Sinus Membrane Perforation: How Long Should I Wait?

Anon. asks:
I am a general dentist and have been placing my own dental implants for quite some time. I also do sinus lifts and have been very successful. But, recently I had a bad perforation during a sinus lift. Previous perforations that were generally small were fairly easy to patch with resorbable collagen membrane fragments and they have healed quite nicely. But this recent sinus membrane perforation was quite large and I could not patch it with a collagen membrane or suture it back together so I closed the surgical site as best I could and will allow it to heal. How long should I wait before going in again?

26 thoughts on “Sinus Membrane Perforation: How Long Should I Wait?

  1. Wait 4 months and the Schneidereian membrane will regenerate and you can try again. Evaluate why you had such a large tear as there must have been a reason. CT scan? Septa? Pathology? ENT’s remove the entire membrane without thinking twice. Read Misch’s Surgical Text, the best in the world, bar none……….

    Duke Aldridge, MAGD, MICOI

    Duke Aldridge, DDS, MAGD, MICOI

  2. Hi Anon,
    why didn’ t you fix the membrane with some Loma Linda pouch or Pikos technique?
    Instead of abort the procedure, i would have tried to repair it…

  3. Hi Anon,
    To begin with you could have managed the perf by using a collagen pouch tacked to the external wall .In case of abortion of the procedure I suggest a waiting period of 4-6 months.You should cover the window with a membrane in order to eliminate the possibility of soft tissue penetrating the window from the flap.

  4. I once had a Bicon implant knocked into the sinus. The folks at Bicon should really not indicate their implants for sinus lifts. If you don’t knock hard enough, the implant doesn’t seat. Knock a little harder and the implant ends up in the sinus. For sinus lifts, always use an implant that you can gradually torque in.

    Well, I tried retrieving the implant (with help from an OMS colleague) a couple of weeks later and found that the membrane had completely healed. We had to cut through it to get to the implant.

    Bone takes a long time to form, but the membrane heals like soft tissue. For a large perforation, 1 to at most 2 months should be sufficient.

  5. Chan Joon Yee, You have to develop a greater tactile sense with your fingers. Ypu have to learn to feel through your instruments. I am not trying to be flip. The Bicon is ok but be careful.

  6. Dear Chan Joon Yee,

    If you attach a sinus lift abutment (the hint is in the name), or any other temporary abutment that is larger than the implant, onto the implant BEFORE you put the implant into the osteotomy, then it is completely impossible to push the implant into the sinus.

    It’s really not complex stuff – a large peg will not fit through a small hole!

    I use a number of different implant systems, including Bicon, and I never have problems using them for sinus lifts.

    May I suggest that you firstly get some training on how to use your implants and secondly that you change your post to “The folks at Bicon should really not indicate their implants for use by idiots!”

    Kind Regards,

    Bill Schaeffer

  7. Dear Bill & Hughes,

    I know about the sinus lift abutment, but my supplier did not have it. I was informed that there was very little danger of tapping the implant into the sinus, being the cautious and experienced operator that I was (Bicon was the first surgical kit I’ve bought and I’ve placed hundreds of Bicon implants). Failures with complex cases are the exception, but a more common exception with this system. As a matter of fact, I have placed quite a few Bicon implants without ending up in the sinus but they popped out a little and ended up supracrestal when the patient sneezed at the height of osteoclastic activity.

    Though the majority of cases ended up OK, I can’t afford to have any more implants ending up in the sinus or popping out – not even one more. My OMS colleague who assisted me told me quite categorically that Bicon is never a system of choice for practitioners who are into complex cases like ridge splits and sinus lifts.

    That’s why I now use a much safer system like Osstem. The threads at the coronal portion grip the bone very well. There’s excellent primary stability even with as little as 4mm of bone. I got it right the first time and EVERY time afterwards. No funny things like sinus lift abutments required. None of them popped out even when the patient sneezed.

    Why should a responsible practitioner risk his patient’s welfare with a system which has inherent risks? I would rather use an idiot-proof system and let the cocky fellows call me an idiot than to make my patients angry.

    As an experienced Bicon user, I can say that Bicon is an acceptable system for beginners using it on straightforward cases. Once a practitioner has progressed to more challenging cases like I have, Bicon becomes a difficult system to use. In fact, I’ve pulled out a few failed Bicon implants and successfully replaced them with a Korean system.

    I guess unlike the surgeons who think they are gods, at least some of us are well aware of the fact that we are mere mortals. I don’t find it right to insist on a system even after we have become aware of the limitations. Risks, costs and inconvenience must be minimised because our patients always come first.

  8. Once again, a practitioner uses an implant system – has problems with it – fails to learn how to use the system properly and avoid making these mistakes – blames the system instead – and buys a different implant system.

    I suspect we’ll hear the same story about the new system after you’ve placed a few hundred of their implants! I hear this same story over and over again….

