Perforating the Maxillary Sinus with an Implant: Comments?

Dr. Z. asks:

I have a question which may be rather naive for the experienced implant surgeons. What is wrong with perforating the floor of the maxillary sinus with an implant? The implant will engage two cortical plates which should provide greater initial primary stability. This should be especially helpful in Type IV bone. Will bone grow up from the floor of the maxillary sinus to eventually cover the implant? I have attended lectures where plastic surgeons have demonstrated procedures where they perforate the maxillary sinus with screws when doing reconstructions. They do not seem to be as concerned as we are about the problems that perforations might cause. Any comments?

28 thoughts on “Perforating the Maxillary Sinus with an Implant: Comments?

  1. Like any epithelial tissue, the sinus membrane will usually heal uneventfully. I’m not suggesting having an implant 10mm into the sinus cavity obviously, but if we are dealing with a small perforation 1-2mm into the sinus, it will heal. However take caution that an infection can take place.

    If you had perforated through bone and membrane, I don’t think it will be as likely for bone to form itself around the implant. Then again, I don’t have evidence either way.

  2. As you said, we perforate the sinus membrane all the time when we’re doing osteosynthesis in trauma and reconstuctive cases. It seem to work out fine, but I’m not sure if that is 100% comparable with dental implants. BV and other OMFS – what do you think?

  3. Bi-cortical stabilization for implants in area around sinus was how it was done originally during the branemark era with smooth surf. implants with some surgeons. Have you ever seen Zygomatic Implants which Nobel used to sell? (Do they still sell it?) Anyways, perfing the sinus with the implant does not mean your implant is doomed.
    HOWEVER, the sinus is not a sterile area and would you want your implant (which is surface treated with little grooves and holes) to communicate with the bacteria in the sinus. Because practically all implants these days are rough surface, it’s a good nidus for bacteria accumulation if exposed in the sinus. If exposed, it *could* lead to problems in the future during healing of after, but the key word is *could* b/c implants have been shown to be okay clinically even if the sinus is perfed (within reason of course) during implant placement.

    Basically, it just makes sense for me to have the rough titanium surface of the implant heal within bone; less probability for infection, sinus irritation and more probability for osseointegration in vital bone.

  4. Bill stark , you know better! It depends, as dr Dan says on how far you go into sinus. If its 2-3 mm , probably no big deal assuming the sinus is healthy. Again the reason dr. Caldwell designed this procedure the way he did ,was to avoid placing a foreign body where it shouldn’t be. The respiratory mucosa does have a purpose . Yes we rupture and invade this area on a weekly basis with osteotomies and trauma, but we don’t leave a large diameter screw in there. Again, a small retaing screw used to hold up some ladies brow accidentally perforating the dura may not cause a problem either, But I’m not gonna do it. Why does dentistry have to be a ” crap shoot”? Some of us wonder why some of the medical community refuses to give us the respect we deserve. I would suggest not making a big deal about it , but get a cbct and see how far in you are. Bv

  5. I can think of a few reasons why NOT to perforate right off the bat:
    1. If you perforate, you are leaving a portion of the implant unsupported by bone, which is the goal of placing implants. Otherwise, we’d just stick them under the gum line. Forces from the occlusal surface of the tooth are transmitted along the entire length of the implant, not just the crest.
    2. Leaving a rough surfaced implant perforating into the sinus leaves a totally non-cleansible bacterial trap in an avascular area.
    3. Perforating the membrane leaves you with a non-controlled tear in a potentially thin membrane opening up the patient to further infections, complications.
    Is that enough reasons why you should place these implants properly?

  6. Actually nothing will happen if you in the sinus and it has no active infection, and that is more true if your implant threads are wide enough to get full oclusion of the osteothomy of the sinus floor. If that is the case, then you really get bicortical stabilization. I usually go in with no remorse or real fear, leaving the implants 3 or up to 4 mm in and due to the shape of my prefered implants I get great stability. OMF surgeons leave protruding implants and screws in the sinus with total disregard and have no real issue with that. Our fear comes from the early Branemark Techniques and from the sinus elevation concerns but actually you can clearly go in and dont expect problems.
    best luck

  7. clearly not an issue perforating the sinus. in fact engaging the sinus floor which has dense bone is preferable in some cases. i do it routinely to place zygoma implants. we dismantle the sinus and place bone plates and screws which extend into the sinus during lefort osteotomies.

