Sinus floor perforation during implant placement: recommendations?

I treatment planned this patient for four implants in #4, 5, 12 and 14 sites.  Patient already had an implant in #13 site.  I advised the patient that he would need a sinus lift and bone graft on the left for #14 as there was only 6.5mm of vertical bone height. He declined the graft so I placed the implant without the graft.  The implant is 4.3x8mm.  I achieved good primary stability of 35Ncm. The post-op radiograph showed that #14 had perforated the sinus.  I prescribed an antibiotic, antihistamine spray and steroids.  I advised the patient that if #14 developed complications, I would have to remove it and do a sinus lift and bone graft and try again.  Do you have any recommendations on how to proceed?  Some studies show that the membrane will form over the implant apex projecting into the sinus.  Patient is returning for 2-week post-op.  Should I reverse torque out the implant?  What are the key signs and symptoms I should be focusing on?

15 thoughts on “Sinus floor perforation during implant placement: recommendations?

  1. Dr. Gerald Rudick says:

    How did you prepare the osteotomy….. did you drill into the bone with a bur, or did you prepare the osteotomy with non rotational Osteotomes?
    Did you do a pressure test (have the patient hold his/her nose and then force air into it) after you prepared the osteotomy? If you did this and you heard a hiss, then you perforated the Schneiderian membrane.
    All is not lost…. when the patient returns, if he/she is asymptomatic, there is nothing to do… you gave good medication, the implant is stable in solid bone that required 35 ncm of force to seat it.
    The implant is not loaded ….. just give it time to heal; and make sure that you don’t get loaded loosing sleep worrying about it…… nature has its way of healing.
    It will probably work out well, and you have learned something from this experience.

  2. Brian says:

    I wouldn’t touch it, You did all the right things. Definitely test to see if membrane is perf’d. If not I believe the success rate is pretty high. Next time don’t let a patient tell you what to do. Like we all have from time to time. Let us know how it goes

  3. Dr Saad says:

    Leave it with out loading for 4_5 months with mouth wash and good oral hygeine .
    It will be o.k and ready for crown loading.!!
    I had such experience before.

  4. John T says:

    This is a regular topic on this site. It’s all a matter of common sense. As a rule one should avoid perforating the antral floor with an implant: it serves no useful purpose, is a small but potential source of antral infection and if you are dealing with a cylindrical implant there is a risk of displacing it into the antrum. However, in a case such as this where no more than a millimetre or so of implant is protruding into the sinus it is most unlikely to cause any problems and you can safely leave it in situ.

    Why the antihistamine and steroids? They are a waste of time. Just part of the great American love of overmedication.

    Will the antral lining grow over the protruding implant apex? Well, the answer is it all depends. If there’s a substantial length of implant protruding it certainly doesn’t and if you scope the antrum you will see a tiny piece of metal smiling back at you. If you had a piece of metal poking through your skin anywhere else in your body you wouldn’t expect the skin to heal over it would you? You might get a localised granulomatous reaction in the surrounding mucosa which hides the metal but this isn’t true healing.

  5. Gregg says:

    I concur with suggestions for use of a 6mm implant or use of densah burs. However, I have (intentionally) on innumerable occasions done exactly what you have. Boyne’s original animal studies support this concept which was also advocated years ago by the Branemark group. I do not believe this requires additional antibiotic, steroids or antihistamines.

    • Juan Carlos Echeverri says:

      Please don’t loose sleep over this. The studies have shown conclusively that the bone will regrow over an implant perforating & sealing the sinus up to 3 mm of height. Longer that this, it will grow bone, but then it will just recreate the membrane and life continues. Treat it as a normal implant and restore as usual.

  6. John T says:

    Juan Carlos, I’m intrigued by this. Would it be possible for you to post x-rays of just one case of an implant protruding 3mm into the floor of the antrum in which the bone has grown over the implant?

  7. Dr. Will Johnson says:

    It’s possible to place two short implants in conditions offered by such patients. See Dr. Shadi Dahar at Bicon for his great lectures on such!
    I agree with Dr. John T’s comments entirely as well. Patients really need these implants, so expand offerings with multiple manufacturers’ products. They’re the best thing current dentistry offers. Won’t break, don’t hurt, cheaper than bridges, and never decay.

  8. John T says:

    Gregg, Juan Carlos, Richard H – I’m looking forward to seeing x-rays of your cases in which antral bone has grown over implants protruding 3-4mm through the antral floor.

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