    If the majority of people are using an implant system WITHOUT the problems you have been experiencing, and yet you still have the problems – then may I politely suggest that the problem is NOT with the implant system.

    No implant system can do everything – at least not yet – but if one person is having problems when others using the same tools are not, then it’s a question of training and experience rather than the system itself.

    Kind Regards,

    Bill Schaeffer

  9. Forgot to include this – I just looked at the Bicon website and found this video showing how to do an internal sinus lift with Bicon implants. Just stick www. in front of this link;

    bicon.com/interactive/i_mov_case_studies.html

    Please note that I have no financial interest in ANY implant system and that I use a number of different systems.

    Kind Regards,

    Bill Schaeffer

  10. great posts by Bill, i really appreciate the way he explained the topic…
    i agree with him on proper understanding of the system before using it.
    sometimes we use so many systems that we tend to neglect finer details of each of them, but i’ve been using bicon for quite some time now n am pretty satisfied with the results…

  11. In the beginning of my young career, I repaired it via PIkos technique. It worked just fine. But now i prefer to wait 4 months and relift if the tear is large. The membrane almost always seem thicker and is more willing to be lifted, making it easier.
    It’s just my personal preference

    I also agree with Bill in most of his comments. But I wouldn’t jump too quickly in calling somebody and idiot and question their training or experience.
    I, too, have several implant systems in my office. It’s not that I don’t feel competent with one system and i purchase other systems. There are certain implants i like to use for immediate loading, upper ant, molar region, sinus area, etc… It all depends on what I feel comfortable with, and what i think will bring best results for my patients with MINIMAL risk.
    If you think Bicon is safe for sinus area, all power to you. if you think Bicon sucks at sinus area, use something else. Simple as that. No reason for name calling.

  12. Use what works in your hands. Everyone is a little different and finds the nitch that works for them. Personally, I repair the roof of the sinus with a large tear and worry mostly about getting the sinus membrane off the floor and walls where I am placing the graft material. I place the collagen membrane before placing the graft material, to create a roof to help hold the graft material and over graft a little to make sure there is enough bone when it is healed. This works in my hands, virtually 100% of the time. I don’t get too excited about sinus membrane tears! Use what works for you. Best of luck.

  13. in these cases i perform an implant that has a greater diameter than the hole that you lived. Naturally with all presupposed therapy after, during and later the interventetion.

  14. Dear Bill,

    It is really unprofessional to call someone an idiot. I am sure you have made some mistakes throughout your career. By the way, its 2008, you no longer need to put www. in front of web sites anymore.

    Cheers,

    John Nazzaro

  15. Dear John,

    The poster to whom I responded hurt his patient not because of a poorly designed implant, but because he hadn’t bothered to learn how to use it properly.

    The complication he caused was ENTIRELY AVOIDABLE and the patient suffered because of it. He then chose to blame the implant system, rather than himself, on a public website.

    What would you suggest he be called?

    As you suggest, I have made LOTS of mistakes throughout my career, but when it happens, the first person I look to to blame is myself.

    Kind Regards,

    Bill Schaeffer

  16. Bill,

    When you looked into the mirror to blame yourself, did you write the word “idiot” on your forehead so that your colleagues could judge you. This is a great website and even though some of these guys are not specialist, they are just wanting to learn and be a better practitioner for their patients.

    Most sinus lifts I can repair / cover with a collagen membrane. If the tear was so large that I could not repair it, I would be safe and wait 4 months.

  17. Dear Joseph,

    When I make mistakes, I tend not to post them on a public forum blaming someone else for them.

    I repeat, this was an easily avoidable mistake, that hurt his patient and that was caused merely because the poster did NOT know how to properly use the implant system – and then he blamed the implant system!

    Kind Regards,

    Bill Schaeffer

  18. Dear Bill,
    I usually like your comments and found them helpful. However with the way you defend the Bicon system every time and especially this I become to wonder. If you don’t have any financial interest, why would you call your colleague an “idiot” because he just describe a complication that happened with him using a particular implant. He did not critisize the whole system, he just described what happened to him. And if you use the Bicon system you must know what is he talking about. I have used Bicon and Chan is right. Disengaging the implant into the osteotomy is not always simple because it’s a press-fit system somehow and the implant platea doesn’t engage the osteotomy. That is also why the Bicon never has an initial stability. Does that mean Bicon is bad? Of course not it’s just how the implant is designed and function. Maybe if you place hundreds of these implants it become less hassle for you, but does that make someonelse who placed tens or less than 500 and IDIOT? I personally believe that Bicon is a great implant but it has its flaws (like every implant does), and for sure it’s not an easy system. I just want you Bill to look at how always you defend the Bicon system so badly so it become hard to believe that there are no personal reasons.
    Now as for the question, I think it depends on what exactly did you do after the perforation. If you leave it for 4 months you have to start all over with your lateral window but sometimes you have to wait. However the Schneiderian membrane will repair in 2-3 weels like almost any epithelium.

