floor exhibits
recesses extending between adja-cent teeth or between individualroots of teeth. The alveolar bonecan become thinner with increas-ing age, particularly in the areassurrounding the apices of teeth, sothat root tips projecting into thesinus are covered only by anextremely thin (sometimes absent)bony lamella and the sinus mem-brane. The deepest point of themaxillary sinus is normally locat-ed in the region of the molar roots,with the first and second molarsbeing the two most commonlydehiscent teeth in the maxillarysinus at 2.2% and 2% respective-ly.
13However, with extensive
pneumatisation, the third molar,premolars and canine teeth mayall be exposed into the sinus.
11
Several studies have reported therelative positions of the roots withrespect to the sinus.
14,15According
to these studies, the frequency ofclose proximity (0.5 mm or less)of roots of posterior maxillaryteeth to the sinus floor is: secondmolars 45.5%, first molars 30.4%,second premolars 19.7% and firstpremolars 0%.
15
Two radiographic studies clas-
sified the relationship between theroots of the maxillary teeth andthe sinus inferior wall. Freisfeld et
al.
16described 3 types of vertical
relationships and, more recently,Kwak et al.
17used the Dentascann
reformatted cross-sectionedimages and suggested 5 verticalrelationships: Type I, inferior wallof the sinus located above thelevel connecting the buccal andpalatal root apices; Type II, inferi-or wall of the sinus located belowthe level connecting the buccaland palatal root apices, without anapical protrusion over the inferiorwall of the sinus; Type III, apicalprotrusion of the buccal root apexobserved over the inferior wall ofthe sinus; Type IV , apical protru-sion of the palatal root apexobserved over the inferior wall ofthe sinus; and Type V , apical pro-trusions of the buccal and palatalroot apices observed over the infe-rior wall of the sinus. In addition,the horizontal relationshipsbetween the inferior wall of themaxillary sinus and the roots ofthe maxillary molars were allocat-ed to 3 categories: Type 1, alveo-lar recess of the inferior wall of
Figure 5
Root overfilled with paste in the maxillary sinus, leading tochronic maxillary sinusitis (teeth 14, 15, 16).

Maxillary sinus and endodontics 171
the sinus located more towards the
buccal side than towards the buc-cal root; Type 2, alveolar recess ofthe inferior wall of the sinus locat-ed between the buccal and palatalroots; and Type 3, alveolar recessof the inferior wall of the sinuslocated more towards the palatalside than towards the palatal root.The authors found that the mostfrequent vertical relationship wasa sinus floor that did not contactthe dental roots and that the mostfrequent horizontal relationshipwas sinus recess located betweenthe buccal and palatal roots.
The patient with suspected
maxillary sinus disease of odonto-genic origin should be examinedclinically. The affected sinus maybe markedly tender to tapping orpalpation.
18The teeth affected by
sinusitis will be moderately orextremely sensitive to palpationand/or percussion, but willrespond within normal limits toconventional pulp sensitivity tests.Pain typically radiates to all theposterior teeth of the quadrant, sothat all the teeth usually becometender to percussion. The nasalpassage of the affected side maybe partially or completelyblocked. Nasal discharge is con-sidered to be a significant sign ofthe sinus infection. Severe acuteor subacute sinusitis rarely pro-duces fever, but a severe fulminat-ing sinusitis will produce a hightemperature and some degree ofmalaise. If only one tooth demon-strates tenderness to percussion,this may be the source of the diffi-culty and sinusitis may be exclud-ed. Radman
19suggested the place-
ment of a cotton swab saturatedwith 5% lidocaine in the nostril ofthe affected side as a differentialdiagnostic test. The swab shouldbe placed posterior to the area ofthe middle meatus and left inplace for 20-30 seconds. If thepain is of sinusal origin it will bemodified or eliminated within 1-2 minutes and therefore lead to thepresumptive diagnosis of maxil-lary sinusitis. Similarly, the use ofa topical nasal decongestant mayhelp in differentiating betweenpain caused by sinusitis and painof dental origin. In contrast to painof sinusal origin, pain of dentalorigin is much more variable andranges from thermal sensitivitiesto spontaneous episodes of sharpand unrelenting severe pain andmay be associated with regionalswelling and cellulitis. Inadvanced dental disease, radi-ographic involvement is usuallyapparent.
