Volume 2, Issue 3 US $6.00

Editor: Pathologic conditions of the Allan G. Farman, BDS, PhD (odont.), DSc (odont.), maxillary Diplomate of the By Dr. Allan G. Farman in American Board of Oral image layer will be demonstrated. collaboration with Dr. C.J. Nortjé and Maxillofacial As the panoramic image layer most Radiology, Professor of closely reflects the dental arch, Radiology and Imaging Radiography of the maxillary sinus disease occasionally arises Sciences, Department of sinuses is often undertaken using within the sinuses outside the image Surgical and Hospital computed tomography, magnetic layer. Dentistry, The University of resonance imaging, or the Diseases of the maxillary sinus Louisville School of occipito-mental plain x-ray film are comparatively frequent, even in Dentistry, Louisville, KY. projection. However the panoramic apparently young individuals – with radiograph has been found rates in excess of one in five Contributor: superior to the latter for detection individuals examined using the of “cyst-like densities.” [1]. The Waters’ projection (mucosal Dr. C.J. Nortjé, BChD, PhD, DSc, occipito-mental technique, first thickening 12.3%; cysts or polyps Professor and Chairman of described by Waters and Waldron, 7.2%; opacified sinus 3.3%) [5]. For Oral and Maxillofacial clearly demonstrates the superior, this reason, it is incumbent upon the Radiology, Tygerberg, South inferior and lateral margins of the dental practitioner to understand Africa, President-Elect of the International Association of maxillary sinuses while reflecting the panoramic radiological features Dentomaxillofacial Radiology. the shadows of the petrous of disease and normal variations temporal downwards below within the . the inferior margin of the sinuses [2]. Certainly the patient should not be Featured Article: It also demonstrates well any soft referred to an ear, nose and throat tissue or fluid contents of the sinus specialist for every instance of Pathologic conditions of [1]; however, this method does not antral mucosal thickening or the maxillary sinus display the cortices of the anterior mucous retention cyst (Fig. 1 &2), nor and posterior wall. should the dentist ignore features In The Recent Literature: While CT, MRI and the Waters’ that possibly reflect an early projection are well suited to malignancy. The reputation of a Oral Cancer demonstrate the maxillary sinuses, practitioner is greatly enhanced these methods are only employed given appropriate referrals that can Maxillofacial Trauma if there are signs and symptoms of make the difference between life disease, by which time the and death. Failure to diagnose, on prognosis for patients having such the other hand, can result in insidious disease as squamous-cell notoriety. can be poor [3]. Nortjé et al [3] were among the Extensive lesions occupying the first to comprehensively study the maxillary sinus can produce appearance on panoramic dental surprisingly few clinical features [4]. radiographs of pathological For this reason, the panoramic conditions affecting the maxillary radiograph can be the primary sinuses, comparing inflammatory indication of maxillary sinus conditions of dental origin, disease. While panoramic iatrogenic disease/foreign bodies, radiography can be used to non-odontogenic inflammatory detect maxillary sinus disease, it conditions, cysts, benign cannot be used to entirely exclude neoplasms, malignant neoplasms sinus pathology. Only the portions and dysplasias affecting the of the sinus that are within the . “ The early detection of insidious maxillary sinus disease can be very important for the patient’ prognosis, especially in the case of malignant neoplasia.”

