Penetrating the Maxillary Sinus

Dr. Chin asks:

I recently placed 4 dental implants in the maxillary jaw. The panoramic
radiographs I took before the procedure showed a 13mm vertical bone
height in the left premolar area. I was planning to place 11.5mm length
implants there.

The panoramic radiographs I took after the procedure show that 1 dental implant I placed penetrated the maxillary sinus by about 3mm. Primary stability is very good for all 4 dental implants. Will I have to trephine out the dental implant and replace it with a shorter implant? Or can I leave them all as is and have a delayed loading? I am planning to restore the case with an overdenture. How long should I wait to load the dental implants?

22 thoughts on “Penetrating the Maxillary Sinus

  1. According to your case describtion , you over exceeded your planed length by 4.5 mm which is not logical comparing to your measurments of pre op panorex for (13 mm)unless you placed the implant 5 mm subcrestally. I would suggest to redo the pan with the exact head position and I think you will find your implant in the right place,
    But supposingly you really missed your correct pre op measurments and the implant is really 3 mm inside the sinus , according to my experience I have seen more than 50 implants which have a 2-3 mm inside the sinus with no symtoms at all and no reaction on x rays ,and surviving more than 5 years.
    just give 4 months time to heal and proceed with your planned prostho, good luck

  2. Leave it as it is. Results should be great.
    Remember that all Branemark;s early implants penetrated into the sinus – bicortical stabilization it was called.
    CR

  3. Leave it alone and it should be just fine. Many do an “internal” lift with around 3mm apically wihtout any exogenous grafting done and it works quite well. You should have really felt the dense sinus floor before you penetrated it though. I’d take another radiograph either way to confirm what you have and just let them heal a bit longer.

    Good luck,

    Jackson

  4. Wait atleast 6 to 8 months for healing.What’s the rush? It should be just fine but if there are any issues I’d prefer to find out before the restorative phase is completed.You have nothing to lose by waiting.
    Good Luck

  5. No reason to wait any longer than usual. 3-4 months. If you had excellent stability, you did everything right. I’ll take bicortical stability over a short implant any day!

  6. 2 issues. Sinus penetration will not propose a problem. Wait 3-4 months and go forward. Panorex has 25% distortion so the fact that your measurements are off do not surprise me. Take a periapical to ckeck your actual placement.

  7. Shouldn’t necessarily be a major problem. In the future when you take panoramic x-rays, use a metal ball in or near the edentulous space to calibrate just how much magnification has occured.

    I would be happy to explain this formula for you, but it may be easier to find it in a text-book.

    There is a great example of how to do this on the STRAUMANN website, a short video that shows use of such a ball and how to calculate your actual distances.

    Good luck

  8. This shouldn’t be a problem. However, I have had one case where the implant penetrated the sinus. After it being submerged for six months it had failed at stage II surgery. We then had an oral-antral communication to close and a sinusitis had developed. In your case I would leave it, just be aware of potential complications.

  9. Are you sure that the implant is in the sinus? You can not decide the implant’s tip is in the sinus looking at the panoramic X ray only, you should get the tomographic radiograph to understand this. Usually I use the bone which is behind of sinus on the palatal side and after taking x-ray, it seems the implant’s tip in the sinus because of superposition.

  10. As in your case it appears you have done an indirect sinus lift procedure (sinus floor elevation) from the osteotomy site , without bone graft.It is a well accepted procedure recently. If there is no tear in the schneider membrane & there is adequate primary stability i feel u can go ahead with your normal protocol for loading. Does’nt need extra time.

  11. Leave it alone. I think it was Andre Saadoun (France) who have shown some nice work on that few years ago. It should heal WNL. I would rather worry about the gap in measurements you expected and what you ended up with!

  12. Dear Dr Chin
    Unintended Implant penetration of the maxillary sinus occur more often than we think. Usually you would be aware of this as you get a sudden ‘sinking feeling’ of the drill during surgery. Most times it will be fine and you should proceed as you normally would. But do remember that having the implant sticking into air in the sinus has no advantage. So we want to be more accurate.

    Panoramic images are magnified by as much as 25% and the distortion and magnification may not be consistent in different part of the jaw in the same film. A known dimension ball bearing marker placed close to the surgical site will be a great help.

  13. ussualy it appears a lot of granulation tissue around the apex of the implant
    / the cause for avoidig the perforation of the schneiderien membrane

  14. I am the recipient of dental implants 20 years ago that caused chronic sinusitis 8 years ago – they penetrated the sinus membrane from day one. They are scheduled to be removed. Please be aware that complications occur beyond 5 years. I spent 8 years seeing allergists and ENTs (2 sinus surgeries) when my dental implants were the culprits all along.

