Advanced Surgery 5:

Sinus Lifting techniques: direct (Caldwell Luc) and indirect (Summer’s), Anatomy, Technique, Complications of sinus lift                                 

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Anatomy

1. Solar P, et al. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res. 1999 Feb; 10 (1):34-44.

2. Ulm CW, Solar P, Krennmair G, Matejka M, Watzek G. Incidence and suggested surgical management of septa in sinus-lift procedures. Int J Oral Maxillofac Implants. 1995 Jul-Aug;10(4):462-5.

3. Pommer B, Ulm C, Lorenzoni M, et al. Prevalence, location and morphology of maxillary sinus septa: systematic review and meta-analysis. J Clin Periodontol. 2012 Aug;39(8):769-73.

Technique

• Misch, Resnik, Misch-Dietsh. Maxillary Sinus Anatomy, Pathology and Graft Surgery. (CH 38) pp 1055-1072. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.

4. Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, Stoupel J, Del Fabbro M, Testori T. Maxillary sinus elevation by lateral window approach: evolution of technology and technique. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):161-71.

5. Romero-Millán J, et al. Indirect osteotome maxillary sinus floor elevation: an update. J Oral Implantol. 2012 Dec;38(6):799-804.

6. Zhen F, Fang W, Jing S, Zuolin W. The use of a piezoelectric ultrasonic osteotome for internal sinus elevation: a retrospective analysis of clinical results. Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):920-6.

Complications

• Part IV Complications Associated with Lateral Window Sinus Elevation. pp 135-169. Surgical complications in oral implantology : etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.

• Wallace, S. Complications in lateral window sinus elevation surgery. (CH16) pp 284-309. Dental Implant Complications: Etiology, Prevention, and Treatment. Froum, SJ. 2010. Wiley-Blackwell.

• Rosen P. Complications with the bone-added osteotome sinus floor elevation: etiology, prevention, and treatment. (CH 17) pp 310-324/

7. van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000;11(3):256-265

8. Penarrocha-Diago, M et al: Benign Paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: A study of 4 cases. Int J Oral Maxillofac Implants 2008:23:129-132

9. Fugazzotto PA, Vlassis J. A simplified classification and repair system for sinus membrane perforations. J Periodontol. 2003 Oct;74(10):1534-41.

10. Froum SJ, Khouly I, Favero G, Cho SC. Effect of maxillary sinus membrane perforation on vital bone formation and implant survival: a retrospective study. J Periodontol. 2013 Aug;84(8):1094-9.

11. Proussaefs P, Lozada J, Kim J, Rohrer MD. Repair of the perforated sinus membrane with a resorbable collagen membrane: a human study. Int J Oral Maxillofac Implants. 2004;19(3):413-420.

12. Cho SC, Wallace SS, Froum SJ, Tarnow DP, Influence of anatomy of Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis. Pract Proced Aesthet Dent 2001; 13:160-163.

13. Vlassis JM, Fugazzotto PA. A classification system for sinus membrane perforations during augmentation procedures with options for repair. J Periodontol 1999;70(6):692-699.

14. Jensen SS, Eriksen J, Schiodt M. Severe bleeding after sinus floor elevation using the transcrestal technique: a case report. Eur J Oral Implantol. 2012 Autumn;5(3):287-91.

15. Testori T, Weinstein RL, Taschieri S, Del Fabbro M. Risk factor analysis following maxillary sinus augmentation: a retrospective multicenter study. Int J Oral Maxillofac Implants. 2012 Sep-Oct;27(5):1170-6.

16. Manor Y, Mardinger O, et al. Late signs and symptoms of maxillary sinusitis after sinus augmentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jul;110(1):e1-4.

17. Moreno Vazquez JC, et al. Complication rate in 200 consecutive sinus lift procedures: guidelines for prevention and treatment. J Oral Maxillofac Surg. 2014 May;72(5):892-901

18. Najm SA, Malis D, Hage ME, Rahban S, Carrel JP, Bernard JP Potential adverse events of endosseous dental implants penetrating the maxillary sinus: Long-term clinical evaluation. Laryngoscope. 2013 Dec;123(12):2958-61. doi: 10.1002/lary.24189. Epub 2013 Oct 2.

Topic: Maxillary sinus arteries

Authors: Solar P, et al.

Title Blood supply to the maxillary sinus relevant to sinus floor elevation procedures

Source: Clin Oral Implants Res. 1999 Feb; 10 (1):34-44.

Type: Clinical

Keywords: sinus floor elevation, maxillary artery, posterior superior alveolar artery, infraorbital artery, blood supply

Purpose: To evaluate maxillary arteries relevant to sinus floor elevation surgery and examine the vascularization of the lateral maxillary after tooth loss.

Material and methods: The vessels of the lateral maxilla of 18 maxillary specimens (10 males, 8 females, mean age 67 years) were prepared anatomically and the local main arties, the number of macroscopically discernible branches and anastomoses, their calibers, and the distance between the caudal main branches and the alveolar ridge recorded.

Results:  The lateral maxilla is supplied by branches of the posterior superior alveolar artery (PSAA) and the infraorbital artery (IOA) that form an anastomosis in the bony lateral antral wall, which also supplies the schneiderian membrane.

This intraosseous anastomosis was found in ALL of the specimens.