Chronic abscesses resulted in a Fig. 1. Mucous retention loss of the outline of the lower “cyst”: detail from panoramic radiograph shows border of the sinus where it abutted domed soft tissue density in the associated tooth, and a related left maxillary sinus (arrow). thickening of the sinus mucosa was occasionally evident. Radicular cysts (generally associated with the root apex of a carious or fractured tooth) and residual cysts caused an upward displacement of the floor of the sinus, but the cortical outline remained intact. Extensive dental cysts extended into the sinus away from the original epicenter (Fig. 3). Even a very large radicular cyst arising in the maxilla resulted in surprisingly little in the Fig. 2. Mucous retention way of clinically noticeable cyst of maxillary sinus (arrow) shown using the expansion. Dentigerous cysts had a occipito-mental projection similar effect on the floor of the (Waters’ projection). This maxillary sinus to that observed for projection can be made radicular cysts, however, the using the ceph dentigerous cyst enveloped the attachment available for use with panoramic crown of an unerupted tooth. As the systems. tooth was displaced there was the appearance of a tooth suspended within the sinus. Odontogenic keratocysts are homogeneous radiolucencies that might be unilocular, crenulated or multilocular in outline, and occasionally they envelope unerupted teeth (Fig. 4). These also tend to displace the sinus floor and to extend into the sinus while producing little in the way of jaw expansion. Benign tumors in general displaced the sinus floor and expanded into the maxillary sinus rather than outwards (Fig. 5). Trabeculation within multilocular tumors such as the myxoma and the ameloblastoma frequently obscured the maxillary sinus outline. In comparison with benign Fig. 3. Radicular cyst on carious right neoplasms, malignant tumors maxillary lateral incisor. The lesion is a affecting the portion of the sinus well-delineated unilocular homogeneous radiolucency. It has grown so large that it screened by the plane of the has caused a displacement of the panoramic radiograph resulted in ipsilateral anterior wall and floor of the irregular erosion of . maxillary sinus. Primary malignancies affecting the maxillary sinus include squamous-cell carcinoma, cystic carcinoma and adenocarcinoma [7]. The maxillary sinus may also be affected secondarily by extension malignancies of the oral soft tissues or jaw, and also, although rare, is the site of metastases from distant sites [8]. Owing to their radio-opacity, roots or whole teeth displaced into Fig. 4. Odontogenic keratocyst: multiple lesions in the sinus are readily apparent even both in nevoid basal cell carcinoma syndrome. when not centered within the The maxillary lesions are unilocular while the image layer. These need to be mandibular lesions are crenulated and multilocular. There is displacement of “enveloped” teeth, some differentiated from sinus bone of which apparently “float” in the maxillary sinuses nodules and antroliths (calcified (e.g. arrows). “stones” arising in the antral lining) both of which entities could be Fig. 5. Benign mistaken for teeth or displaced neoplasm, roots [9]. Foreign bodies, such as adenomatoid bullets, are clearly demonstrated; odontogenic tumor: however care needs to be made to unilocular lesion in the left maxilla subjacent differentiate between clearly to the canine tooth demarcated real images, and (cropped panoramic, blurred magnified ghost images of occlusal and foreign bodies or jewelry more specimen distally and lower placed in or on radiographs). Note displacement of the contralateral side of the face. maxillary sinus floor Oroantral fistulas following dental (arrow). extraction are only noticeable on panoramic radiography when large – and within the panoramic image layer. Regarding inflammatory conditions of non-odontogenic origin, these are usually clearly demonstrated on panoramic radiography if they involve mucosal thickenings arising from the floor of the maxillary sinus. The most Fig. 6. Fibrous dysplasia: cropped panoramic radiograph frequent example of such a showing mature (late) lesion of process is the mucous retention the left maxilla, obscuring the phenomenon. This is seen as a sinus. The lesion is radio- smooth dome-shape swelling of opaque with some radiolucent the mucosa with homogeneous mottling. It has a ground (frosted) glass appearance. radiodensity. The sinus floor is not The lesion melds with the displaced or eroded. A mucous normal surrounding bone. retention phenomenon is rarely symptomatic; it requires no Fig. 7. Paget’s treatment. Antral polyps are only disease of bone: clearly demonstrated when Note cotton-ball situated in the panoramic image radio-opaque layer. This is rarely the case; sclerotic deposits. There is maxillary hence, other radiographic views cortical expansion. are preferred. Opacified sinuses The lesion is or fluid levels may be found with bilateral, crossing acute , which the midline accompanies the common (panoramic and lateral cold in 0.5-5% of cases [5;6]. radiographs). The maxilla can also be the site of a variety of dysplastic and fibro-osseous conditions. Fibrous dysplasia can cause the partial or complete occlusion of the sinus on the affected side of the maxilla (Fig. 6). This may arise in young children and is usually apparent by adolescence. It is generally unilateral. By way of comparison, Paget’s disease of Fig. 8. Late stage bone can also cause occlusion maxillary sinus of the sinus, but can affect both squamous-cell carcinoma sides of the maxilla and is found eroding through in an aging population (Fig. 7). the palate. Cherubism may affect the Prognosis is poor. maxillary tuberosities bilaterally This patient has as well as the mandibular rami. fixed cervical lymph nodes due The lesions are initially to metastasis. multilocular radiolucencies and later sclerose.