Diagnostic evaluation of the
maxillary sinus may be obtainedby radiographic examination. Awide variety of exposures readilyavailable in the dental surgery,otolaryngology, or radiology clin-ic are available.
20,21These include
periapical, panoramic and facialviews, which may provide ade-quate information to either con-firm or rule out pathology. Onperiapical radiographs, the borderof the maxillary sinus appears as athin, delicate tenuous radiopaqueline and is seen as a fusion of thelamina dura and the floor of thesinus.
22This view may fail to show
lamina dura covering the rootapex in areas with defective bonycovering.
The lamina dura is the thin hard
layer of bone that lines the socketof a tooth and that appears as adark line in radiography(Figure 1). It surrounds the peri-odontal ligament and consists ofbundle bone. This type of boneusually forms attachments of ten-dons and ligaments in differentparts of the human bone structure,and it is usually more calcifiedthan other types of bone. The dis-ruption of the continuity of thelamina dura in the periapical areais the first sign of periapicalpathology resulting from dentalroot canal infection. This fact is ofgreat clinical importance as it canlead to the early diagnosis ofendodontic infections.
Panoramic radiography pro-
vides an extensive overview of thesinus floor and its relationshipwith the dental roots. It allows forthe determination of the size ofperiapical lesions and cysts aswell as radio-dense foreign bod-ies. Furthermore, local swelling ofthe sinus membrane and opacitiescan be diagnosed.
12,21
Periapical and panoramic radi-
ography are routinely used for thediagnosis, treatment, and monitor-ing of the healing process of peri-apical lesions. These techniquescompress three-dimensionalanatomic structures into two-dimensional images, resulting inthe superimposition of anatomicstructures onto the features ofdiagnostic interest, sometimes tothe extent of concealing the latter.It is well known that, under certainconditions, periapical lesions maynot be seen in intra-oral radio-graphs. These limitations becomeparticularly evident in the maxil-lary molar region with its complexanatomy. Other disadvantages arehorizontal and vertical magnifica-tion (10-33%) and a lack of cross-sectional information.
22,23
Additional information can be
obtained with the help of spe-cialised skull views.
22The occipi-
to-mental or Water’s projection isoptimal for the visualisation of theparanasal sinuses, including themaxillary sinuses. With varyingangles (15°, 30°, and 35°), it ispossible to compare internalanatomy, bony continuity and

172 V . R. Nimigean et al.
defects, as well as sinus pathology
or foreign objects.23Other images
that may be included are submen-tovertex, posteroanterior and later-al skull views. Unfortunately, thesensitivity of conventional radio-logical skull views is low and theyhave been replaced recently bycomputerized tomography (CT)that has become increasinglyimportant for the evaluation ofsinus disease.
22This modality pro-
vides multiple sections throughthe sinuses at different planes andtherefore contributes to the finaldiagnosis and determination of theextent of the disease.
9,22CT sur-
passes the limitations of conven-tional views owing to uniform lowmagnifications, but its disadvan-tages include limited availability,expense and the high radiationdose.
24Dentascan is a CT dental
reformatting program that allowsreconstruction of the mandibularor maxillary alveolar ridges indirect coronal and panoramicplanes (Figure 6). This softwarewas developed as a more accurateand sophisticated method of eval-uating the mandible and the max-illa for the purposes of dentalimplant technology. The imagespredominantly show the osseousanatomy of the jaw. However, thissoftware is not yet established inthe routine evaluation of the max-illary sinuses.
