Sinus Perforation: Close or place shorter implant?

The bone grafting is unnecessary. You could have just continued with placement of the implant. Implants are inert, there is never a consequence to placing an implant into the floor of the maxillary sinus. The sinus lining will reform over the implant. You might inform the patient that he/she might experience some bloody nasal discharge for several days. Coverage with a broad spectrum antibiotic is recommended. Good luck.

Check out the Bicon Short implants and also the Internal Lift procedure on their site, Bicon.com. There appears to be a lot of vertical for the 6 mm lengths and maybe an 8. We commonly use 6x6, 6x5, or 5x6 in this situation.

I disagree with the statement there are never complications with perforating the floor of the sinus. Complications can arise!! If the sinus is not functioning or draining properly then yes more surgery for the sinuses might be indicated.

I would be concerned in this case about the amount of vertical bone loss and the resultant unfavorable C:R ratio, especially with a short implant fixture. I know this subject is controversial, but it seems intuitive to me that since implants are most susceptible to harmful and excessive occlusal forces that we would want to avoid this situation if possible especially with a maxillary molar implant.

I believe that Starck may be misinformed. There is a possibility that the membrane may form over the implant and seal it off from the sinus space but what will probably happen is that you will get a seal down near the bone but the threads that are exposed to the air will become a possible nidus for infection. Most likely even if it gets a low grade infection there will be minimal clinical issues unless the pt is more susceptible to them. You would have been ok to place a piece of collagen plug or tape into the osteotomy and placed your 8 mm implant with no future problems.

Bicon's flanged design has more bone surface contact area per mm length than most threaded implants, and are proven to hold up well to high crown root ratios for decades. They have research showing the shorter designs actually build more bone and have higher long term success than longer cylindrical implants. Their shorter, wide designs actually transmit off axis forces down to the apex, across the bottom, and back up the other side of the implant. They are almost "ball" shaped. No unloaded, dead space, contacting bone.

This is all in the planning. I would have used a 6 or 8mm implant (Bicon) to start with. If I was that close to the sinus I would have grafted some Synthograft mixed with the patient's blood...placed the implant and let it heal. If I knew there was a sinus membrane tear I would have used A-PRF with mineralized FDCB..into the osteotomy and then placed the implant. I normally let these heal for 6 months. I do not usually immediately load these cases, esp. if in the posterior. Good luck next time!

You have 10mm to the floor of the sinus. The floor in this sinus looks thick and strong. I would use an 11.5mm implant and do a 'sinus bump' with the proper osteotomes. You don't penetrate the sinus with the drill. You will feel it distinctly when you hit the sinus floor, at that point use the osteotomes to break through the floor of the sinus and elevate the membrane. Add some bone graft before placing implant. Seek help if you have not done this before. Very easy and will not damage the sinus membrane. Then you have two cortical plates for added strength.

I aagree with Dr; Sargent. If possible, I would have stopped 2-3 mm short of the sinus floor (determined pre-op with panorex (correlate with 1st molar with 11 mm MD length) or CBCT, then use an osteoto\me to gently elevate to 13 mm, then pack Puros up the prep site (transveolar graft) and push it up (with each additional material). Use any implant. The Bicon messages seem to be from Bicon reps. And I am dealing with less than 1% failure rate. I use Zimmer, but most implant systems will work fine. I should add, I have a CBCT, but can gather most info from a pan, comparing to known distances (molar crowns)

I can assure you all that I am not a "Bicon rep"... I have been placing Bicon implants since early 1986 and have a 97.6% success rate with implants over 20 years old...and I do have the documented facts, and have had the good futune to be able to follow many of these patients for many years. I just happen to have started with Bicon...way back when Tom Driskell owned the company. I have almost never seen bone loss around the neck of the implant... it is very rare...if one places these implants correctly. SInce 1986 I have placed and restored almost 3000 Bicon implants with little or mostly no problem. omfseric should get his facts straight before he accuses anyone of anything. It is a stupid, childish thing to do!

To the contrary, Dr T... First of all, being placed 2-3 mm below the bone crest, and abutment connected so tightly that bone grows over the abutment/implant interface, Bicon's usually have more bone grow atop the implant with passing time. They are postulating a load thru fibrous tissue under the spherical abutment bottom as likely responsible for this increase in bone atop the taper-topped implants. However, should a more shallowly placed Bicon get an exposed "fin", it does not guide the inflammation down the spiral staircase provided by a threaded cylinder. Whatever fin level is exposed is equally accessible 360 degrees for clean out and grafting. Any exposure is self limiting at each level.