  19. Dear Sam,

    Thanks for your comments.

    To everyone out there, including Chan Joon Yee, I apologise if any of my earlier comments caused offence.

    Sam – I may defend Bicon, (and any other implant system), when I see comments about it with which I disagree, but I repeat that I have no financial interest in any implant company, other than that I place implants.

    I use a lot of different implant systems (Ankylos, Bicon, Astra and Nobel Biocare), and if you know how to use them correctly, I truly believe that every implant system out there works.

    Of course the opposite is also true, that if you don’t know how to use any particular system correctly, you will have problems – and blaming the system, (particularly on a public website), merely highlights exactly where the problem really lies!

    The problem posted here earlier is so stupendously easy to avoid, (a large plug will simply not fit through a small hole), that I could not believe it when the poster blamed the implant system for it.

    I do sinus lifts with these implants, (and other ones), every week and have never had this problem because, when you attach a wider abutment than the implant before inserting it into the osteotomy, it is simply IMPOSSIBLE to have the complication described earlier – there’s nothing complex or difficult about this.

    The earlier poster knew about the sinus lift abutment but claimed that his “supplier did not have it” and yet he STILL he did the sinus lift procedure – knowing he did not have the right tools for the job – and then he STILL blamed the implant system when he had this complication.

    I will try to be more tactful in the future in the way in which I point out
    how easily a problem could have been avoided if only the clinician had bothered to learn the correct way use his tools – even if they publicly blame the tools.

    Kind Regards to everyone,

    Bill Schaeffer

  20. it horrifies me to witness my colleagues scrutinize ‘political incorrectness’ more than ‘professional misconduct’ in a way, which may have resulted and probably did in harming a patient!!!

    the most harmfult thing we could do as caregivers is crossing our limits. if you don’t know how to do it, don’t frikkin do it.

    lets drop the hoo ha about words like damn or frikkin and focus on the facts:

    1. chan joon yee droppd an implant into a pt’s sinus, couldn’t repair it with a collagen graft…. so we all know the largest graft we can get is 25mm. just how big was the trauma that he couldn’t close it? so he did his best to close it. patient walks with implant in sinus for 3 weeks after which omfs had to open it again 3 weeks later to pick up implant.

    2. bill calls chan an idiot

    yet we all jump at bill? hello? isn’t anyone appaled at what chan did??

    chan – learn your limits before torturing your patients.

  21. another series of posts demonstrating why the general public refers to us as ‘a dentist’ and not a ‘real’ doctor.

  22. Dr Bill I was fortunate to have heard two of your lecture last year and more fortunate to have exchanged few pleasantries with you. Yours was the best lecture I have ever heard(in my life),considering that along with you the greatest of the greatest implantologists were were present. It has got etched into my memory.

    Tell me do you need to call a colleague an “idiot”? That should be Bicon’s job, because it’s their reputation at stake not yours. You earn credits as the best presenter in the implant world ever then wash away gains by name calling.

    It’s not Bicon we are bothered of, it’s your fine reputation that’s at stake here.

    You let me down.

    Secondly if you have no financial interests in Bicon why do you react so aggressively?

  23. Dear Dr. S,

    You are of course correct – there was no need for me to imply anything in my first post – and for this I have and again do apologise.

    I wish the earlier poster all the best in continuing his excellent work and I am sure that any problems he has experienced in the past were all due to the implant system.

    Kind Regards,

    Bill

  24. Dr Bill
    WOW You really like to beat a drum!
    Apology with sarcasm…spare us
    I would never want you as a teacher, which apparently you are, we would never know by your teaching techniques demonstrated.
    I have to assume all your students are idiots because that is after all why they are being taught..no?

    This is a great website to discuss various problems that we have all had
    That surly is the essence of teaching and learning
    I hope we dont all present our best flawless cases for discussion ..we could just talk about Dr Bills cases where he has never made a mistake
    We could just pat each other on the back and be master of the universe……
    The errors our collegue made are obvious as you have made pellucidly clear.
    Systems have limitations and operators make mistakes in EVERY field .
    The biggest mistake is not to learn from your mistake.
    The bravest operator is the one who is prepared to openly discuss his experiences on an open forum

  25. DR SS

    Brave indeed, because if you are a patient (like me) and happen to visit this forum then you might recognise yourself as somebody’s mistake! Fortunately, I’m not!

    Surely making an entirely avoidable mistake on a patient shouldn’t be treated as a learning/training opportunity. In the spirit of such candidness, I am left wondering if the patient was informed that it was operator error that had led to the complications they were now experiencing? Perhaps not, as the place for such admissions appears to be amongst ones peers where you will be applauded for your oppenness, rather than admonished for creating complications to some poor unsuspecting person who has placed their trust in you.

    About me: I went to my dentist about a single implant and he said, “yes I do implants, but I wouldn’t tackle yours as it’s too complicated. But, here’s a list of 3 people who could do a good job – you choose”.

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