Sinus perforation and insertion torque: feedback?

First off Happy Holidays to everyone, and thank you in advance for your feedback on this case.

My patient presented today for placement of an implant replacing tooth #4, (patient will be getting a crown on #5 to address recurrent decay and restorative space). Upon initial exam of radiograph, I noted that the patient did indeed have a pneumatized sinus floor in close proximity to where we would be placing our implant. I went into this procedure anticipating placement of the implant with a crestal lift by Summer’s technique if necessary. My plan was to place a 4.3x10mm fixture.

As I worked my way through the drill sequence I was able to get my osteotomy to just shy of 10mm (with the CASKit lift kit) with no sinus perforation, verified visually and tactilely with a probe. I then decided to place the 11mm stopper on my drill just to get a little more depth to ensure good crestal even slight sub placement 360 degrees around my implant. Well as I took it a little further, I did in fact get sinus communication on the distal apical portion of my osteotomy.

Upon visual inspection, I could see the perforation, however was unable to visualize the sinus membrane which I’m assuming could have been due to a perforation. I decided at this point to place a collagen tape dressing at the site of the perforation, and opted to not place any bone as I felt it would not be necessary due to the minimal perforation of the sinus floor. At this point I decided to hand torque my implant to the desired position upon which an insertion torque of around at least 70Ncm was attained… My patient was already pre medicated with 2g of amoxicillin with a prescription for a week worth of abx coverage post surgery.

So short story long, my questions are…

1. With the assumption that a perforation (1-2mm) did occur in the apical portion of the implant, was placement of a collagen dressing at the site of the perforation a proper means of repair?

2. Given that the implant may in fact be in communication with the schneiderian membrane (1-2mm) what kind of complications should I be looking for?

3. I may be beating this dead horse but I have seen so many conflicting opinions and reports referencing high insertion torque as it relates to crestal loss, pressure necrosis, what are your thoughts currently from those who have been doing this a whole lot longer than myself?

Again, thank you very much and I appreciate any and all input.

24 thoughts on “Sinus perforation and insertion torque: feedback?

  1. John Beckwith DMD, DABOI,FAAID says:

    I think the radiograph looks good e apical bone above implant. With a perforation identified, I personally would of used a prf plug, followed by a small membrane and cortical bone. Perhaps overkill but I feel better w a layered approach. The insertion torque is somewhat high but in type 2-3 bone which is often the case in posterior maxilla, I think you are fine.
    Good luck and good job
    Take a cbct in a few months and see what u have

  2. Raul R Mena says:

    I venture to say that you will have no problem with this case.
    Of course it is better not to perforate the membrane, but I have seen many cases with the implant perforating into the sinus with no long term pathological sequela.
    I fail to understand the purpose of the 70 Ncm, but to each its own, and that will be my main concern in this case, but being in the maxilla you should have no problem.
    You could also had used a Short Bicon or a Short Quantum Implant and you could had avoided the perforation. (for full disclosure I am the President of Quantum Implants).
    By the way sometimes you can place the collagen and then small amount of grafting material and then place the implant. In many of those cases the membrane covers the sinus membrane grows over the collagen and you obtain bone formation at the apex of the implant.
    Sleep well tonight.
    Raul

  3. Paul says:

    Bicon implants have been around for a long time and never reached a great deal of popularity with the dental community. There must be a reason. One of the reasons is that one has to have the appropriate condition like available space. The other is that it defies many mechanical principles for long term solution to replacing missing teeth.
    If everything else goes well, your implant should not cause any problems with the sinus since the membrane will overgrow the implant. The mechanical value of implants submerged beyond osseous support are none. Protecting the sinus from a bacterial track from the oral cavity is essential. The implant should have a cover screw and be subgingival during the initial stages of osteointegration.

  4. Periodoc says:

    I agree, this will likely heal well.

    To answer your questions:
    1. Yes placement of a collagen tape dressing was a good approach. As others have said, you could have placed some bone graft material, but you are still fine with the approach you took.

    2. Complications may include congestion, sinusitis. Keep in mind, I think there is a very low risk. Most likely the Schneiderian membrane will heal over the apex of your implant.

    3. Conflicting results are around regarding insertion torque and ‘pressure necrosis’. However, I have found a positive correlation between high insertion torque and implant loss.

  5. Adibo says:

    No problems in perforate and plugg with implant 1-2mm in to the sinus.
    I wouldn’t place anything else in the perforation such as graft or membrane. The implant is benefiting from the cortical fixation in the sinus floor.
    Adding 1-2 mm graft does not fulfill any function except increasing risk of complications by possible travel through the perforation.
    Don’t worry, your implant looks good.
    Is the Summer’ s technique still a valid approach when you can place short implants with good success rate. In case of insufficient bone and needing sinus lift, lateral window approach is more predictable compared to ‘blind’ grafting through the osteotomy site.

  6. andrew says:

    I am very confident this will be fine. Even if there is a perforation, it is only minor (few mm) and will most likely not have any complications. I have seen cases that I have done where perforation occurred 3-4mm into sinus floor (with confirmed perforation of membrane) and I was surprised to see bone still growing over apex of implant over time.

    Regarding 70NcM insertion torque, you must have very dense maxillary bone there, and must have under prepped your oesteotomy a lot, to be able to get that level of primary stability in the maxilla in that area. Whenever I feel insertion is too high upon seating, especially in posterior mandible (and rarely in maxilla) I always turn counter-clockwise 180 degrees as a last thing I do, to relieve pressure at the sensitive crestal region of bone. That’s my 2 cents.