8/18 (44.4%) also showed an extraosseous anastomosis between PSAA and IOA.

PSAA had a mean caliber of 1.6mm and exhibited an average of 2 endosseous and 1 extraosseous branches.

IOA had a mean diameter of 1.6mm and showed an average of 1 endosseous and 3 extraosseous branches.

The mean distance between the intraosseous anastomosis and the alveolar ridge was 19mm and in 2 defined measuring sites. Mean length was 44.6mm.

The epiperiosteal vestibular anastomosis was situated further cranially, at a mean distance of 23-26mm from the alveolar ridges and had a mean length of 46mm.

Conclusion: Large caliber of the vessels supplying the lateral antral wall seems to be crucial to the fact that the periosteal blood supply is maintained even in severe maxillary atrophy and after complete disappearance of the centro-medullary vessels.

Topic: Maxillary sinus

Authors: Ulm CW, Solar P, Krennmair G, Matejka M, Watzek G.

Title: Incidence and suggested surgical management of septa in sinus-lift procedures.

Source: Int J Oral Maxillofac Implants. 1995 Jul-Aug;10(4):462-5.

Type: Cross sectional study

Rating: Good

Keywords: sinus, septum, septa

Background: A variable number of septa, also referred to as Underwood’s septa, divide the floor of the maxillary sinus into several recesses and may thus cause various complications during sinus-lift procedures.

Purpose: To examine the incidence, location, and height of Underwood’s septa.

Methods: 41 edentulous maxillas obtained from the collection of the Department of Anatomy of the University of Vienna were examined. The mean age of the deceased was 76 years. The maxillary sinus was exposed from the cranial aspect by a horizontal section below the floor of the orbits, then the alveolar recess of the antrum was examined. Only those bone lamellae were considered as septa that showed a height of at least 2.5 mm were recorded.

Results: In 13 of these maxillas (31.7% of the cases), sinus floors with at least one septum were observed. 26.8% showed one septum, whereas 4.9%) exhibited two septa. Most of the septa were located in the region between the second premolar and the first molar. The mean height of the septa was 7.9 mm, with the highest septum showing a height of 17 mm.

Conclusion: One third of the the maxillas studied had a septa. A possible cause of septal formation could be the variable phases of maxillary sinus pneumatization of the empty alveolar process followind tooth extraction.

Topic:Maxillary sinus septa

Authors: Pommer B, Ulm C, Lorenzoni M, et al.

Title: Prevalence, location and morphology of maxillary sinus septa: systematic review and meta-analysis.

Source: J Clin Periodontol. 2012 Aug;39(8):769-73.

Type: Meta-analysis

Rating: Good

Keywords: dental implants, maxillary sinus floor elevation, radiographic diagnosis, sinus anatomy, sinus membrane perforation.

Purpose: To examine the literature regarding prevalence, predominant location, and morphologic variability of maxillary sinus septa.

Method: Literature search (electronic and hand) of English literature from 1995-2011. Only septa 2-4 mm or higher were included. 33 publications made the final selection.

Results: 8923 sinuses were examined, septa were present 28.4% of the time. Prevalence was slightly higher in atrophic sinuses when compared to dentate sinuses. Septa were more common in the molar region (54.6%) than the premolar (24.4%) and retromolar (21.0%) regions. Orientation of the septa was most often transverse (87.6%). Average septa height was 7.5mm. Complete septa (dividing entire sinus) was rare (0.3%). Multiple septa in one sinus only occurred 4.2% of the time and bilateral septa was found 17.2%. Panoramic diagnosis of septa was found to be incorrect 29% of the time.

Conclusion: 3D radiographic imaging should be used to help reduce complication rates in the presence of maxillary sinus septa

Topic: Sinus Lift

Authors: Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, Stoupel J, Del Fabbro M, Testori T.

Title: Maxillary Sinus Elevation by Lateral Window Approach: Evolution of Technology and Technique

Source: J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):161-71.

Type: Review

Rating: Good

Keywords: Maxillary sinus augmentation, maxillary sinus elevation, sinus augmentation technique, sinus bone grafts, xenografts, piezosurgery, DASK

Purpose: To follow the evolution of the 2 most important trends in lateral window sinus augmentation surgery: the transition from autogenous bone to bone replacement grafts as a donor material and the desire to develop a surgical technique that is simpler to perform and has the least chance for complications.

Method: Data on grafting materials and implant survival rates came from 10 published evidence-based reviews that include all relevant published data from 1980 to 2012. Supporting clinical material comes from the experience of the authors.

Results: The evidence-based reviews report and compare the implant survival rates utilizing various grafting materials, implant surfaces, and the use or non-use of barrier membranes over the lateral window. Clinical studies report on complication rates utilizing piezoelectric surgery and compare them to complication rates with rotary instrumentation.

Conclusion: The utilization of bone replacement grafts, rough-surfaced implants, and barrier membranes result in the most positive outcomes when considering implant survival. Further, the utilization of piezoelectric surgery, rather than rotary diamond burs, for lateral window preparation and membrane separation leads to a dramatic reduction in the occurrence of the intraoperative complications of bleeding and membrane perforation.

Topic: Maxillary Sinus

Title: Indirect osteotome maxillary sinus floor elevation: an update

Author: Romero,  et al

Source: Journal of Oral Implantology. 2012 Dec;38(6):799-804.