Clinical Significance of Maxillary Sinus Disease The early detection of insidious maxillary sinus disease can be Fig. 9. Squamous-cell very important for the patient’s carcinoma: Water’s view showing opacification of prognosis, especially in the case left maxillary antrum of malignant neoplasia. By the (sinus) with destruction of time of overt signs of squamous- nasal and orbital walls cell carcinoma of the maxillary (arrows). antrum (e.g. neck node metastasis or palatal fistula – Fig. 8 & 9), the five-year survival is only one in six [7]. Substantial progress is being made with multi-modality treatment of cancer; hence, the dentist may well make a difference in “...the dentist may well make a difference in patient longevity by the early detection of cancer from astute reading of the panoramic radiograph.”

patient longevity by the early Summary posterior sinus wall than will detection of cancer from astute The growth of tumors within the panoramic radiograph [25,26]. reading of the panoramic maxilla is not concentric; hence, Lesions affecting the floor of the radiograph [8]. Early detection can the site of origin is not necessarily maxillary sinus are better identified result in an 80%, or better, the epicenter of the lesion. The and localized with panoramic films treatment success rate as maxillary sinus, or antra, than with the Waters’ projection determined by 5-year survival constituted the path of least [27]. When dentists are reading the [10,11]. It has been found that resistance for the growth of such radiographs, panoramic panoramic radiography can maxillary lesions as cysts and radiographs have been found demonstrate antral malignancy at benign neoplasms. Even very large equal to Waters’ projection for the time of diagnosis in 90% of benign tumors and cysts might be determination of sinusitis [28]. cases [12]. However, occasional present without resulting in These two techniques, and individual case reports do show clinically noticeable jaw computed tomography, should be that, dependent on the lesion’s expansion. Hence, the panoramic considered complementary rather precise site, even large squamous radiograph is of value in detection than alternatives [1]. cell might be missed of unsuspected disease. References when relying on panoramic Antral malignancies are usually 1. Ohba T, Katayama H. Comparison of radiographs alone [13,14]. panoramic and Water’s projection in the insidious and produce clinical diagnosis of maxillary sinus disease. Oral The prevalence of mucosal signs and symptoms relatively late, Surg 1976;42:534-538. retention cysts in the maxillary when the prognosis is often quite 2. Waters CA, Waldron CW. Roentgenology of the accessory nasal sinuses describing sinus averages around 5%, but poor. Panoramic radiographs have a modification of the occipito-frontal varies considerably from report to been found of utility in detection of position. Amer J Roentgenol (Detroit) 1915;2:633. report, perhaps as a function of antral carcinoma, particularly that 3. Nortjé CJ, Farman AG, Joubert JJ de population, geography and season affecting the posterior wall of the V. Pathological conditions involving [15-18]. The prevalence is the maxillary sinus: their appearances on sinus [24]. Caution should be used panoramic dentalradiographs.Brit J Ora approximately twice as high in in that the panoramic radiograph is Surg 1979;17:27-32. men as in women. The detection not the technique of choice for 4. Farman AG, Nortjé CJ, Grotepass FW, Farman FJ, van Zyl JA. Myxofibroma of and correct interpretation of the viewing the maxillary sinuses – the jaws. Brit J Oral Surg 1977;15:3-18. retention cyst is important for however, it is incumbent on the 5. Savolainen S, Eskelin M, Jousimies-Somer H, Ylikoski J. Radiological findings in the preventing unnecessary