  15. dear melanie, experiencing ENT problems is one thing but in terms of dental implant research, there are numerous publications showing excellent biologic reactions to titanium screws inadvertently or purposely placed into the maxillary sinus.

    Drainage from the sinus is an issue and to my knowledge has more to do with sinus lift procedures not pushing the membrane on the medial wall and therefore leaving a gap which avoids anteroposterior adequate drainage.
    Some outstanding clinicians have been violating while drilling healthy sinus membranes and their long term results did not show evidence of this outcome.
    below found on PUBMed

    An experimental and clinical study of osseointegrated implants penetrating the nasal cavity and maxillary sinus.
    Brånemark PI, Adell R, Albrektsson T, Lekholm U, Lindström J, Rockler B.

    Implants were inserted in the upper jaw of three dogs in such a way that they penetrated the bone wall of the nasal cavity. The dogs were killed one year later, and the hard and soft tissues around the penetrating implants were analyzed. Radiographic and histologic examinations did not show any signs of adverse tissue reaction. The implants were all integrated in bone without fibrous tissue formation in the interface. A total of 139 implants, which pierced the bone of the sinus or nasal cavity, were inserted in the upper jaws of 101 patients. Forty-four sinus- and 47 nasal-penetrating implants were observed for five to ten years. The success rates were 70% and 72%, respectively. For 25 sinus- and 23 nasal-penetrating implants that were observed for two to five years, the success rates were 88% and 96%, respectively. The implant losses in nearly all clinical cases occurred during the first two years of function.

  16. I had a failed sinus lift in 1999, but after several surgeries, I was finally able to have three maxillary dental implants placed in 2005. They started out fine. But about a year later, I began having chronic sinusitis and chronic maxillary nerve pain. I’m almost always on antibiotics and often in pain. It was recently discovered that one of the titanium screws penetrated my sinus floor. It appears the infection always masses around the screw. My ENT tells me the only way to stop the chronic infections/pain is to have the implants taken out, and if possible, start again after the area heals.

    My oral surgeon says the titanium screw in my maxillary sinus is NOT the cause of the infection, and feels that removing the implants would not solve the infection issue. He has offered to “shave down the screw” so it no longer pierces my sinus, but otherwise leave the implants in as is.

    As a patient, I’m completely torn between conflicting advice from two doctors I know well, trust and respect. I want to find a way to solve the chronic pain issue in my maxillary nerve. I’m also concerned about the long-term health impacts of chronic infection — but I don’t want to lose my implants unless my health is clearly at risk.

    It’s also very expensive, painful and time-consuming to have to start over again. I don’t have any insurance to cover any of this, either.

    I would appreciate anyone’s view from a medical perspective. Thanks so much.

  17. Usually penetrating the sinus is no big deal. That said, if you have recurrent infections, then get to the source and treat. Recurrent sinus infections are not good for your health.

  18. I have a photo of new bone growing over exposed mini-implant threads in the maxillary sinus. I routinely use the cortical bone of the sinus floor for primary stabilization and immediate loading of mini implants (2.0 mmD)using my FixtTeeth protocol. If micro-movement is minimized by rigidly connecting two or more mini implants together, I’ve had better than 95% success rate for more than 3000 mini implants. The prosthetics are always fixed, rigid, and non-removable. I use a CBCT scanner for accurate measurements and placements. Anyone wanting pre-op, post-op, or radiographs showing eight to ten mini implants in an arch, just e-mail me at wflopnwyd@aol.com My web site is http://www.LetcherDMD.com click FixtTeeth.
    William Letcher, Tulsa

  19. Dear Barbara Chandler,
    Your problem sounds just like mine. I had two sinus lifts for dental inplants. Prior to that I had to
    have sinus surgery for chronic sinusitis. Later, I had two inplants placed. Then I kept getting chronic infections. So I saw a new ENT and he did another ct scan that showed one of my inplants was into my sinus and the other was almost into my nasal cavity. I recently went through another sinus surgery and the ENT
    took pictures showing the inplant into the sinus. I had all the tissue around the inplant in my sinus removed. I have an appointment with an oral surgeon to
    see what he says. I do not want to have to go through
    another inplant procedure. Please let me know if you find a solution to this problem.
    Thank you.
    Lori Burke

  20. 1, Without a cat scan you don’t know that the implant is in the sinus.
    2, Read the literature concerning Zygomatic Implants. By design every implant perforates the Maxillary Sinus. Thousands have been placed without resultant Sinus Complications
    3, Be conservative in loading the implants with a final prosthesis. If there is a problem, it’s better to deal with it before you make the Prosthesis.

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