Type: Literature Review

Rating: Good

Keywords: indirect sinus elevation, osteotome technique, osteotome sinus floor elevation

B: Indirect osteotome maxillary sinus floor elevation (OMSFE) is generally employed when the

residual bone height is equal to or greater than 6 mm; in cases with higher resorption, the direct sinus elevation technique is used. Advantages: the surgery is more conservative, sinus augmentation is localized, there is a low rate of postoperative morbidity, a shorter time to implant loading is possible than with the direct technique, and high survival rates of around 90% are obtained.

P: To review publications reporting on indirect OMSFE; to evaluate the influence of the graft material, the gain in bone height, and the amount of bone resorption; to assess the complications

of this surgical technique and the survival rates of implants placed in these areas.

M&M: Studies published between 1999 and 2010 on patients with a minimum of 1 year of follow-up were analyzed. Ninety-seven articles were identified, of which 83 studies were excluded; Fourteen studies were included. Indirect OMSFE is indicated for a bone height of 6-8 mm.

R: More bone height was gained when graft material (deproteinized bovine bone, autologous bone with xenograft and or allograft) was used. Schneiderian membrane perforation was the most frequent complication. Survival rates varied between 93.5% and 100%. 

BL: Osteotome sinus membrane elevation is a predictable and effective procedure for placing implants in areas of the posterior maxilla with low bone height.

CR: It is a good systematic review with carefully screened articles and briefly outlines the surgical procedure, grafts and post op complications. However, there is a need for larger pool of articles for review.

Topic: sinus lift with piezo osteotome

Authors: Zhen F, Fang W,

Title: The use of a piezoelectric ultrasonic osteotome for internal sinus elevation: a retrospective analysis of clinical results

Source: Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):920-6

Type: retrospective analysis

Rating: good

Keywords: dental implants, internal sinus elevation, maxillary sinus, piezoelectric ultrasonic osteotome

Purpose: To evaluate the clinical outcome of maxillary internal sinus floor augmentation with the use of piezoelectric osteotome, in conjuction with implant placement.

Methods: Patients needing implant in post maxilla with pneumatization of the maxillary sinus were enrolled. Sinus augmentation with piezo osteotomes and implant placement (immediate or delayed) were performed.

Results: 30 patients in need of 36 implants with insufficient alveolar bone height in maxilla were selected. 28 immediate and 8 delayed implants were placed. Systemic antibiotics prescribed. Only 1 membrane perforated (2.78%, which is much lower than what the literature shows, ranging from 5% to 85%) and one implant lost. No mobility or rapid bone loss seen in the rest of the implants. (5-27-month follow-up)

Discussion: Precautions;

• Pressure control: cutting efficacy of the piezo is not increased by applying additional pressure. The pressure may be transferred into heat and damage the tissue. Different bone modes and frequencies should be chosen according to the density and thickness of the bone.

• Directional control: both the tip and side walls of OT4 and OP4 are cutting. Therefore, pressure should be directed toward the bottom of the cavity.

• Use of negative pressure:

Conclusion: Application of a piezoelectric osteotome for internal sinus elevation simplified manipulation of the membrane and greatly reduced the chance of perforation.

Critique: small number of cases.

Topic: Anatomy of Maxillary Sinus

Author: van den Bergh JP

Title: Anatomical aspects of sinus floor elevations

Source: Clin Oral Implants Res 2000;11(3):256-265

Type: Review

Rating: Good

Keywords: anatomy, maxillary sinus, sinus lifting, sinus floor elevation, bone grafting

Purpose: To review the anatomical considerations in regards to the maxillary sinus.

Discussion:

Anatomy of the maxillary sinus

• A pyramidal shaped cavity in the facial skull, with its base at the lateral nasal wall and its apex extending into the zygomatic process.

• Sinus is internally lined with a thin mucosa of “ciliated” respiratory epithelium, which is continuous with that of the nose. This ciliated epithelium has a transport function for fluids like pus and mucus towards the internal ostium.

• Pneumatization seems to complete at the end of the growth to approximately 12-15 cm^3

• Average dimension of adult maxillary sinus:

  • Width: 25-35mm

  • Height: 36-45mm

  • Length: 38-45mm

• Convex sinus floor usually reaches its deepest point at the first molar region.

• At the edentulous stage of life, the size of the maxillary sinus will increase further. The process of Pneumatization can vary from person to person and side to side. Apart from inner expansion of the sinus, the outer aspect of the alveolar process is also thinned.

• Blood supply of maxillary sinus: Infra-orbital artery, the greater palatine artery and the posterior superior alveolar artery

• The two most important walls in regards to sinus floor elevation:

  • Anterior/Buccal wall: thin compact bone, containing neurovascular canals to the ant teeth

  • Internal/Nasal wall: covered by musculo-periosteal tissue, containing the facial artery and vein, the lymphatic system and the infra orbital nerves.

• Internal wall has a rectangular shape and forms the bony septum between the nasal and maxillary sinus.

• The inferior portion of the internal wall corresponds with the inferior meatus of the nasal cavity.

• In the middle of the internal wall is the sinus hiatus

Surgical considerations with regard to the anatomy

• The flap design: incision is made on the top of the alveolar ridge, or slightly palatal.