21
New approaches to evaluating
the maxillary sinuses with mag-netic resonance imaging (MRI)continue to develop rapidly.However, standard T1-weightedand T2-weighted images still pro-vide the basis of imaging.Advantages include better soft-tis-sue discrimination than with CTand easier multi-planar imageacquisition. The limitation of MRIis its inability to image bone dueto the lack of signal for corticalbone. In addition, the air withinthe sinus does not produce a signal. This makes evaluation ofthe bony anatomy and pathologydifficult. Currently, MRI is mainly useful in determining the spread of disease, especiallyintracranially and intraorbitally.Distinguishing between neoplasticand inflammatory tissue is anadditional advantage.
19,21
The radiographic appearance of
EAS usually varies consistentlyfrom normal appearance. The typical radiographic pathologicalEAS changes are: development ofa periapical radiolucent area; lossof the osseous lamina dura charac-teristically defining the inferiorborder of the maxillary sinus; the appearance of a faintly radio-paque rounded mass bulging into the sinus space above theapex of the involved tooth; andvarying degrees of radiopacity ofthe contiguous sinus space.
4,5
Radiographically, changes in thelower part of the sinus stronglyindicate odontogenic involvement,and this is a notable finding repre-senting the initial sign of dentalinfection that leads to severesinusitis.
20Other signs include
fluid accumulation and maxillarysinus wall thickening.
7In our
cases, the most frequent radi-ographic sign was mucosal thick-ening of the maxillary sinus.Other investigators agree with thisfinding.
7,22
Microscopically, the involved
areas showed the destruction ofthe bone separating the sinus fromthe teeth, with particular loss ofthe cortical bone normally foundon the sinus floor. In addition, thesinus mucosa was seriouslyaltered in many ways, such asswelling with inflammation, gran-ulation tissue, hypertrophy,fibrous changes, hyalinisation orcomplete necrosis.4In the past
these mucosal changes in the sinusled to the belief that the involvedteeth should be extracted.
25By
contrast, newer studies seem toindicate that most cases of EASwill respond satisfactorily to non-surgical root canal treatment. Asurgical approach has been recom-mended for cases refractory toroutine conservative manage-ment.
2,4
Root filling materials have,
occasionally, been reported ascausative agents of maxillarysinus fungus ball.
26,27Kopp et al.28
and Stammberger et al .29found
that the typical radiopaque maxil-lary sinus concretions seen inmore than 50% of the cases with
Figure 6
Dentascann view

Maxillary sinus and endodontics 173
diagnosed sinus fungus ball con-
sisted of iatrogenically placedendodontic materials. These find-ings were confirmed in a study byLegent et al .
30who reported that
85% of 85 reported cases of fun-gus ball of the maxillary sinuswere related to overextended rootcanal sealer in maxillary teeth.Stammberger et al.
29and Kopp et
al.28described the influence of
root-filling materials containingzinc oxide-eugenol on the patho-genesis of sinus fungus ball.According to this “dental” hypoth-esis, sinus fungus ball is caused byoverfilling of the root canal, withthe zinc oxide in the root fillingmaterial inducing the infection.However, Odell and Pertl
31found
that zinc oxide eugenol sealersshowed antifungal activity againstAspergillus . The cross-correlation
of endodontic therapy and fungusball continues to be controversial.
Pathological exposure of the
sinus floor predisposes many sur-gical endodontic procedures tomaxillary sinus communication.
4,32
The thickness of bone separatingthe apices of the teeth in the later-al segments of the maxilla fromthe sinus is shown to range from0.8 to 7 mm.
14Perforations of the
maxillary sinus following apicec-tomy of premolar and molar teethin the maxilla have been report-ed.
33,34Ericson et al .35found oro-
antral communications in 7.7% ofcanines, 8.8% of first premolars,26.1% of second premolars and40% in molars, whereas Freedmanand Horowitz
34found a rate of
23% for perforations in molars,13% in second premolars and 2%in first premolars.
