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Ask UsInadequate Bone Height: Elevate Maxillary Sinus Membrane During Implant Placement?
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Dr. C. asks:
Is it necessary to elevate the maxillary sinus membrane during placement of implants through the floor of the sinus when there is inadequate bone height? In one course I heard that even if the implant perforates the sinus membrane, if there is initial primary stability, the sinus will reform around the implant projecting into the sinus. If this is a predictable outcome, I would rather perforate the sinus membrane then do a sinus lift. What are your experiences?
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16 Responses to “ Inadequate Bone Height: Elevate Maxillary Sinus Membrane During Implant Placement? ”
If that was true then none of us would be performing sinus lifts. I don’t know of anyone recommending to routinely place implants into the sinus and then hope all will be well.
This is a great question and one that is controversial. The literature has shown that a 1-2mm perforation will be covered by the membrane. With adequate stability, the implant is thought to be fine. So, with 8-9mm of bone it is an option…
I feel that grafting in these cases by means of osteotome is better since osteotomes will easily achieve an ideal situation. If the patient has chronic sinusitis, or worse yet develops one after implant penetration, it becomes subjected to bacteria apically. If the implant needs to come out, you aren’t tearing the membrane causing a OA fistula.
One caveat to this way of thinking includes aiming for 10mm length implant,as suggested by the literature. If you have 5mm of bone and place a 7mm implant…good luck. Plus, sinus grafting is very predictable and routine with long term follow ups showing high success.
My experience is you want to stay away from as many complications as possible. An implant intentionally projecting into the sinus is subject to bacterial elements that can be avoided. I have seen this technique done intentionally, with some implant companies actually promoting it. I don’t feel comfortable with it (not in my mouth or done be me)but I wouldn’t freak out if I saw it.
To the suggestion of 5mm bone and placing a 7 mm implant. if we are talking about the same implant (Endopore) then the recommendation is to do a sinuselevation througt the drillwhole or with the osteotomes. Putting in graft material to elevate the sinusmembrane some more and then putting in the 7 mm implant as a plugand in contact with normal bone except at the top!
Unfortunately our treatment is often dictated by legal, rather than medical, ramifications. If you place an implant directly into the sinus and the patient develops chronic sinusitis or chronic pain you have an indefensible case. Interestingly I opened my new malpractice premium today and saw that it had TRIPLED. That is with a clean record. I called the carrier and they said it is because a large portion of my practice is implant surgery. The lawyers have found a new target. Be careful what you expose yourself to.
You cannot have the implant intruding into foreign teritory and not expect complications, unless of course you R one of those extremely lucky individuals some of whom I have come across.
There is no way I can think of that would avoid the slightest of ingress of bacteria into the sinus from the oral cavity if the memb. tears. Even with the implant placement rpm the margin of the osteotomy will carry some debris into the sinus which would cause trouble later on.
Go ahead n do a lift , if you are diffident with a lateral wall approach then do a Summer’s technique but PLEASE DONT FORM A HABIT OF PERFORATING THE MEMBRANE. Thats in your best interest.
Any queries, please write, I’d be glad to reply.
Regards
perforating the sinus membrane means high risk of sinus infection if the patient is already free of sinsitis(which should be).actually it is true that it is not affecting the implant regarding load distribution as most of the load is distributed on crestal 1/3 of the implant.
ther is no enough information about titanium & bacteria in the sinus,but still thispatient can catch sinsitis for any other cause.
the other thing if for any reason implant failed,then you r confronted with oro-antral fistula
Perforating the sinus membrane intentionally instead of performing sinus lift is of course a contraindication.Penetrating the sinus might lead to complications mostly sinusitis.
Why on earth one would deliberately perforate the sinus?If you don’t know how to perform a lift I can advise you with some courses…
in my experience with round nose implants, like thats i use in Italy (one piece implant) , and carrying contemporarely graft material like Biocoral, you can elevate very gradually the sinus membrane for some mm. with any damage and you can control finally with an endoral Rx if you exposed the sinus because Calcite and such materials are dispersed or not in the sinus hole.