  8. Hold on a minute. So unless you perforate the sinus your not getting bicortical engagement. That is essentially what a couple of you have said. The reason we do the sinus lift, with regard for the membrane, is so we can get bicortical purchase. The analogy of our lefort one osteomy plates is a poor one , in that two weeks after the procedure ,the mucosa is completely closed over those screws. This mentality maybe why ent surgeons cringe , everytime they hear the term sinus lift. An implant that is perforated into the sinus, has a microscopic communication with the oral cavity, with the steady handed surgeon. With the” implantologist” who’s ostoetomies are wider than they should be, then the communication is supramicroscopic. I have been involved in the removal of three implants from the sinus in a single week. Just imagine the state of those implants, had they not been pushed into the Antrum . You can be sloppy or you can operate by the standard of care. In my lifetime, placing implants into the sinus will never be the standard of care. I agree, there is a lot we get away with , in that the head and neck is a forgiving part of the body. This does not give us the right to operate like a bunch of first year dental students. Bv

  9. Dr steve, you routinely place zygoma implants? I’ve placed ten max. and they are a mess to clean. The reason your not seeing nobel push these fixtures is because they are an engineering nightmare. Only indication I’m seeing for these, today, is large maxillectomy cases, when the prosthodontsist is trying to get rid of the old obturator. Bv

  10. Dr Baker,
    You seem pretty passionate about this thread. I think Dr Z’s question is a very valid one and I am not following your “hold on a minute” post, specifically in regards to sinus lifts and bicortical stability. It’s perfectly rational to question that an implant could be more stable being a thread or two into the sinus than it would be after a sinus lift. Obviously pushing the implant into the sinus cavity is not the goal and thank goodness for doctors like yourself who can get them out but I dont see anyone on this thread acting like a first year dental student. On the contrary, I aplaud Dr Z for post.

  11. Dr Brant , only a first year dental student would not understand that you engage both cortices , regardless of wether the sinus is perfed or not. I honestly believe , with some of the questions posed, there are some people that have no clue as to what they are doing. Go back a few questions ,and read them. You may not have noticed , but I use a bit of sarcasm, to make a point, but a lot more science. Hope your not a first year dental student. Bv

  12. Thanks Dr Baker for continuing this bc I respect your opinion and am pretty interested in this. I am embarrassed that i didnt pick up on the sarcasm. I think my point is, and I don’t txp my patients this way, but there are obvious risks and complications associated with a sinus lift, as well as a considerable financial investment for the patient. Are those offset by the reward. Is there less risk by a skilled surgeon perforating the sinus 1-2mm with an implant. Especially when you consider how many options there are for grafting materials and how much contraversy there is with some of them.

  13. Brandt, my answer to that rhetorical question, is autogenuos bone mixed with prp in almost all sinus lifts. There is little controversy associated with that. There are a couple of good studies that prove that an intact sinus grows bone without placing any material(graft), primarily because you have created new space, and that space is maintained with your Implant. I have become less dogmatic about only using the patient’s own bone , in that most of my local colleques( for whom I have lots of respect) only use demin. Or min. bone. I think using anything else ,other than bmp,makes little or no sense. Enjoying the intelligent banter. Bv

  14. okay Dr Baker,
    Pts cbct shows just less than 11mm vertical height and plenty of width at site 3. no contraindications but pt refuses sinus augmentation. you could place a 9mm with minimal risk of perforation, place a 10 knowing that the surgical drill will probably enter the sinus or an 11 mm knowing you are in the antrum. or obviously refuse to treat. which implant do you think would be the most stable?

  15. The 11mm is my answer. Are they refusing an internal lift as well? I feel like I’m sitting in the drake hotel in chi town, taking my oral boards. Like I said before ,1-3 mm into the sinus is probably no big deal. I must confess, I have done sinus lifts before where there was 13 mm of bone and my implant barely reached the sinus. This was before I got my scanner. Boy, that implant looked good five years later.bv

  16. You win Dr Baker,
    There is no right answer. My answer is i refer to a specialist if its close to the sinus. my recommended trx would be an internal lift and i think that is the standard of care. but i really dont know if it is necessary. nor do i know if its more stable. thanks for your insights.