I would have placed the implant. The sinus will tolerate a few mm of implant without problems the membrane will heal over It. These posters don't know what they are talking about but do what you are comfortable with.

I would also place the implant. 1 - 2 mm in sinus in most cases will not make any problems. If you want you can lift sinus floor for 1-2mm with osteotomes and place longer implant (10, 11, 13 mm) but I think it is unnecessary. There is a lot of research on short implants expecialy in molar region. Ankylos has 3.5 x 6.6 mm implant just for cases when you don't want to elevate the sinus or when you are to close to mandibular nerve.

Hallo... Check with Astra 6mm ... it is the best solution for all these of kind of cases .. forget about sinus or surgery .. 8 weeks and the patient will get crown . Take care

I, also, am not a Bicon rep, but cannot help wondering why so many here are stressing out and suggesting invasive treatment plans for procedures which could easily be done with high reliability and low risk by the Bicon system. The supporting research about crown/root ratio, bone growing atop implants, high success rates is available free on their site. I, too, once routinely placed implants in the 10-15 mm lengths, but have been using 5-8 mm lengths almost exclusively for many years now. I am suggesting that, regardless of specialty or company ties, everyone should be able to offer a reliable, low risk option to long implants. I only post here after I see scary tx plans and multiple surgeries suggested where a simple, short implant would perform well.

1) Basic surgical principles . If you have a non-pathological sinus and septic working area you have no problem . I routinely perforate the sinus floor using it for extra anchorage ( if needed ) and place the implant ( 1- 2mm into the sinus ) Should obtain at least 30N/cm torque . 2) Where are the zygomatic implants placed nowadays ? 3) Could be more conservative and use osteotomes ie drill 2mm short and tap the bone up !

Thanks John! I see no reason to use any implant longer then 11mm...and I rarely used them. 6-8mm implants will work just fine... I have many 8mm implants in patients for over 20+ years without any bone lose or other prolems. Why "we" are still placing long implants is beyond my understanding!

the bottom line is you can't fit a 10mm implant in a 8mm hole. you certainly wouldn't try that on a lower posterior near the nerve. trying to convince yourself that you have more length than is shown on xray never works.

Dr. Manuel is correct! This is an ideal situation for the Bicon System. Give it time to integrate and it will give many, many years of reliable service. One may consider the Quantum implants for a situation like this. The Quantum also has a plateau design and has much more prosthetic versatility than the Bicon System. Either one will allow the doctor to reliably and simply treat their patients and contain cost.

Re: Restorative Options using Bicon implants... I use the Bicon Stealth Shouldered Abutments for the most part. They have a nice, wide margin step to allow almost any type of crown you'd choose with almost no prep needed except for occlusal clearance. For some cases, I use E-Max, for some others, Porcelain Fused to Precious Metal, but for most posteriors, I rely on the Zirconium types, like Brux-Zir, K-Zir, etc. I send the impression to the lab for pouring/mounting and have it immediately returned to me for abutment selection and preparation. I make a temporary healing abutment of normal temp acrylic to maintain whatever soft tissue shape I want so the Lab can see exactly what emergence is needed. This makes the delivery appointment one of the simplest dental procedures there is. I always securely, fully seat the abutment into the model's implant analog to eliminate any surprise occlusal changes since the abutment does "sink" a few thousandths of an inch when fully seated in the mouth. When the patient returns, I try the abutment and separate crown on in the mouth to ensure it could be seated as a single, bonded unit. If it's OK, I cement the crown to the abutment on the model and polish the margin before easily sliding it to place in the patient's arch. Note that there are some cases where the implant axis does not align with the interproximal axis - i.e., sometimes you have to insert the abutment and then cement the crown. This requires diligent control of excess cement and cleaning. By carefully paralleling interproximal contacts and implant axis, the entire operation is pleasant and simple. You must take interproximal contact axis into consideration when making alignment devices or sighting devices for the implant. It's not that hard to do, but saves much time and bother in the long run.