• The sinus floor: Shape of the door should ideally follow the inner shape=curved. Rounded corners with a usually wide cranial hinge based are used. Rounded corners reduces the chance of damaging the Schneiderian membrane

• Lateral sinus wall preparation: If the lateral sinus wall consists of thick bone the whole lateral sinus wall should be thinned out. Too thick of bone makes it extremely difficult to release the membrane from the inner aspect of the bony sinus. Door luxation is best performed with finger pressure.

  • Healthy membrane= dark greyish-blue

  • Smoker membrane= atrophic and be extremely thin and fragile to touch

  • Chronic sinusitis membrane=thick and spongy

• The Schneiderian membrane: Freeing the membrane from bone floor using instruments designed by Tatum. Starts at the caudal edge slowly and carefully working towards the mesial and distal sides of the sinus. Overfilling with grafting materials may cause necrosis of the Schneiderian membrane. Previous sinus surgery results in scar tissue formation, and might be a contraindication for sinus lift procedures.

• Schneiderian membrane perforations: Most likely to happen at sharp edges and ridges like Underwoods septa and at spines.

  • Small perforation and located in an area where elevated mucosa folds together when lifting the door: no need for further measurements

  • Large and unfavorable areas: Perforation needs to be closed and covered with a resorbable membrane and bioglues. Re-entry might be considered, but must wait 6-8 weeks.

• Maxillary sinus septa: Especially more prominent in younger adults. Divide the caudal part of the sinus in multiple compartments known as recesses. These septa act as a masticatory force carrying struts during the dentate phase of life. These septa seem to disappear slowly when teeth have been lost.

  • Septum located at the bottom of the sinus: door can be of normal shape

  • Septum located higher: door must either follow the contour making a W-shape or two trap doors, or it must be located on one side of the septum (usually mesial)

• The narrow sinus: A narrow sinus is rare. One option is to do an antrostomy on the lateral sinus wall instead of a door preparation.

• Hemorrhages: Hemorrhages during sinus grating are rare, since the main arteries are not within the surgical area.

• Bone grafting, bone healing and remodeling: Healing and remodeling of the graft material depends on the vascularization of the Schneiderian membrane, buccal muco periosteal flap, the bone segments of the former sinus floor, and the elevated sinus wall. Therefore its an advantage to save the bony trapdoor (Tatum, 1986).

• Primary alveolar bone height and width: Primarily stability of the implant determines if one or two stage surgery should be used with sinus lift procedures

  • One stage: at least 4mm of bone height of the original alveolar process

  • Two stages: less than 4mm of bone height. Implant should be placed 4 to 6 months after sinus floor grafting.

Topic: Maxillary implants

Authors: Penarrocha-Diago, M et al

Title: Benign Paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: A study of 4 cases

Source: Int J Oral Maxillofac Implants 2008:23:129-132

Type: Case study

Rating: Good

Keywords: benign paroxysmal positional vertigo, dental implants, osteotomes

Purpose: To discuss the etiology, diagnosis, treatment, and prevention of benign paroxysmal positional vertigo (BPPV) following osteotome prepatation of implant beds.

Methods: 812 implants were placed on 320 patients between 1996 and 2004. 4 of these patients developed BPPV (1.25%).

Conclusion: BPPV is characterized by short, recurrent episodes of vertigo initiated by certain head lateralization and extension movements toward the affected side. It usually presents in middle age and could have a degenerative component. The most accepted theory as to mechanism of BPPV is canalithiasis- free-floating particles detach from the macula and gravitate into the endolymph of the semicircular canal. Treatment consists of maneuvers to restore the calcic carbonate crystals from the anomalous location in the semicircular canal to their correct place in the utricle (Epley maneuver). During placement of maxillary implants using the osteotome technique, trauma induced by the percussion along with hyperextension of the neck during the procedure can displace otoliths and produce BPPV. Minimizing trauma when using this technique is advised to reduce the incidence of BPPV, especially in older patients.

Topic: Complications

Authors: Fugazzato & Vlassis

Title: A Simplified Classification and Repair System for Sinus Membrane Perforations

Source: JOP October 2003, vol. 74, No. 10; 1534-1541

Type: Classification & case series

Rating:

Keywords: Maxillary sinus/surgery; maxillary sinus augmentation

Purpose: Present a classification and repair system for management of sinus perforations based on their location and severity

Background: The efficacy of sinus augmentation therapy and the attainment of an increased bone volume in the maxillary posterior region has been documented through animal and human histologic evaluations and clinical case reports. Implant success rates in these augmented areas are comparable to the success rates of implants placed in non-regenerated bone, both in the maxillary posterior regions and other areas of the mouth. However, the presence of preexisting Schneiderian membrane perforations, or the creation of a membrane perforation at the time of sinus augmentation, may cause clinicians to pause and reevaluate the feasibility of performing the planned augmentation therapy, and implant placement, during the same visit.

CLASSIFICATION FIRST BY LOCATION

CLASS I Perforations: occur at any point along the most apical wall of the prepared sinus window

CLASS II Perforations: occur along the lateral or crestal aspects of the prepared sinus window, further subdivided according to their relative positions to the most mesial, distal, or crestal extension of the underlying sinus

CLASS III Perforations: occur at any location within the body of the prepared sinus window.