diagnostic dentist to evaluate the portion of maxillary sinuses of symptomless young procedures or surgical intervention the maxillary sinus shown in the men. Acta Otolaryngol Suppl [19]. It has been demonstrated that 1997;529:153-157. panoramic radiograph made for 6. Lee RJ, O’Dwyer TP, Sleeman D, Walsh M. the retention cyst, unlike the antral other purposes. This might well be Dental disease, acute sinusitis and the mucocele, has no relationship to the first sign of disease and the orthopantomogram. J Laryngol Otol 1988;102:222-223. sinus obstruction [20]. Antral only reason for pursuing further 7. Kim GE, Chung EJ, Lim JJ, Keum KC, Lee mucoceles are associated with diagnostic tests. Early detection of SW, Cho JH, Lee CG, Choi EC. Clinical significance of neck node metastasis in osteal closure and complete sinus such sinister occurrences improves squamous cell carcinoma of the opacification, pain, jaw expansion the prognosis for the unfortunate maxillary antrum. Am J Otolaryngol and erosion of the antral outline [21, 1999;20:383-390. patient. 8. Koscielny S. The paranasal sinuses as 22]. There are limitations to the use metastatic site of renal cell carcinoma. When dealing with panoramic of panoramic radiography in the Larungorhinootologie 1999;78:441-444. 9. Jain RK, Frommer HH. Incidental finding radiographs, one needs to detection of maxillary sinus of antroliths in panoramic radiography. consider the possibility of ghost disease; namely, only the areas NY State Dent J 1982;48:530-531. 10. Hayashi T, Nonaka S, Bandoh N, images being reflected well away within the selected image layer will Kobayashi Y, Imada M, Harabuchi Y. from the actual lesion. This is be in focus. Experimental studies Treatment outcome of maxillary sinus particularly the case with highly squamous cell carcinoma. Cancer have shown that axial computed 2001;15:1495-1503. radiopaque foreign bodies such as tomography provides a better 11. Tiwari R, Hardillo JA, Mehta D, Slotman B, those associated with gunshot evaluation of osteolytic lesions in Tobi H, Croonenburg E, van der Waal I, Snow GB. Squamous cell carcinoma of injuries [23]. the latero-superior or middle of the maxillary sinus. Head Neck 2000;22:164-169. 12. Epstein JP, Waisglass M, Bhimji S, Le N, cysts in a Chinese population. 24. Greenbaum EI, Rappaport I, Gunn W. The Stevenson-Moore P. A comparison of Dentomaxillofac Radiol 1993;22:208-210. use of panoramic radiography in computed tomography and panoramic 19. Bohay RN, Gordon SC. The maxillary detection of posterior wall invasion by radiography in assessing malignancy of mucous retention cyst: a common maxillary antrum carcinoma. the maxillary antrum. Eur J Cancer Oral incidental panoramic finding. Oral Health Laryngoscope 1969;79:256-263. Oncol 1996;32B:191-201. 1997;87:7-10. 25. Perez CA, Farman AG. Diagnostic 13. Lillienthal B, Punnia-Moorthy A. Limitations 20. Tufano RP, Mokadam NA, Montone KT, radiology of maxillary sinus defects. Oral of rotational panoramic radiographs in Weinstein GS, Chalian AA, Wolf PF, Weber Surg Oral Med Oral Pathol 1988;66:507-512. the diagnosis of maxillaryn lesions. Case RS. Malignant tumors of the nose and 26. Ohba T, Ogawa Y., Shinohara Y, Hiromatsu report. Aust Dent J. 1991;36:269-272. paranasal sinuses: hospital of the University T, Uchida A, Toyoda Y. Limitations of 14. Haidar Z, Diagnostic limitations of of Pennsylvania experience 1990-1997. Am panoramic radiography in the detection orthopantomography with lesions of the J Rhinol 1999;13:117-123. of bone defects in the posterior wall antrum. Oral Surg 1978;46:449-453. 