Invasion of the maxillary sinus
does not seem to result in the per-manent alteration of either thesinus membrane or its physiologi-cal function. Selden
3andBenninger et al .36observed that
the mucous membrane, completewith cilia, regenerate in about fivemonths after total surgicalremoval. There is also agreementthat the sinus membrane willrecover from sinusitis, once prop-er ventilation is restored. Watzeket al.
37found no significant differ-
ence in the healing rate betweenpatients with and without intraop-erative sinus exposure in 146apicectomies. These findings wereconsistent with those of Ericson et
al.,
35who found no difference
between the results regardingtreatment outcome of apicec-tomies obtained in the groupswithout, and with, oro-antral com-munications. In the same study,the results of the operation in theoro-antral communication groupwith ruptured sinus mucosa didnot differ from those in the groupwith intact mucosa. Surgical treat-ment of maxillary teeth with peri-apical periodontitis refractory toconventional endodontic treat-ment is therefore recommended,regardless of the anatomical rela-tionship of the teeth to the maxil-lary sinus.
4However, it should be
noted that, in these cases, there isonly limited involvement of themaxillary mucosa, by contrastwith extensive mucosal strippingof the maxillary sinuses, as seen inthe Caldwell-Luc sinus opera-tions, which may be followed byextensive fibrosis and occasional-ly, massive osteitis. Even afterfunctional endoscopic sinussurgery, sinus mucosa repairsslowly and many pathologicalfindings are evident in the mucosasix months postoperatively, someof which may even be irre-versible.
38,39
In the present study we found
EAS as an endodontic complica-tion in a significant percentage ofthe patients, owing to dental sinusmorpho-pathological correlations.The knowledge of dento-antralrelationships is particularlyimportant in the prevention ofsinusal accidents and complica-tions during various therapeuticmanoeuvres, which should be per-formed according to and depend-ing on the regional morpholo-gy.
40,41To minimise the risk of
odontogenic sinus complications,it should be assumed that anythingintroduced in the root channels ofthe sinus teeth could create anaccess path to the sinus tissues.This fact requires a re-assessmentof drainage procedures, of endo-dontic medication and of knownbiologically compatible materials.Additionally, it is compulsory todetermine in advance the length ofthe root channel as accurately aspossible.
ConclusionsThe close anatomical relationship
of the maxillary sinus and theroots of maxillary molars, premo-lars, and, in some instances,canines, can lead to severalendodontic complications. Peri-apical periodontitis may result inmaxillary sinusitis of dental ori-gin, with resultant inflammationand thickening of the mucosal lin-ing of the sinus in areas adjacentto the involved teeth. In cases ofsinusitis of dental origin, conven-tional endodontic treatment or re-treatment is the treatment ofchoice, with surgical interventiononly indicated in refractory cases.Conventional root canal treatmentmay result in the perforation of thesinus floor in one or more treat-ment stages, with resultant irrita-tion and inflammation of themaxillary sinus mucosa. Thisinflammation may be due to

174 V . R. Nimigean et al.
over-instrumentation and/or inad-
vertent injection or extrusion ofirrigating intracanal medicaments,sealers, or solid obturation materi-als. Furthermore, endodonticsurgery performed on maxillaryteeth may result in sinus perfora-tion. Perforation caused duringendodontic surgery constitutes alow risk for the maxillary sinus,provided that there is a good
knowledge of the specific anatomic
conditions and an appropriate sur-gical procedure is applied. Rootends and/or materials may enterthe sinus during conventional orsurgical endodontic therapy, withthe need for subsequent surgicalapproach for their removal.
References
1. Stafne EC. Oral roentgenographic
diagnosis . WB Saunders,
Philadelphia; 1985.
2. Selden HS, August DS. Maxillary
sinus involvement – an endodonticcomplication. Report of a case. Oral
Surg Oral Med Oral Pathol.1970;30:117-122.