*Upon discovery of any perforation, AVOID MANIPULATION of the membrane to ascertain the size of the tear. Will likely have to extend mesial and distal releasing incisions to fully visualize and access the extent of perforation.

*MATERIAL MODIFICATION BASED ON MATERIAL SELECTION:

- Non-autogenous particulate – first mixed with microfibrillar collagen.

-Osseous coagulum +non-autogenous particulate or bone blocks: no need to add microfibrillar collagen

- Use of PRP obviates need for microfibrillar collagen.

*Post op Therapy: CHx rinses bid for 21 days, amoxicillin 500X30 tid for 10days; don’t blow nose for 10 days. No removable prosthesis prior to suture removal @ 10-12 days.

If implants placed at time of augmentation – wait 8 months for uncover. If 2^nd stage surgery, placement is at 8 months post augmentation.

Materials and Methods:

Results:

Nineteen patients were treated for detectable sinus membrane perforations that were noted during sinus augmentation therapy. The classification of these perforations, the course of therapy, and the subse- quent treatment outcome are noted in Table 1. All patients eventually received implants that were restored and are functioning successfully accord- ing to the Albrektsson et al. criteria9 as confirmed through clinical and radiographic evaluation at the time of statistical compilation. The following short case reports are indicative of patient experiences.

Conclusions: There is no doubt that an intact Schneiderian membrane pro- vides a significant containing func- tion for inserted graft materials and the subsequent forming blood clot. Presence of a torn Schneiderian membrane encoun- tered during sinus augmentation therapy should not be viewed as a contraindication to either pro- ceeding with planned augmenta- tion with or without simultaneous implant placement, or to the attain- ment of satisfactory sinus aug- mentation results. Utilization of a repair and classification system, which directly relates to sinus membrane perforation location and treatment options, enhances the delivery of pre- dictable sinus augmentation therapy. Regardless of the

type and severity of sinus membrane perforation encountered, acceptable augmentation results are obtainable.

Topic: Sinus Membrane Perforations

Author: Froum SJ

Title: Effect of maxillary sinus membrane perforation on vital bone formation and implant survival: a retrospective study

Source: Journal of Periodontology, August 2013, Vol. 84, No. 8, Pages 1094-1099

Type: Retrospective Study

Rating: Good

Keywords: Bone grafting, dental implant, histology; sinus floor augmentation

Purpose: to evaluate the effect of the maxillary sinus membrane perforation (MSMP) on the percentage of vital bone and implant survival obtained after the sinus augmentation procedure (SAP).

Methods: Data were obtained retrospectively from an Institutional Review Board–approved anonymous database at New York University, Kriser Dental Center, Department of Periodontology and Implant Dentistry, New York, New York, from 23 patients (10 males, and 13 females; The age range of patients included was 46 to 75 years and the mean was 59 years) who had undergone SAP with a total of 40 treated sinuses. Sinuses were grafted with mineralized cancellous bone allograft (MCBA), anorganic bovine bone matrix (ABBM), or biphasic calcium phosphate (BCP). Perforation complications occurred in 15 sinuses with 25 non-perforated sinuses. All perforations were repaired during surgery with absorbable collagen membrane barriers. Histologic cores were taken from all treated sinuses 26 to 32 weeks after surgery. The implant success rate of 79 placed implants was recorded.

Results:

1. The implant success rate in perforated sinuses was 100% (35 of 35) compared with the non-perforated sinuses with 95.5% (43 of 45).

2. There was no statistical significance in implant failure between non-perforated sinuses and implant failure in the perforated group.

3. There was a statistically significant difference in the vital bone percentage between the non-perforated (19.1%) and perforated (26.3%) sinuses. There was no statistically significant effect for treatment.

4. The average percentage of vital bone was 28.25% for MCBA, 12.44% for ABBM, and 30.6% for BCP.
   
   

Conclusion: treated sinuses that exhibited MSMPs that occurred during the SAP (which were treated during surgery) showed statistically significant greater vital bone percentages compared with the non-perforated sinus group. However, there were no statistically significant differences in implant survival in the non-perforated versus perforated sinus groups.

Topic: Repair of perforated sinus membrane

Authors: Proussaefs P, Lozada J, Kim J, Rohrer MD.

Title Repair of the perforated sinus membrane with a resorbable collagen membrane: a human study

Source: Int J Oral Maxillofac Implants. 2004;19(3):413-420

Type: Clinical

Keywords: artificial membranes, collagen, dental implants, maxillary sinus, sinus augmentation, sinus membrane.

Purpose: to evaluate the results of the repair of perforated sinus membrane with resorbable collagen membrane.

Materials and methods:

• A split-mouth design was followed of 12 patient requiring bilateral sinus grafting were included.

• One site had been “accidentally” perforated during sinus augmentation, and the other site had not been perforated.

• The perforation was repaired with a resorbable collagen membrane.

• Dental implants were placed during a second surgery 6-9 months after graft, and biopsy samples were harvested from both sinuses during implant placement.

• New bone formation was measured for all sites. Implant survival was recorded at second-stage surgery. Panoramic radiographic were taken before/after sinus grafting and after implant placement.

Result:

Conclusion: Repairing the perforated site of the sinus membrane with resorbable collagen membrane may result in reduced bone formation and implant survival rate.

