Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures

doi:10.1016/j.joms.2015.01.039

Journal of Oral and Maxillofacial Surgery

Volume 73, Issue 7, July 2015, Pages 1275-1282

https://doi.org/10.1016/j.joms.2015.01.039 Get rights and content

Purpose

To test patient- and sinus-related risk factors for an association with intraoperative membrane perforation and postoperative complications after sinus floor augmentation surgery.

Materials and Methods

Sinus floor elevation procedures using a lateral approach were retrospectively analyzed for patients' medical history and sinus anatomy on computed tomographic scans. Complications per sinus after membrane elevation and augmentation using a mixture of autologous bone and deproteinized bovine bone substitute (Bio-Oss) were recorded. Logic regression (adjusted using the generalized estimation equation approach) was performed to analyze the influence of patient age, gender, smoking habits, sinus septa, residual bone height, and mesiodistal elevation width.

Results

Of 407 sinus grafts in 300 patients (mean age, 56 yr), perforation of the Schneiderian membrane occurred in 35 sinuses (8.6%) and was significantly associated to the presence of sinus septa (odds ratio [OR] = 4.8; P = .002) and decreased residual bone height (OR = 0.01; P < .001). Smoking increased the risk of membrane perforation (OR = 4.8; P = .002), sinusitis (OR = 12.3; P < .001), and wound dehiscence (OR = 16.1; P = .005). Cases of sinus membrane perforation had higher odds for postoperative sinusitis (OR = 10.5; P < .001). The probability of wound dehiscence increased with the size of the elevated area (OR = 3; P < .001).

Conclusion

The results of the study suggest that the presence of sinus septa and residual bone height less than 3.5 mm are the main risk factors increasing sinus membrane perforation rates. There was a higher prevalence for sinusitis in cases of membrane perforation (31.4%) despite intraoperative closure with resorbable membranes (Bio-Guide). Smokers generally exhibited greater chances for complications.

Section snippets

Study Design

The authors implemented a retrospective observational study. The study population was composed of all patients requiring sinus augmentation for implant placement in the edentulous posterior maxilla at the Division of Oral Surgery, Medical University of Vienna (Austria) from January 2001 through December 2012. Inclusion criteria were a thorough medical history, preoperative panoramic radiographs and computed tomographic (CT) scans, augmentation using the lateral approach with delayed implant

Results

Three hundred patients (107 men and 193 women; age range, 20 to 83 yr; mean, 55.9 ± 14.0 yr) were included in this study. Fifty-seven patients considered themselves current smokers (20.6% of men and 18.1% of women). A total of 407 sinus graft procedures were conducted (196 on the right and 211 on the left side).

Discussion

Prevalence of Schneiderian membrane perforation was 8.6% and was statistically associated to the presence of sinus septa (OR = 4.8), smoking (OR = 4.8), and decreased residual bone height (OR = 0.01). The frequency of postoperative sinusitis was statistically higher for sinus membrane perforation (OR = 10.5) and in smokers (OR = 12.3). Wound dehiscence was more frequent in smokers (OR = 16.1) and in large elevation areas (OR = 3.0).

Compared with the overall prevalence of maxillary sinus septa

References (48)

J.C. Moreno Vazquez et al.
Complication rate in 200 consecutive sinus lift procedures: Guidelines for prevention and treatment
J Oral Maxillofac Surg
(2014)
G. Watzek et al.
Treatment of patients with extreme maxillary atrophy using sinus floor augmentation and implants: Preliminary results
Int J Oral Maxillofac Surg
(1998)
M. Berengo et al.
Endoscopic evaluation of the bone-added osteotome sinus floor elevation procedure
Int J Oral Maxillofac Surg
(2004)
M. Chiapasco et al.
Methods to treat the edentulous posterior maxilla: Implants with sinus grafting
J Oral Maxillofac Surg
(2009)
S.A. Zijderveld et al.
Anatomical and surgical findings and complications in 100 consecutive maxillary sinus floor elevation procedures
J Oral Maxillofac Surg
(2008)
M.J. Zinser et al.
The predictors of implant failure after maxillary sinus floor augmentation and reconstruction: A retrospective study of 1045 consecutive implants
Oral Surg Oral Med Oral Pathol Oral Radiol
(2013)
L. Ardekian et al.
The clinical significance of sinus membrane perforation during augmentation of the maxillary sinus
J Oral Maxillofac Surg
(2006)
G. Krennmair et al.
The incidence, location, and height of maxillary sinus septa in the edentulous and dentate maxilla
J Oral Maxillofac Surg
(1999)
B. Ella et al.
Septa within the sinus: Effect on elevation of the sinus floor
Br J Oral Maxillofac Surg
(2008)
L. Maestre-Ferrin et al.
Prevalence, location, and size of maxillary sinus septa: Panoramic radiograph versus computed tomography scan
J Oral Maxillofac Surg
(2011)

Y.-B. Park et al.