21. Bhattacharyya N. Do maxillary sinus of the maxillary sinus. Dentomaxillofac 15. Halstead CL. Mucosal cysts of the retention cysts reflect obstructive sinus Radiol 1994;23:149-153. maxillary sinus: report of 75 cases. J Am phenomena? Arch Otolaryngol Head Neck 27. Duker J, Fabinger A. Evaluation of the Dent Assoc 1973;87:1435-1441. Surg 2000; 126:1369-1371. basal parts of the maxillary sinus by 16. Myall RW, Eastep PB, Silver JG. Mucous 22. Barsley RE, Thunthy KH, Weir JC. Maxillary means of panoramic tomography. Dtsch retention cysts of the maxillary antrum. J sinus mucocele. Report of an unusual Zahnarztl Z 1978;33:823-826. Am Dent Assoc 1974;89:1338-1342. case. Oral Surg Oral Med Oral Pathol 28. Lyon HE. Reliability of panoramic 17. Ruprecht A, Batniji S, el-Neweihi E. Mucous 1984;58:499-505. radiography in the diagnosis of maxillary retention cyst of the maxillary sinus. Oral 23. Blaschke DD, Sanders B. Radiology of sinus pathosis. Oral Surg 1973;35:124-128. Surg Oral Med Oral Pathol 1986;62:728-731. maxillofacial gunshot injuries. Oral Surg 18. MacDonald-Jankowski DS. Mucosal antral 1979;47:294-299. In The Recent Literature: Oral cancer: Panoramic radiography from the gingival carcinomas. radiographs. Fractures were induced is a useful adjunct in evaluation of Outcomes were calculated using the using blunt trauma to 25 cadaver bone invasion by gingival squamous Kaplan-Meier method. Primary local . Panoramic radiographs cell carcinoma. control was achieved in 72 patients and mandibular series comprising an Gomez D, Faucher A, Picot V, (87%). Overall survival and rate of antero-posterior view, two lateral Siberchicot F, Renaud-Salis JL, recurrence were comparable to those oblique, and a reverse Towne’s Bussieres E, Pinsolle J. Outcome of reported for other squamous cell projection were made. The squamous cell carcinoma of the carcinomas of the oral cavity and mandibular series was viewed both in gingiva: a follow-up study of 83 oropharynx. analog and in digitized forms. Six cases. J Craniomaxillofac Surg 2000 observers recorded their Dec;28(6):331-35. [From the Bergonie Maxillofacial trauma: Panoramic interpretations using a five-point Institute, Regional Cancer Center, radiographs proved significantly more confidence rating scale. The data Bordeaux, France.] reliable than mandibular film series was studied using receiver operating for the detection of mandibular jaw characteristic (ROC) curve analysis. Squamous cell carcinoma of the fractures. Significant differences based on gingiva is relatively uncommon. Nair MK, Nair UP. Imaging of mandibular imaging modalities were found (p < Standard treatment involves surgery trauma: ROC analysis. Acad Emerg 0.0015) in the area under the curves and/or radiotherapy. From 1985 to Med 2001 Jul;8(7):689-95. [From the (A(z)): mandibular series, 0.75; 1996, 83 patients with squamous cell Department of Oral and Maxillofacial digitized mandibular series, 0.77, carcinoma of the gingiva were Radiology, University of Pittsburgh, panoramic radiograph, 0.87; and treated at the Department of Pittsburgh, USA.] panoramic plus antero-posterior Surgery, the Bergonie Institute and at radiographs in combination, 0.89. No the Department of Maxillofacial and The objective of this study was to observer-based differences were Plastic Surgery of the University compare the diagnostic efficacy for found. Intra- and inter-observer Hospital, Bordeaux, France. A detection of mandibular fractures of agreements were high (kappa(w) = retrospective review of panoramic panoramic radiography versus 0.81 and 0.76, respectively). It is radiographs and clinical records was mandibular trauma series presented concluded that panoramic used to evaluate bone involvement both as analog and as digitized radiographs are adequate for the detection of mandibular fractures. The addition of an antero-posterior view only marginally improved diagnostic accuracy. ©2002 Panoramic Corporation (07-02) (847) 458-0063

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