  7. John S. Keadle, DDS says:

    70 Ncm is fine. Tons of literature to back that up. I wouldn’t add bone or anything else when you have a perf that can be obturated with the implant. You risk putting debris into the sinus that has to come out one way or another. The membrane will heal over the implant in almost every case in a healthy sinus. You need to make sure the sinus is open, so keep a watch for congestion and prescribe meds as needed. I agree with your slightly subcrestal platform height, sometimes you can actually grow bone over the edge. Next time crack the floor with an osteotome and then drive the implant into place. You don’t need to add bone, blood makes bone just fine. Stryker/Bicon implants have a lot of huge advantages, but the surgical protocol is a bit technical for most, and their marketing/sales strategy is beyond awful if anyone is wondering why they haven’t found widespread use. I’ve been using them for nearly 30 years, alongside other expensive name brands, and there is no comparison when it comes to single tooth replacement, from both a surgical and prosthetic perspective, if you do it correctly.

  8. Don Rothenberg DMD says:

    I think the use of a shorter implant is your answer next time. Bicon makes a 6 and an 8mm Implant thus avoiding the sinus completely in many cases.
    I have been using the DB/Stryker/Bicon since 1986…31+years…with few problems. I enjoy not needing to use screws. Bicon has proved the be way ahead of the time!

  9. DrFrankC says:

    I think you should encounter no complications. If you were concerned at the time you could have backed the implant off since you are almost 2 mm sub-crestal, used a flat cover screw and covered the implant with your flap. Even if the implant had a fraction of that torque you would be fine as long as it was covered. Of course if the patient coincidentally has or develops a chronic sinusitis you could be the first person thrown under the bus by ENT or one of your “colleagues” so best to avoid perforating. Chances of that are small so forget about it and enjoy the holiday. Cheers!

  10. Saurabh Gupta says:

    There should not be any problem. Good that you have packed it with collagen plug.
    The sinus membrane will form in next 48 hours. Ensure a proper antibiotic coverage.
    Also remember, whenever in doubt put coverscrew and just submerged the implant.
    70N torque in D3-4 bone is fine.

  11. scott berdelle says:

    I place Branemark Implants and take Xrays during the Osteotomy. It appears that your angulation could have been towards the root of the bicuspid slightly. That may have prevented a perforation or a 4.3 by 8 might have been placed. There probably will not be a problem.
    Cover the implant and wait.

  12. Richard Hughes DDS says:

    Most likely the implant will unenentually integrate and bone will grow over the exposed portion , if there is an exposed aspect of said implant. This is a Google question, because this seems like a concern but Boyne et al , proved that bone, depending upon implant design, will grow up to 4 mm. on dental implants placed in the sinus.

  13. Raul Mena says:

    I used Bicon for many years with excelent results, no bone loss and no periimplantitis, you will be surprissed how popular they are. I have no reason to favor them since I am the president of a different implant company.

  14. Dr Kamil KS says:

    I wouldn’t worry about it. You followed a good treatment protocol by given AB before the treatment and one week after.
    We all introduce a very clean and sterile material into the treatment site in a very clean & controlled environment. Minimum or no complications of sinusitis will occurs provided a good contaminantion control achieved during the procedure.
    The implant it self is a good seal to OAF.
    I think achieving 70NCM obtained from the sinus cortical bone, which is an advantage.
    Need to review regularly.
    Well done & good luck.

  15. Robert J. Miller says:

    Deliberate perforation through the cortical floor in posterior maxilla is actually a strategy I have been using for years. From the radiograph, it appears that the crestal bone is of poor quality and the rest of the site still contains a fair amount of graft material. Initial stability would therefore be on the low side, increasing the possibility of early implant loss. If you have a higher insertion torque as well, this problem is magnified. By deliberately passing through the cortical floor, the apex of the implant in now in very dense bone. This dramatically increases initial stability and, therefore, implant survival. You have pushed apical bone ahead of the implant apex and is well contained. This is the kind of radiographic verification I look for . RJM

  16. drsb says:

    I agree that in all likelihood all will be fine. However, I’d like to point out that high torque values are commonly encountered when using a tapered implant in these circumstances. Due to the fact that the impact drills are tapered, and because you cannot (or at least should not) be inserting the drill to the final length to avoid having the drill enter the sinus cavity, the net result is that the crestal preparation is significantly underprepared. I have seen cases of crystal bone loss, which I attribute to this phenomenon.
    I believe this is a good indication for parallel implants to avoid this issue

  17. GYzag says:

    Don’t make this a habit perforating but you probably did yourself a favor by using the cortical floor. That will always help stabilize your implant. Depending on the apex of the implant, perforation of the sinus floor and membrane will usually grow bone over the apex. Later, you may see bone formation over the apex of your implant.

  18. S. Robert Davidoff says:

    Over the years, I have intentially engaged the cortical bone of the maxillary sinus for increased stabilization of hundreds of implants. Never had a problem. Just know that if you are doing it with the drill, you are tearing the membrane and forcing in contaminants. Twenty years ago, I started using Osteotomes to avoid this potential problem and this seems to me to be a more elegant solution.

  19. rsdds says:

    anything above 60 Ncm is excessive torque in my book lost an implant due to pressure necrosis. perforating the sinus not a big deal any ENT will tell you that sinus membrane regenerates. Implant was placed on point good luck

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