I don't understand why people think that the Bicon system does not have "prosthetic versatility". Unless they are refering to the locking taper abutment vs. a screwed in abutment. I have used Bicon since 1986. I have never had any problem with restoring implants, whether it be the anterior or posterior regions. We do everything from single tooth reconstructions to "All on 4/6" reconstructions. The system is simple, logical and has great design. I would like to hear why people think that Bicon does not have "prosthetic versatility" ... as this baffles me. Also Bicon is always open to new ideas and is helpful in coming up with solutions to any problem I have ever encounted. I look forward to seeing these comments.

Love the Bicon commercial. I believe there are other short implant systems on the market from other manufacturers, that are just as good. But, the original question was not about a particular brand of implants or the restorative aspects of Bicon, so maybe we can get back to some of the original concepts referenced here as the discussion was in fact interesting. We get it already, Bicon's a great system. Moving on...

Lyle, good question and good points: When you place an implant into the floor of the sinus you actually do achieve better anchorage as you are now engaging two cortical plates (the alveolar ridge crest and the floor of the sinus). However, I agree that simply perforating the sinus intentionally and placing an implant is not the best way to go about things as you are now taking the sterile apical threads and placing them into a non sterile environment (the sinus with all of its mucus and bacteria). When a sinus lift is done (either with osteotomes, as Dr. Sargent suggested, or with another internal sinus lift kit) theoretically there is no tear in the membrane and therefor the implant stays in a sterile environment and is engaging two cortical plates giving increased stability. With that being said, it is hard to be sure with an internal sinus lift that there is no tear in the membrane but chances are much better. I will say I have seen many implants placed into the sinus without a sinus lift and no bone around the apical threads and they are totally fine and never became infected...I personally don't choose to intentionally perforate the sinus with my implants...but it can and does work and I would do that before I would place an "extra short" implant that has no screw to hold in the abutment (Bicon) and no option for a true custom abutment (Bicon). On that note, I work in an area where many Bicon Implants were placed...once the abutments come loose they come loose over and over...Why not have a screw? As far as all on 4 or 6 cases, the only option with Bicon would be a cemented restoration. Personally when I do a big case like this I prefer better retrievability in case of a future problem. Yes they likely cement these full arch cases with Temp cement and hope that they can "tap" it of if there is a problem...good luck...and when your abutments with no screws come out with the prosthesis? I will say that Bicon did contribute to the implant world by showing that primary stability is not as critical as we originally thought and that a "spinner" will likely still integrate just fine. We also know that in a pinch we can get away with shorter implants than we originally thought...but that is in a pinch and when possible longer is still better in my personal opinion. I guess we are getting a little away from the original question posted but interesting discussion.

Only to correct some misinformation... Bicon has a full range of straight and angled, Threaded, abutments. If you want to use screws, no problem, and in some cases, screws are better.

If that is the case then I stand corrected. I took a Bicon course several years ago and those options were never discussed. So maybe this is a recent addition? In any case good to know. Thanks John

Bicon has had abutments with screws since 1985... we used to use them all the time. We now used cemented abutments... the thing is we never have any problems. We do tap off large cases at least once a year to examine and clean underneath. The next time I do I will be sure to take pictures. The tissue always looks excellent. And the interesting part is that when the abutment comes out of the implant there is no smell of percolation...which can only mean that there is no bacteria in the connection. When we see implants with screws (for various reasons) and have to remove the abutment (ie:screw) there is always the awful smell of percolation ...this bacteria is what leads to peri-implantitis. I have rarely seen any peri-implantitis around a Bicon implant except in reare poor hygiene/medical problem cases. Again.. I am not a Bicon rep...and have no investment in the company. Wish I did!

I'm not Bicon rep to begin with. I graduated from GPR at OSU & worked with implant clinic using several implant systems, most of them 11-13 mm. And that's the problem. Our concept need to be changed. I rarely use implant that is longer than 8 mm anymore. At the university environment, no one ever work or has experience with Bicon, because Bicon never give money to any school to do their "fake" research. Let's be honest, Bicon started this short implant and now many try to imitate. If we try to restore this case with 6-8 mm implant, I don't think there never be this issue of sinus perforation. Anyway to answer the question, little sinus perforation should not be a contra indication of placing implant at the same time. As long as we can "seal" the perforation with stable implant, the implant itself will function as permanent obturator. If the perforation is big and the implant is not stable, I will not put the implant right away. Bicon is not stable implant - at the beginning of the placement, because we need to prepare bigger space than implant itself. I will be very careful to put Bicon in the perforated sinus case. I'll stop the drill 0.5 mm smaller than intended implant to make it more stable by tapping it with hammer. Screw type implant on the other hand will work better in the case of perforated sinus. But again in this case, if the surgeon use Bicon system (5mm implant) or other short implant - there should be no concern of sinus perforation. The other thing with Bicon, the implant never get bone lost versus other screw type that always get radiolucency after 1 year or so. I use Bicon more and more, because I try to stay out of trouble of having bone lost or loose screw in the future.