BL: perforation and repair of the sinus membrane may compromise new bone formation and implant survival.

Critics:

• Small sample size.

• The authors didn’t mention the size and the severity of the perforation. It was only mentioned larger than 2mm.

• Only placing a collagen membrane without being using tacks for stability (Pikos technique) for a larger perforation may not be adequate for the repair.

Topic:  Maxillary sinus

Authors: Cho SC, Wallace SS, Froum SJ, Tarnow DP

Title: Influence of anatomy of Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis.

Source: Pract Proced Aesthet Dent 2001; 13:160-163.

Type: Cross sectional study

Rating: Good

Keywords: sinus, Schneiderian, membrane

.

Purpose: To determine if variations in sinus anatomy influenced the perforation rate of the Schneiderian membrane .

Methods: Residents under the supervision of faculty performed 49 randomly selected sinus elevation procedures on 34 patients. Preoperative radiographic evaluation included panoramic Xray and CT scan. Three anatomic variations were selected for evaluation. Each of these variables consisted of the angle formed by intersection of bony walls relating to the inverted pyramid-shaped maxillary sinus. For purpose of comparison each angle was divided into three groups. Group I: specimens with an angle of 30 degrees or less. Group II: Angles between 31 to 60 degrees. Group III: Angles of 61 degrees of greater.  These measurements were analyzed to investigate any correlation between the anatomic variables and the experienced perforation rate.

Results: Of the 49 sinus elevation procedures, nine resulted in visible perforations of the Schneiderian membrane. If perforation occurred an absorbable barrier membrane would be use to occlude the perforation. Only the different groups within angle A demonstrated a significant correlation with the observed perforations. The perforation rates were Group I: 37.5%, Group II: 28.6% and Group III: 0%

Conclusion: The greatest risk of perforation is when the sinus is narrow, mostly on the anterior portion of the sinus.

Topic: Classification for sinsus membrane perforation

Authors: Vlassis JM, Fugazzotto PA.

Title: A classification system for sinus membrane perforations during augmentation procedures with options for repair.

Source: J Periodontol 1999;70(6):692-699.

Type: Case study

Rating: Good

Keywords: Alveolar ridge augmentation, dental implants, endosseous, grafts, bone, maxillary sinus/injuries, Schneiderian membrane

Purpose: To propose a classification for sinus membrane perforation during sinus augmentation and options for repair.

Method: Case study of five perforations, classify them, and make recommendations for repair.

Results: Classification was determined by both position and extent. Be sure to isolate the area to maintain a clear field.

Class 1: Often are sealed off as a result of folding of the membrane across itself. If this occurs no further steps need to be taken other than being delicate when packing membrane material. If perforation still evident after reflection, collagen tape is placed over the area to cover the perforation 3 mm in all directions. Graft is placed in the location of the collagen tape last. If the collagen tape does not suffice a resorbable material can be sutured with the membrane to close the perforation.

Class II: Located in the mid-superior aspect of the osteotomy, extending mesiodstially for 2/3 the dimension of the osteotomy. Typically happens when reflecting with the intact internal portion of the osteotomy rather than a detached window. To repair you can try reflecting the rest of the membrane to see if it folds over on itself. If this does not occur, collagen tape, a resorbable membrane, or freeze-tried human lamellar bone sheets can be used to cover the perforation. Suturing is also an option.

Class III: Located in the inferior border of the osteotomy at its mesial or distal sixth. This is the most common perforation, and often results from inadequate osteotomy design or improper membrane reflection. Round edged osteotomy helps to reduce this risk. You may attempt to relieve the margins of the tear and then follow up by suturing them together and cover with a lamellar bone sheet. Graft material must first be placed on the borders of the lamellar bone sheet to stabilize the sheet over the perforation and then over the bone sheet. This is difficult and not always practical. A final attempt to repair a Class III is to trim a lamellar bone sheet and place it within the osteotomy site so that a pouch is created over the perforation. Graft material is then placed all around the bone sheet to stabilize it but this approach is not as stable as the others.

Class IV: Located in the central two thirds of the inferior border of the osteotomy site and often enlarges dramatically as management is attempted. This is relatively rare but can be seen in improper septal elevation. If both margins around the tear can be elevated then the tear should be sutured and covered with a lamellar bone sheet. If suturing is not feasible, an attempt may be made at enlarging the osteotomy site (may not be possible depending on the position to the crest of the alveolar ridge). Again if these attempts fail a pouch can be made with a lamellar bone sheet.

Class V: Perforation that results in inadequate residual bone between the most inferior border of the sinus and alveolar crest. A prior oral-antral fistula may have been a contributing factor. Perforation is often only evident following flap reflection.

Class 1 and Class II perforations are more easily repaired. Class IV perforations is the most difficult to successfully treat.

Conclusion: When classified and managed appropriately, sinus membrane perforations are not an absolute indication for aborting the augmentation procedure while in progress.

Topic: Sinus Lift

Authors: Jensen SS, Eriksen J, Schiodt M.

Title: Severe bleeding after sinus floor elevation using the transcrestal technique: a case report.

Source: Eur J Oral Implantol. 2012 Autumn;5(3):287-91.

Type: Case Report

Rating: Good

Keywords: complication, bleeding, sinus lift, transcrestal

Purpose: To present a rare but clinically significant complication to sinus floor elevation (SFE) using the transcrestal technique.