Analysis of the anatomy of the maxillary sinus septum using 3-dimensional computed tomography

J Oral Maxillofac Surg

(2011)

G. Rosano et al.

Maxillary sinus septa: A cadaveric study

J Oral Maxillofac Surg

(2010)

R. Haas et al.

The relationship of smoking on peri-implant tissue: A retrospective study

J Prosthet Dent

(1996)

T.B. Dodson

A guide for preparing a patient-oriented research manuscript

Oral Surg Oral Med Oral Pathol Oral Radiol

(2007)

P.J. Nolan et al.

Correlation between Schneiderian membrane perforation and sinus lift graft outcome: A retrospective evaluation of 359 augmented sinus

J Oral Maxillofac Surg

(2014)

B.E. Pjetursson et al.

A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation

J Clin Periodontol

(2008)

M. Esposito et al.

The effectiveness of immediate, early, and conventional loading of dental implants: a cochrane systematic review of randomized controlled clinical trials

Int J Oral Maxillofac Implants

(2007)

Wen S-C, Lin Y-H, Yang Y-C, Wang H-L: The influence of sinus membrane thickness upon membrane perforation during...

B. Pommer et al.

Mechanical properties of the Schneiderian membrane in vitro

Clin Oral Implants Res

(2009)

L. Levin et al.

Smoking and complications of onlay bone grafts and sinus lift operations

Br J Oral Maxillofac Implants

(2004)

T. Testori et al.

Risk factor analysis following maxillary sinus augmentation: A retrospective multicenter study

Br J Oral Maxillofac Implants

(2012)

T. Von Arx et al.

Perforation of the sinus membrane during sinus floor elevation: A retrospective study of frequency and possible risk factors

Int J Oral Maxillofac Implants

(2014)

S. Kasabah et al.

Can we predict maxillary sinus mucosa perforation?

Acta Medica

(2003)

H.G. Yilmaz et al.

Are gingival phenotype, residual ridge height, and membrane thickness critical for the perforation of maxillary sinus?

J Periodontol

(2012)

Cited by (112)