A lot of technical jargon, the implant is not finally stabilized by bicortical engagement, osteointegration and bone remodeling does. The implant is not sterile once it passes thru the oral cavity unless there is a rubber dam in place and the site is prepped aseptic ally. I would not advise deliberately perforating the sinus floor with implant placement. The implant type does not guarentee that it will work. These are clean contaminated cases, knowledge of sinus and bone biology are more helpful vs type of implant. A good surgeon with good surgical technique can minimize complications and select the appropriate technique for the clinical situation. When I look at this periapical, this is a straight forward placement with adequate bone, if a small amount of implant perforated the floor it will heal over. Each case is different and most of the comments here are technician based vs understanding surgery. The more helpful comments are on the restorative questions in implant management, a lot of anecdotal misinformation, I would be more circumspect in what is posted.

Unless you can seal the membrane tear you cant contain any graft material if any is placed. Placing the implant with no graft material as long as the tip of the implant doesnt extend more then say 2mm into sinus wont be an issue as the membrane will regrow over the tear and over time some bone will form with a tapered implant which is what is used these days loading wont place apical pressure and the wider coronal will prevent displacement apically after integration. I would suggest in the future using safe tip crestal sinus drills like Hiossens CAS Kit to decrease membrane tears

For what its worth I have been using Bicon implants for years and have had few issues. Indeed, the only time I had a problem is that I did not place the implant deep enough and had porcelain occ fracture on the crown, my fault NOT the implant. I only use them in the case of insufficient bone below the sinus to avoid a sinus lift/graft. Not to say that there is anything wrong with a sinus lift but having HORRIBLE sinus issues myself (4 sinus surgeries and counting) why have the extra expense and more invasive procedure if there is an alternative and in my view there is its call a BICON! (BTW I am NOT a paid spokesman). To me they are a class act. Funny thing is if you trace the evolution of implants in the 80's when I graduated everything was 13/16/21 mm now every implant company comes out with a NEW and revolutionary implant design they are shorter guess what BICON had that years ago! I was resistant to use Bicons but after literally years of following them I took the plunge and I have never looked back. They are "funny looking" compared to what is a "normal" implant but they work. Many of us have the idea in mind that the "crown/root ratio" is wrong when restoring an implant but that is a principle that holds up for teeth NOT implants! The load bearing area of an implant is the crestal 3mm or so therefore why do we need a 16mm implant when 6 or 8 is sufficient??? The short answer is we don't. If the sinus membrane is NOT torn a "bump" of 1-3 mm. is usually not an issue. I often place particulate graft apical to my Bicon when I am seating the implant as I feel if I am close radiographically I may have invaded the sinus space. Thanks for reading! good luck to all.

The key concept is whether you have a tear in the membrane and if the sinus looks healthy on the CT scan. If your osteotomy is wide enough you should be able to see an intact or torn( looks black) membrane. If the membrane is torn I would place an 8mm long implant and definitely no graft material, if not you can use one of the many crestal kits but I typically use Versah burs these days. With the Versah approach you could have placed a 10mm implant without the need for any additional bone or if you want to you can place some bone in the osteotomy and push it into the sinus at 600 rpm with the final versah bur. I have also used short implants successfully in these cases but I think that it is important to view your final result as if a specialist was being asked to comment on it in a court of law. I have no doubt that Bicon implants work and I really like some of their philosophies but I can guarantee you that few specialists like them and that they are going to say( in court) that you placed this implant below the standard of care(which again, I disagree with) . Call me paranoid but I have seen this happen to colleagues in California and I don't want to have to deal with this. Maybe some OS or Perios can chime in here? Either way thanks for sharing- keep placing implants, ask questions, you never stop learning in this field.