Method: Transcrestal SFE with simultaneous implant placement was performed in the maxillary right second premolar region of a healthy 70-year-old woman with no history of a bleeding disorder.

Results: The patient reported to the emergency care unit a few hours after the surgery with ongoing bleeding and progressive swelling of especially the right side of the midface. The buccal swelling did not allow the patient to close her mouth and the discoloration extended to the sternum. A computed tomography scan showed pronounced swelling of the facial soft tissue and the right sinus cavity completely filled with blood. The patient was kept hospitalized for 3 days until regression of the swelling was attained and acceptable oral function was regained.

Conclusion: The present case illustrates that severe complications may accompany transcrestal SFE.

Topic: Risk factors for sinus lifts

Authors: Testori T, Weinstein RL, Taschieri S, Del Fabbro M.

Title Risk factor analysis following maxillary sinus augmentation: a retrospective multicenter study

Source: Int J Oral Maxillofac Implants. 2012 Sep-Oct;27(5):1170-6.

Type: Clinical

Keywords: sinus floor elevation, risks, implant survival, complications

Purpose: To identify risk factors affecting implant survival in those patients who have undergone maxillary sinus surgery.

Materials and Methods: Three centers were involved in this retrospective multicenter study; over a 9-year time frame 106 patients were examined with 144 sinus elevation procedures whom received 328 implants. The mean follow-up was 48.4 months, and the longest follow-up period was 72 months. The analysis considered patient age, gender, health status, and smoking habit; implant size, shape, and surface; residual ridge height; timing of implant placement with respect to grafting; graft material; and the occurrence of surgical complications (sinus membrane perforation).

Results: The cumulative implant survival rate was 93.0% up to 5 years. Complications occurred in 41 patients. Intraoperative sinus membrane perforation occurred in 40 sinuses (28%) however was not a significant risk factor for implant survival. Six patients experienced postoperative infection leading to graft failure, and two patients had considerable intraoperative bleeding. No statistical significance was seen between one or two staged implant placement, implant size, surface, bone graft material in terms of implant failure. However, smoking more than 15 cigarettes daily and a pre-operative ridge height of less than 4 mm were significantly associated with reduced implant survival.

Conclusions: Smoking habits and residual ridge height were determined in this study to be an associated risk factor to implant failure whereas other factors were found to not contribute. .

Topic: Maxillary Sinus

Title: Late signs and symptoms of maxillary sinusitis after sinus augmentation

Author: Manor Y, Mardinger O, Bietlitum I, Nashef A, Nissan J, Chaushu G

Source: Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology. 2010 Jul 31;110(1):e1-4.

Type: Case study

Rating: Good

Keywords: indirect sinus elevation, osteotome technique, osteotome sinus floor elevation

P: To assess the incidence of late signs and symptoms of acute and chronic maxillary sinusitis after sinus augmentation and to correlate them with predisposing factors.

MM: A total of 137 individuals (54 males and 83 females; 153 sinus augmentation procedures) were evaluated retrospectively for signs and symptoms of maxillary sinusitis, 12-80 months after surgery, using a questionnaire and clinical and radiographic examinations.

R: The incidence of acute and chronic sinusitis after sinus augmentation was low (<5%). History of preoperative sinusitis (P = .001) and sinuses with thick mucosa (P <.0001) were statistically significant factors correlated with late signs and symptoms of sinusitis. There was a slight correlation between chronic sinusitis and women (P =.079) or 2-stage procedures (P =.098). There was no statistical correlation to intraoperative complications, such as membrane perforation and excessive bleeding.

BL: The occurrence of postoperative chronic sinusitis appears to be limited to patients with history of preoperative sinusitis and sinuses with thick mucosa, despite control of the disease before sinus augmentation.

CR: Future prospective studies with direct visualization of the sinus cavity are encouraged to validate the conclusions of the present retrospective study.

Topic: sinus lift

Authors: Moreno Vazquez JC, Gonzalez de Rivera A,

Title: Complication Rate in 200 Consecutive Sinus Lift Procedures: Guidelines for Prevention and Treatment

Source: J Oral Maxillofac Surg. 2014 May;72(5):892-901, DOI: 10.1016/j.joms.2013.11.023

Type: retrospective

Rating: fair

Keywords: sinus lift, implant, postsurgincal/presurgical complications,

Purpose: to evaluate the prevalence and types of complications after sinus lift procedures.

Methods: Retrospective analysis on 127 patients over a period of 8 years (1999-2007), undergoing preprosthetic surgery with implants and a maxillary sinus lift procedure. 202 sinus lifts (modified Caldwell-Luc) and 364 implants into the treated regions (117 simultaneously and 247 delayed). Intraoperative and postoperative complications and possible contributing factors were recorded.

Results:

• Intraoperative: Perforation of the Schneiderian membrane was most common complication (25.7%). Various methods have been proposed to deal with these complications, from leaving them untreated to suturing the Schneiderian membrane, sealing with reabsorbable membranes, and using glues obtained from autologous fibrin gel. In general, small perforations may regenerate spontaneously.