  17. I have 2 dental surgeon friends ( have worked together for 30 years ) one of whom placed 2 implants into the others sinus in the late 80s , whilst it is a source of great humour there has never been an issue. Thus the issue here is while it can be done with no issues it is not protocol and looks a bit messy when another surgeon may see it later and comment on it . ( bit like a poor crown marginal fit ).
    With systems such as Dask , Sla etc the procedure is that much easier to perform .
    Peter

  18. I still believe the studies that strongly suggest a minimum of 13 mm in the maxilla are relevant . This was published before the bicon implants even were around, I believe. Longer, wider is better! That’s what she sa……….? Bv

  19. Dr.Z, I guess I didn’t read your initial query as closely as I should have. You said you attended a course where plastic surgeons entered the sinus and were not concerned. A bit of real insight , should enlighten you as to the fact that “they ” are not the specialty to follow when you are looking for a standard by which to practice. “Most” plastic surgeons , just as the ent doctors are typically out of their comfort zone , when they enter the” abyss” between the lips. I have for 20 plus years watched these doctors do things that were absolutely tragic . I have seen these guys completely deglove the palate for a non displaced palatal fx, and actually plate it. They rarely know when not to operate facial trauma, and the majority of them in my part of the country frankly refuse to fix mandible fxs, even though they might suggest they are the only ones the should be doing cosmetic surgery of the lower half of the face. I have treated more than fifty facial fractures that were first ” repaired” by plastique sturgeons. I’m going to suggest this one more time , please look to your maxillofacial colleques that spent years becoming proficient in treating conditions of this area. Are you aware of the fact that we are the only specialty that can treat every facial trauma patient. The percentage of facial fx’s that has some dental component is greater than 65 percent. What this means is , when either plastics or ent is on call for facial trauma , there is a 65 percent chance that they will need the help of a dentist to comprehensively fix their patient . I have yet to summon a plastic or ent doctor to help me for a facial trauma case. I certainly don’t speak for all omfs, but would suggest most would agree. Bv

  20. Absolutely agree with BV, many plastic surgeons unfortunately have no idea about the oral structures, dental occlusion, etc… I have also seen many cases of irreparable sequelae left behind by inappropriate reductions of mandibular and maxillary fractures done by plastic surgeons. But the undisplaced palatal fx reduction you mention with degloving and plates… OMG!

  21. Good reasons explained by Robert Horowitz
    I just want to add the point that if you might perforate into the sinus,you can use a shorter implant,can’t you?

  22. Just reviewed about twenty five ct scans of patients that had either osteotomy of the upper jaw, repair of maxilla fxs , tumor surgery or dental implants that penetrate just into the maxillary sinus and did not see one case with sinus dz.. Obviously this is not a definitive scientific study, it does appear , that it is safe to suggest that placing a fixture 2-3 mm into a healthy sinus will probably not cause any adverse sequalie . It also appears( based on these ct scans) that the mucosa that heals over the exposed screws is consistent with the respiratory mucosa in areas where there are no screws. This opinion does not apply to the loose implant, or a case of an actively infected sinus. Bv

  23. While really enjoying the input of the experienced, highly trained Drs. above, I wonder why the use of the Bicon short implants is not considered as an alternative to 13 mm long implants, requiring major surgeries?

    I just snuggled a 6.0 x 5.7 mm right up against the sinus floor in a fresh extraction site with no problems in an 8 mm deep socket, and have done so many times before.

    Why is this not a valid option?

    John

  24. Jon , I can’t honestly argue one way or the other, but have always lived by the 13 mm rule. I was trained 20 plus years ago and all of my ce has been on reconstructive, cosmetic, trauma and tumor surgery. I do read a lot of implant lit. And if the science supports the wide bodies, then they have to be considered an option. Even though I don’t restore implants , it’s tough to look at something that doesn’t at least have 1:1 crown / root ratio. I am learning a bunch on the sight, but have found a Lot of sound principles never change! Bv

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