Minimal sinus floor penetration: thoughts?
I have a 30-year old patient who presented with #14 [26] missing, having been extracted 2-years prior. The alveolar ridge at that site had resorbed significantly on the buccal and occlusal (no clinical image). CBCT scan showed 6-7mm of vertical bone remaining at that site. During surgery I raised full thickness flap without releasing incision from second molar to first premolar. In spite of CBCT findings, when performing the osteotomy I found that at 9 mm I could still feel full bone support with probe.
I considered using 8mm (without maximum utilizing the bone) or 10mm (having bicortical support and sinus penetration) Alpha-Bio SPI implant, since I did not have a 9mm implant. In the end I decided on the 4.2*10mm Alpha bio SPI implant. I installed the 10mm implant and achieved bicortical support and good primary stability, but with a minimal sinus penetration. I placed bovine bone graft, collagen plug, covered with membrane and sutured with Assucryl 4/O. This is my tenth implant case and first sinus penetration. Clinical case photos are below. What are your thoughts on this case?
20 Comments on Minimal sinus floor penetration: thoughts?
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Irbad Chowdhury DMD, FICO
8/24/2016
Should be just fine. This is a minor perforation. Just monitor the patient for any symptoms of sinus infection in the future. Also, limit size and occlusion on the future restoration. How much torque did you get on that implant?
In the past, sinus perforations were done on a regular basis. It was supported by the bicortical stabilization theory, where the implant was stabilized by the cortical bone on the sinus floor and crest.
You should look into a sinus tent and augmentation course. Judging by your intra-procedure radiograph, you're ready to start using an osteotome to lift that sinus. Best of luck!
mario
8/30/2016
Question: What is "minimal perforation into sinus"? 0.5mm, 1mm, 2mm 6mm
Who set the standard?
Why was this not removed after insertion and then confirmed with a radiograpgh.... it could have been replaced with a shorter implant or grafted and allowed to heal for future placement.
What happens when the rough surface becomes a site to harbour bacteria that will never be cleaned with an antibiotic? Just like the chronic patient that is told they need root canal therapy due to a necrotic tooth leaching toxins into the surrounding tissues until it is temporarily "cleaned up" with an oral antibiotic.
Crossing fingers is not predictable treatment.
This is not a defendible treatment IMO.
Peter Rock
8/31/2016
Nothing will happen.
The portion of the implant will be covered with sinus mucosa in some weeks.
Branrmark protocol included this way of implant placement for years without any complications.
rsdds
8/25/2016
nice implant system from Israel it should be fine..
Richard Hughes, DDS, FAAI
8/26/2016
No problem. Review the work of Phil Boyne. It's not a cardinal sin to slightly perforate the sinus floor.
John
8/27/2016
Dr.Hughes, is it an acceptable standard of care to intentionally perforate the sinus floor 1-3 mm in order to maximize implant length?
Alejandro Berg
8/30/2016
Dear John, I dont think that is a standard of care but to tell you the truth there is nothing wrong in bi cortical fixation, by the way omfs leave sinus protruding screws all the time and noting happens. If he penetrated the sinus and did not tear the membrane , he actually did a sinus lift and will get bone arround the implant body inside the tented area.
just a thougt.... if you are going for that scenario use a rounded apex implant, if you like israeli implants go with Paltop.
Gregory
8/30/2016
Just monitor ,if no symptoms consider both of you are lucky
Peter Fairbairn
8/31/2016
Hi Alejandro , yup also with Paltop now as well ....hope all well
Regards
Peter
Dr. Gerald Rudick
8/30/2016
The surgery looks just fine. My only suggestion would be to have used a wider body implant....as much as 6 x 10.5...for the reason that there will be a large discrepency between the diameter of the implant and the diameter of the crown....which could lead to a food trap.... a proxibrush will do just fine!!
I have been using Israeli implants exclusively for more than 25 years.....I use Adin Dental implants and have visited their manufacturing and research facility in Afula many times. It is truly state of the art.... and many other implant companies are in the same general area...... they are competitors, but compete in an honest and respectful way to each other.
Sean
8/30/2016
It will be just fine, check on patient and sleep tight !
Eduardo Morales
8/30/2016
Nothing to worry about, but just keep the patien so close if any sinus sinthoms appears.
Dennis Flanagan DDS MSc
8/30/2016
In the 1970s we used to routinely place implants that perforated the sinus lining but those were machined surface. Nonetheless, one company sells an implant system made specifically to perforate the sinus ling at the sinus floor and roof, the Zygomatic Implant. There is some research that demonstrates that a 2mm ferforation has no adverse effects but that is low credibility evidence. So what now?
Dennis Flanagan DDS MSc
serge goldmann
8/30/2016
This is just fine
That is the way Pr. Branemark did and teached in the 80th. You will see the cortical bone growing around the apex of the implant. This is a perfect method and even if you perfored the membrane it will cicatrise like any tear around the apex. You brightly used the maximal available lenght of bone, reached bicortixal support. This an implant for many years. Sleep well. You did it right.
VD
8/30/2016
I would like to pose this scenario for discussion:
The residual ridge is only 8mm high, but wide enough to accommodate a 4.5mm diameter implant. The missing tooth is Mx first molar.
Would you place a 4.5x8 implant OR do an internal sinus lift & place a 12 mm (or longer) implant OR place a 4.5x10 implant which will perforate the sinus floor 2mm?
BobD
9/2/2016
VD, I would advise the patient to go for sinus lift and place longer implant. Definitely would NOT intentionally perforate the sinus floor with drills and place a 10mm long implant.
Despite several posts in this thread that say "minor perforation" is fine, I personally think it's wrong in principal to purposely do that because this does not minimize risk of infection for pt. Perforating the sinus membrane and place an implant with its apex exposed to the non-sterile sinus cavity can only increase the risk of infection, however small that increase is. But then again some may say if small enough it doesn't matter...
Dai Davies
8/30/2016
There should be no difficulties.
One of my patients had a similar perforation when an implant was placed by a specialist over 25 years ago.
During that time the intra-antral portion of the implant has become covered with bone.
I would leave well alone unless problems develop.
Joe Oleske
9/2/2016
I don't usually leave this , though in many cases I have seen slight perforations of the floor that have no consequences. To be as safe as possible, next time back it out, check for sinus communication using a valsalva maneuver, then place a piece of collagen up there (collaplug, collatape) and place shorter implant.
mehmet güngördü
9/17/2016
dear friend,
do not worry please.nothing will happen because of the perforation .even 4 mm will recover. I seen a lot 3mm perforation that is healthy even after 10 years.
Yaron Miller
5/26/2017
Like most of the comments above I don't think you will have any issues here at all and certainly penetrating the sinus floor is not ideal. The biggest risk here is having some helpful dentist criticizing your work because if you land up in a court of law I'm certain that a sinus penetration is going to be looked at as a negative. These days I routinely default to the use of Versah burs in this scenario which would have given you internal sinus lift up to 3mm, bone densification and some expansion for a wider implant. I very rarely need to go to a lateral window since adopting this technique.