Simultaneous sinus elevation and immediate implant placement without biomaterial: A technical note
2024, Journal of Stomatology, Oral and Maxillofacial Surgery
Sinus floor elevation is widely considered as one of the most reliable and predictable procedures for augmenting posterior maxillary bone volume before implant placement. The lateral window technique is often described as the gold standard, especially when dealing with limited residual bone height. Traditionally, severe vertical defects in the posterior maxilla required a two-stage approach: first elevating the sinus membrane with biomaterial, followed by a second surgery for implant placement. This article introduces an innovative approach to the lateral sinus lift procedure, enabling simultaneous implant placement in sites with less than 5 mm of remaining bone height. This original one-stage surgical approach is interesting because it does not involve grafting of any biomaterial into the sinus. Its main objectives are to enhance safety and predictability while reducing the risk of post-operative infections. However, it's essential to emphasize that achieving an ideal implant position with adequate primary stability is crucial for its viability.
Combination of a surgical template and a collagen strip for guiding sinus floor elevation in the oblique sinus floor: A technical note
2023, Journal of Stomatology, Oral and Maxillofacial Surgery
Sinus floor elevation (SFE) by transcrestal approach has been proven to be a predictable and minimally invasive treatment that augments posterior maxilla with insufficient bone height, allowing the prosthetic rehabilitation of this area with dental implants. However, precise and sufficient elevation of the Schneiderian membrane without perforation is challenging through this blind technique especially in the presence of anatomical restrictions. This note describes a novel technique combining a surgical template and an absorbable collagen sponge (ACS) strip for transcrestal SFE in the oblique sinus floor. A surgical template was used to locate the oblique sinus floor and a collagen strip was placed to orient membrane elevation, meanwhile, protect the sinus membrane. Within the limits of present observation, this technique may increase the manipuility while reducing the risk of complications.
Fabricating a surgical template for guiding sinus floor elevation in the maxillary sinus septa with simultaneous implant placement: A dental technique
2023, Journal of Prosthetic Dentistry
The presence of sinus septa, common anatomic structures of the maxillary sinus, may increase the incidence of surgical complications during sinus floor elevation. This article introduces a digital protocol for achieving safe and precise sinus floor elevation with an individualized surgical template that combines implant placement and the lateral sinus window technique. This technique facilitates precise preplanning and preparation of the lateral osteotomy window and the implant site and reduces surgical complications, shortens surgical duration, and improves patient-related outcomes.
Prevalence of maxillary sinus septa: systematic review and meta-analysis
2022, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Septa orientation is considered a potential factor in SFE surgery outcomes, since this could lead to incomplete elevation of the Schneiderian membrane or even rupture2,3,14. Ten articles evaluated septa orientation, and 86.0% of the detected septa divided the sinus into two sections with a coronal/transverse/buccopalatal orientation22,25,33,39,53,58,60,68,72,83. According to Irinakis et al.77, this orientation presents a higher risk of membrane perforation, with the severity depending on the size and height of the septa.
The aim of this systematic review and meta-analysis was to determine the prevalence and characteristics of maxillary sinus septa using cone beam computed tomography and computed tomography data. Publications were searched until October 5, 2020 in three electronic databases. Additionally, article bibliographies were searched, and authors were contacted if required. This review has been registered in PROSPERO (CRD42019124933). Two independent evaluators assessed methodological quality using the Joanna Briggs Institute levels of evidence; inter-rater reliability tests were performed (Cohen’s κ). The prevalence of maxillary sinus septa was expressed as a proportion; differences according to sex were reported in terms of the odds ratio (OR) and 95% confidence interval (95% CI). Heterogeneity and sources of heterogeneity were evaluated by meta-regression. Publication bias was assessed by visual analysis of the funnel plot. Statistical significance was set at P < 0.05. The 62 studies identified and included in the review involved 13,701 patients (22,460 sinuses). The meta-analysis of 35 studies (14,664 sinuses) revealed an overall mean sinus septa prevalence per sinus of 33.2% (95% CI 27.8–38.5%; I² = 98.32%). The meta-analysis of 42 studies (9631 patients) found an overall mean sinus septa prevalence per patient of 41.0% (95% CI 36.0–46.0%, I² = 96.45%). The OR for the difference in septa prevalence between sexes was 0.785 (95% CI 0.590–1.046; P = 0.098, I² = 73.24%). Septa were most frequent in the middle area of the sinus and with a transverse orientation (86.0%). Within the limitations, the results suggest a high proportion of septa in the sinus, commonly in the middle area, which can interfere with the success of sinus floor elevation required for implant rehabilitation.
A nomogram prediction of implant apical non-coverage on bone-added transcrestal sinus floor elevation: A retrospective cohort study
2024, Clinical Oral Implants Research
Review of clinical effects of disk-up sinus reamer (DSR)-based internal sinus floor elevation with implantation in 10 years
2024, Shanghai Kou Qiang Yi Xue / Shanghai Journal of Stomatology

View all citing articles on Scopus

: Conflict of Interest Disclosures: None of the authors reported any disclosures.

View full text

Dental implantsRisk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures

Purpose

Materials and Methods

Results

Conclusion

Section snippets

Study Design

Results

Discussion

J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

Int J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Oral Surg Oral Med Oral Pathol Oral Radiol

J Oral Maxillofac Surg

J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Prosthet Dent

Oral Surg Oral Med Oral Pathol Oral Radiol

J Oral Maxillofac Surg

A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation

J Clin Periodontol

The effectiveness of immediate, early, and conventional loading of dental implants: a cochrane systematic review of randomized controlled clinical trials

Int J Oral Maxillofac Implants

Mechanical properties of the Schneiderian membrane in vitro

Clin Oral Implants Res

Smoking and complications of onlay bone grafts and sinus lift operations

Br J Oral Maxillofac Implants

Risk factor analysis following maxillary sinus augmentation: A retrospective multicenter study

Br J Oral Maxillofac Implants

Perforation of the sinus membrane during sinus floor elevation: A retrospective study of frequency and possible risk factors

Int J Oral Maxillofac Implants

Can we predict maxillary sinus mucosa perforation?

Acta Medica

Are gingival phenotype, residual ridge height, and membrane thickness critical for the perforation of maxillary sinus?

J Periodontol

Dental implants
Risk Factors of Membrane Perforation and Postoperative Complications in Sinus Floor Elevation Surgery: Review of 407 Augmentation Procedures