3. Selden HS. The interrelationship
between the maxillary sinus andendodontics. Oral Surg Oral Med
Oral Pathol . 1974;38:623-629.
4. Selden HS. The endo-antral syn-
drome: an endodontic complication. J
Am Dent Assoc. 1989;119:397-398,
401-402.
5. Selden HS. Endo-Antral syndrome
and various endodontic complica-tions. J Endod. 1999;25:389-393.
6. Kretzschmar DP, Kretzschmar JL.
Rhinosinusitis: review from a dentalperspective. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod.2003;96:128-135.
7. Obayashi N, Ariji Y , Goto M, et al .
Spread of odontogenic infection orig-inating in the maxillary teeth: com-puterized tomographic assessment.Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2004;98:223-231.
8. Ogundiya DA, Keith DA, Mirowski J.
Cavernous sinus thrombosis andblindness as complications of anodontogenic infection: report of acase and review of literature. J Oral
Maxillofac Surg. 1989;47:1317-1321.
9. Koch F, Breil P, Marroquin BB,
Gawehn J, Kunkel M. Abscess of theorbit arising 48 h after root canaltreatment of a maxillary first molar.Int Endod J. 2006;39:657-664.
10. Sadler TW. Langman’s MedicaI
Embryology. Williams & Wilkins,
Baltimore; 1995:312-346.
11. Bailey BJ. Head and Neck Surgery –
Otolaryngology . 2nd ed. Lippincott-
Raven Publishers, Philadelphia;1998:418-460.
12. Hauman CH, Chandler NP, Tong DC.
Endodontic implications of the maxil-lary sinus: a review. Int Endod J.
2002;35:127-141.
13. Lang J. Clinical Anatomy of the nose,
nasal cavity, and paranasal sinuses .
Thieme, New York; 1989.
14. Eberhardt JA, Torabinejad M,
Christiansen EL. A computed tomo-graphic study of the distancesbetween the maxillary sinus floor andthe apices of the maxillary posteriorteeth. Oral Surg Oral Med Oral
Pathol. 1992;73:345-346.
15. Killey HC, Kay LW. An analysis of
250 cases of oro-antral fistula treatedby the buccal flap operation. Oral
Surg Oral Med Oral Pathol.1967;24:726-739.
16. Freisfeld M, Drescher D,
Schellmann B, Schuller H. The maxil-lary sixth-year molar and its relationto the maxillary sinus. A comparativestudy between the panoramic tomo-gram and the computed tomogram [inGerman]. Fortschr Kieferorthop.
1993;54:179-186.
17. Kwak HH, Park HD, Yoon HR,
Kang MK, Koh KS, Kim HJ.Topographic anatomy of the inferiorwall of the maxillary sinus inKoreans. Int J Oral Maxillofac Surg.
2004;33:382-388.
18. Schow SR . Odontogenic diseases of
the maxillary sinus. In: Peterson LJ,Ellis E, Hupp JR, Tucker MR, eds.Contemporary Oral and Maxillo-facial Surgery . 2nd ed. Mosby, Year
Book, St Louis; 1993:465-482.
19. Radman WP. The maxillary sinus—
revisited by an endodontist. J Endod.
1983;9:382-383.
20. Yoshiura K, Ban S, Hijiya T, et al .
Analysis of maxillary sinusitis usingcomputed tomography. Dentomaxillo-
fac Radiol. 1993;22:86-92.21. Laine FJ. Diagnostic imaging of the
maxillary sinus. Oral Maxillofac Surg
Clin North Am. 1999;11:45-67.
22. Ariji Y , Obayashi N, Goto M, et al .
Roots of the maxillary first and sec-ond molars in horizontal relation toalveolar cortical plates and maxillarysinus: computed tomography assess-ment for infection spread. Clin Oral
Investig . 2006;10:35-41.
23. Sharan A, Madjar D. Correlation
between maxillary sinus floor topog-raphy and related root position of pos-terior teeth using panoramic andcross-sectional computed tomographyimaging. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2006;
102:375-381.