• Postoperative: majority of the cases without complications (85.1%). the most frequent complication was wound infection (7.1%), followed by postoperative sinusitis (3.9%), others include; abscess, or dehiscence with drainage, maxillary sinusitis, partial exposure of the simultaneous onlay graft, and loss of the graft. Postoperative infections are often resolved by systemic antibiotics, local measures, vasoconstrictors, and aerosol sprays.

• Implant complications: 94.2% of the implants placed in the treated areas did not have any complications. 5.4% of the implants had complications such as loss of implant (2.5%), peri-implantitis, bone loss, mucositis, mobility, fracture, and local periapical infections.

• Smoking has been definitively established as a risk factor in the evolution, outcome, and complications of periodontal and implant surgery.

• Other the location of the implant (the premolar region being 60% safer than the molar) and the type of surgery (2-stage procedures being 90% safer than single-stage procedures)

• Complications in the present study: (this table is generated, is not in the original article)

Topic: Implant complications

Author: Najm SA

Title: Potential Adverse Events of Endosseous Dental Implants Penetrating the Maxillary Sinus: Long-Term Clinical Evaluations

Source: Laryngoscope. 2013 Dec;123(12):2958-61.

Type: Retrospective cohort study

Rating: Good

Keywords: Dental implant, sinus membrane perforation, maxillary sinusitis

Purpose: The aim of this study was to evaluate the nature and incidence of maxillary sinus adverse events related to endosseous implant placement with protrusion into the maxillary sinus.

Methods: Implants, with evidence of maxillary sinus penetration, placed between January 1989 and December 2007 in the Department of Oral Surgery and Oral Medicine at University of Geneva were evaluated in this study. Only patients with a minimum follow-up period of 5 years after implant placement were included. Patients who had undergone sinus lift procedures were excluded from the study. Maxillary sinus assessment was both clinical and radiological. All patients were asked about signs and symptoms consistent with a diagnosis of acute or chronic rhinosinusities. Other factors such as headache, dental pain, halitosis, fatigue, cough, ear pain and fever were accounted for.

Results: 83 implants with sinus membrane perforation in 70 patients (40 F; 30 M). 12 patients had more than one implant penetrating the maxillary sinus, and 7 of them had bilateral sinus perforation. Estimated implant penetration was <3mm in all cases. At follow-up appointments (avg follow-up was 9.98 yrs + 3.74), there were no clinical or radiological sings of sinusitis in any patient. Two implants were diagnosed with peri-implantitis. Radiological follow-up demonstrated a normal bone healing process in all subjects.

Discussion: Odontogenic maxillary sinusitis has various etiologies (dental infection, oroantral fistulas, foreign bodies, or odontogenic cysts large enough to obstruct the maxillary sinus). Studies addressing implant-associated sinus complications are scarce. Studies, looking at the reaction of the sinus mucosa around dental implant penetration, showed normal mucosa with no signs of increased secretion or infection around the implants (Petruson et al.).

Bottom Line: This follow-up long term study indicates that no sinus complications were observed following implant penetration into the maxillary sinus.

Conclusion: Sinus lift surgery is a proven and reliable technique because of the low observed rate of postoperative complications and the success rate of implants placed into the grafted area. To minimize

risk, care must be taken with all technical details and risk factors that can lead to fatality.

Critique: data were not statistically analyzed to evaluate the significance of the differences.

Topic: Implant complications

Author: Najm SA

Title: Potential Adverse Events of Endosseous Dental Implants Penetrating the Maxillary Sinus: Long-Term Clinical Evaluations

Source: Laryngoscope. 2013 Dec;123(12):2958-61.

Type: Retrospective cohort study

Rating: Good

Keywords: Dental implant, sinus membrane perforation, maxillary sinusitis

Purpose: The aim of this study was to evaluate the nature and incidence of maxillary sinus adverse events related to endosseous implant placement with protrusion into the maxillary sinus.

Methods: Implants, with evidence of maxillary sinus penetration, placed between January 1989 and December 2007 in the Department of Oral Surgery and Oral Medicine at University of Geneva were evaluated in this study. Only patients with a minimum follow-up period of 5 years after implant placement were included. Patients who had undergone sinus lift procedures were excluded from the study. Maxillary sinus assessment was both clinical and radiological. All patients were asked about signs and symptoms consistent with a diagnosis of acute or chronic rhinosinusities. Other factors such as headache, dental pain, halitosis, fatigue, cough, ear pain and fever were accounted for.

Results: 83 implants with sinus membrane perforation in 70 patients (40 F; 30 M). 12 patients had more than one implant penetrating the maxillary sinus, and 7 of them had bilateral sinus perforation. Estimated implant penetration was <3mm in all cases. At follow-up appointments (avg follow-up was 9.98 yrs + 3.74), there were no clinical or radiological sings of sinusitis in any patient. Two implants were diagnosed with peri-implantitis. Radiological follow-up demonstrated a normal bone healing process in all subjects.

Discussion: Odontogenic maxillary sinusitis has various etiologies (dental infection, oroantral fistulas, foreign bodies, or odontogenic cysts large enough to obstruct the maxillary sinus). Studies addressing implant-associated sinus complications are scarce. Studies, looking at the reaction of the sinus mucosa around dental implant penetration, showed normal mucosa with no signs of increased secretion or infection around the implants (Petruson et al.).

Bottom Line: This follow-up long term study indicates that no sinus complications were observed following implant penetration into the maxillary sinus.