The consequences are minimals if you take littles precautions.
The incidence of perforation during implant placement and simultaneous implant placement is probably higher than reported in the literature. I have found, in the patient free of sinus disease, there is little probability of sinusitis as a result of this event. But if there is no chance for an increase of bone height, there is no advantage of placing the longer implant. I advise my residents to confirm sinus integrity by placing a radioopaque graft material (i.e. bTCP), confirming the encapsulation by radiograph, and then placing an implant to the new height created. If there is evidence of extravasation of the graft into the sinus, either place a shorter implant or come back another day after complete healing.
Histological studies of sinus augmentation procedures have shown that the new bone forms endosteally from the sinus bony walls irrespective of the grafting material used or even at their absence. In accordance with the principles of guided bone regeneration, studies have shown that bone will also form when only a blood clot is present underneath an intact sinus membrane that is left to rest on implants protruding into the sinus cavity. Several investigations have shown that the success rate for non-grafted sinus implants inserted in patients is broadly similar to the success rate observed for conventional implants inserted in grafted sinuses. When placing implants at the posterior maxilla, sometimes the thickness of the antral floor or the alveolar bone height is so low that the implant will necessarily protrude into the maxillary sinus cavity. The drilling process or even the implant insertion may unintentionally lead to Schneiderian membrane perforations. If the sinus has been grafted and the perforation properly sealed off by a collagen membrane, minor perforations do not seem to play a significant role in the clinical outcome. However, if there is no grafting material on premise, it appears that the size of the membrane perforations relates to the prognosis of the implants placed. Some clinicians have found no relation between membrane perforations or postoperative complications and implant survival while the others believe that the size of the perforation correlates with implant failure and the larger perforations represent an absolute contraindication to the continuation of surgery. One should keep in mind that the emerging tip of an implant which is situated in the maxillary sinus through a Scneiderian membrane perforation, may act as a nidus for bacterial colonization and future sinus empyema.
The logic of perforating the membrane deliberatly is COMPLETLY flawed!
Inspite of the possibility to repair and varying outcomes in the literature there is no possible advantage to this.
I completely agree with Dr. Jafari. Although there are a lot of controversial opinions in respect to sinus lift procedure ( in technique , material or out come aspect )and even in some researches ,formation of new bone on the implants which perforated the schneiderian membrane and have been left without using any graft, has been observed (Boyne 1993)but it is not advisable to perforate schneiderian membrane intentionally and it is better to use one of techniques which have been recommended to manage such situations to improve the prognosis and prevent of probable complications
As Dr.Miller questioned,what is the advantage of perforating membrane and pushing implant in to sinus?
10mm Implant with 5mm of it protruding in sinus is as good as 5mm implant with extra burden of extra complications.
It is like placing a 2 inches long nail in 1 inch wall and wrongly expecting better result.
Having read posts on sinus lifts for months, I have yet to do one. I have the cases on which to do them coming up.
Is it better to place graft ahead of the ostotome or a BTI expansion drill, or is it better to break the final bone before placing any graft material?
OR can one create the osteotomy up to the sinus and place graft material, say btcp, in the preparation and force the graft material up by screwing the implant in, breaking through the last bone forcing the membrane up?
Thank you.
Joe
Well said Satish,with regards to Joe once you start things get easier, better to use a lateral window Cauldwell-luc approach as it is easy to see where you are and can carefully raise the lining especially where there is less bone.Osteotomy expansion to raise the sinus floor are better with about 8 mm of bone.
I agree with the comment of Dr K. It is hard to say one way is wrong but we should aim for predictability in our procedures. Most experienced surgeons will tell you sinus elevation is easy and safe. Puncturing an implant through the sinus may be easy but may have its pitfalls in the longterm. Plus, what’s the point of even puncturing the sinus? just place a shorter implant since the portion in the sinus is unsupported anyway. Right?
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