24. Huumonen S, Kvist T, Grondahl K,
Molander A. Diagnostic value ofcomputed tomography in re-treatmentof root fillings in maxillary molars.Int Endod J. 2006;39:827-833.
25. Bauer WH. Maxillary sinusitis of den-
tal origin. Am J Orthod Oral Surg .
1943;29:133-151.
26. De Foer C, Fossion E, Vaillant JM.
Sinus aspergillosis. J Craniomaxillo-
fac Surg. 1990;18:33-40.
27. Krennmair G, Lenglinger F. Maxillary
sinus aspergillosis: diagnosis and dif-ferentiation of the pathogenesis basedon computed tomography densitome-try of sinus concretions. J Oral
Maxillofac Surg. 1995;53:657-663.
28. Kopp W, Fotter R, Steiner H,
Beaufort F, Stammberger H.Aspergillosis of the paranasal sinuses.Radiology. 1985;156:715-716.
29. Stammberger H, Jakse R, Beaufort F.
Aspergillosis of the paranasal sinusesx-ray diagnosis, histopathology, andclinical aspects. Ann Otol Rhinol
Laryngol. 1984;93(3 Pt 1):251-
256.
30. Legent F, Billet J, Beauvillain C,
Bonnet J, Miegeville M. The role ofdental canal fillings in the develop-ment of Aspergillus sinusitis. A reportof 85 cases. Arch Otorhinolaryngol.
1989;246:318-320.
31. Odell E, Pertl C. Zinc as a growth
factor for Aspergillus sp. and the anti-fungal effects of root canal sealants.Oral Surg Oral Med Oral Pathol OralRadiol Endod. 1995;79:82-87.
32. Jerome CE, Hill A V . Preventing root
tip loss in the maxillary sinus duringendodontic surgery. J Endod. 1995;
21:422-424.

Maxillary sinus and endodontics 175
33. Rud J, Rud V . Surgical endodontics of
upper molars: relation to the maxil-lary sinus and operation in acute stageof infection. J Endod. 1998;24:260-
261.
34. Freedman A, Horowitz I. Complica-
tions after apicoectomy in maxillarypremolar and molar teeth. Int J Oral
Maxillofac Surg. 1999;28:192-194.
35. Ericson S. Finne I. Persson G. Results
of apicoectomy of maxillary canines,premolars and molars with specialreference to oroantral communicationas a prognostic factor. Int J Oral Surg.
1974;3:386-393.
36. Benninger MS, Sebek BA,
Levine HL. Mucosal regeneration ofthe maxillary sinus after surgery.Otolaryngol Head Neck Surg.1989;101:33-37.
37. Watzek G, Bernhart T, Ulm C.
Complications of sinus perforationsand their management in endodontics.Dent Clin North Am. 1997;41:563-
583.
38. Toskala E, Rautiainen M. Electron
microscopy assessment of the re-covery of sinus mucosa after sinussurgery. Acta Otolaryngol. 2003;123:
954-959.
39. Forsgren K, Fukami M, Penttila M,
Kumlien J, Stierna P. Endoscopic andCaldwell-Luc approaches in chronicmaxillary sinusitis: a comparativehistopathologic study on preoperativeand postoperative mucosal morpholo-gy. Ann Otol Rhinol Laryngol.
1995;104:350-357.
40. Nimigean V . Teeth-antrum morpho-
pathological correlation [disserta-
tion]. Carol Davila UniversityPublishing House, Bucharest; 1994.
41. Nimigean V . Neck and head clinical
and topographical anatomy . Carol
Davila University Publishing House,Bucharest; 2004.
Vassilis Danielidis, M.D.
Department of OtolaryngologySchool of MedicineDemocritus University of ThraceDragana, GR-68100 AlexandroupolisGreeceE-mail: vdaniili@med.duth.gr