Sinus Tear: How Long to Wait for Regraft?

Dear Dr G, First I usually wait about 2-4 months before going back in depending on the size of the perf and how thin the membrane was. You may have bigger problems on your hands then how long you should wait. If I read your post correctly it sounds like you left the window open post perf. If you didnt put a membrane over the window prior to you closing the case post perf you could be in for a nightmare. I have seen cases where not putting a membrane over your window could lead to several problems: 1) You could have the soft tissue from your flap connecting to your sinus membrane. This is a problem when you go to elevate your flap you could perf again. 2) I also have seen cases where soft tissue in your flap invanginates into your sinus window and merges with the membrane leading to more issues when you go back to redo the lift. So the mural of the story is you probably made the right call on not preceding with the sinus lift when you tore the membrane but you should have place a membrane over the window when you closed. Hope thats helpful

Dr. G Even with the best of surgeons, the membrane will tear in 10% of cases. When you do a sinus lift, have your membranes ready. For tears 1-3 mm, collatape, 3-15 mm, Biomend, > 15 mm, Biomend extend. Have the right instrumentation and take plenty of time to elevate the membrane and the tears will be minimal and minor. If the membrane is dry, place the membrane and have the patient inhale, it will stick to the tissue. Place your allograft and implant and close with a Biomend extend over the window. Very predictable procedure. Good Luck.

Dear Dr. G, I have had the situation described in the first response twice where there is no membrane and soft tissue only over the old window. In both cases a careful split thickness disection to allow full flap reflection and visualization of the tissue/old window allowed a normal reflection and successful graft. In both cases as well, the new membrane appeared to me more robust and less fragile than the original. Good Luck, Jay

Dr. Gosch has given good instructions. I have had the entire thin membrane turn into torn tissue paper and still proceeded with the procedure. It's not the torn membrane, its how you handle the tear. Please review your techniques with an expert before doing another subantral bone augmentation.

I've been told that since the sinus membrane is 100% epithelium healing is rather quick. I had a case were an endodontist perforated the membrane doing a retreatment. I waited 6 weeks before entry and I found the membrane intact. I recently purchased a piezoelectric unit. Its great for lateral windows, however its not the silver bullet. Experience still plays a major role..

Dr Gregory J Gosch is 100% correct.

Dear Dr. Callan, It is so good to hear from a implantologist of your stature. You are the best. Ben

I agree with both perioplastic and Dr Gosch's posts on how to handle tears. I even like Dr Grosch flow chart. I disagree on one of Dr Grosch points. I would not graft large tears. A tear greater then 15mm should probably be closed and come back two months later. Most Oral Surgeons including Pikos will tell you that its better to close up on a large tear. Some say any tears bigger then a quarter should not be grafted. The risks outwieght the benefits. Not everyone is an experienced surgeon, its sometimes better not to be to brazen.

I agree with Dr Hattfield,s position on how to handle tears to avoid those coming from our eyes when things go wrong.I have started using a manually pressurized balloon in treating the larger sinus lifts and this handy aid has given me much more control in elevating the membrane in an evenly and less traumatic manner .

I agree with everything Dr Gregory J Gosch says except that the tear rate is 10%. It is much higher according to Tarnow, Linkow, Froum and Wallace. When the membrane is very thin and you reenter and it will tear again, so what was accomplished with waiting the 2 months? Placing a membrane to keep your graft material in the close approximation with the medial wall of the antrum and protected superiorly by a membrane is probably your best chance at success with large tears. Complications may occur with even the best planned surgeries.

Dr G- You are completely wrong about not waiting two months after a sinus tear, that you will tear it again. Most experienced surgeons will tell you that closing up shop after a large tear and coming back two months later results in a thicker membrane and less likely will tear. Read the studys they all say the same. Here is the problem with grafting a large tear: Your risk of post op infection is greater Your risk of bone graft granules entering into the sinus and coming out the patient nose is greater Your risk of failure is greater. Your risk of litagation is greater, if brought into a court and they ask one of these "experts" should DR G grafted the case with such a large perforation, the expert will say no he shouldnt of. I dont mean to be blunt and dont wish to sound nasty but people who read these boards range from people who have had 6 years worth of residency training to a weekend course in implant training. Sure complications are easily managed if you have the knowledge, but lets remember we arent working on animals we are working on people. Lets not push the envelope just to make a quicker buck. Ask yourself, if I get a large tear and I graft it, how would I handle it if it goes wrong? If you think you know go ahead and graft, if you have concerns, close and come back in later, the patient will understand that you are doing things for the best interest of the patient. Of course if the informed consent is done right the patient should understand this going into the surgery.

Dr G your are right about the tear rate being higher then 10%, the studys show tear rate is anywhere from 30-50%. However in a recent study out of the NYU group they reports tear rate goes from 30% to 7% using peizo technology.

A few remarks to all participants.Indeed membrane perforations are a common finding in sinus elevations and vary between 10-25%.The level of the operator's experience is a key factor both for the perf rate as well as for the handling of the case. In the hands of an experienced "sinus lifter"-I would recommend to correct even a large tear more than 15mm by either using a large membrane as a tea bag filled with the grafting material similar to Dr Lozzada's technique or using a titanium mesh.From our experience going back to torn membranes-big tear in most of the cases the membrane does not regenerate and therefore it doesn't help waiting for 2-4 months. Care should be taken in these cases to control infection which has higher tendancy in these cases.

I am absolutely amazed at the quotations of percentage of sinus tears ranging from 7% to 50%. Obviously this cannot be very scientifically based if these statistics are so disparate. While some empirical clinical observations may be valid, let's be cautious aout pontificating about technique. Especially when quoting Mike Pikos. Mike routinely uses a membrane to cover perforations. In fact, in his article on management of sinus perforations in the journal Implant Dentistry, if there is a large peforation (in the absence of sinusitis), he will remove the memerane entirely to mid-sinus and recreate the floor with a membrane, not abandon the procedure. And he does this with a very high success rate. One of the reasons clinicians have failures of grafts in the sinus in the presence of a large perforation is the failure to remove a portion of the membrane still attached to bone. The graft then sites on TOP of the membrane instead of in contact with bone. Use a surgical microscope with direct lighting and you will be amazed at not only how often there is a sinus tear, but how easy it is to manage when you can visualize the segments and raise them. Then you can tent the floor with a collagen membrane and pack bone against it. Our success rates using this technique has been outstanding. Finish with a membrane on the lateral wall and you will mitigate most of the old problems. RJM

Dr.Miller you are right.A large perforation in sinus augmentation can be manipulated succesfully. But as Dr. Mazor clearly mentioned, "it should be in hands of EXPERIENCED SINUS LIFTER." Every clinician can not and should not play Dr. Miller or Dr. pikos. One must know his/her capability and should procced accordingly.

I mean proceed not procced.

Maxillary sinus membrane perforation is the most common complication that occurs with sinus augmentation; its prevalence is between 20% and 60%. When the perforation is small and located in an area where the elevated mucosa is folded together, it will be healed by itself. If the perforation is large and located in an unfavorable area, the perforation needs to be closed in order to prevent loss of the bone graft. Some clinicians are in favor of using the collagen membrane to close small tears (5 to 10 mm) in the Schneiderian membrane and a cross-linked type I collagen membrane for predictable repair of large perforations (>10 mm). Ostencibly, large perforations pose an absolute contraindication to continuation of the surgery, especially if the graft material is in the form of granules or bone chips. The presence of foreign bodies that are free to move inside in the sinus appears to create the situation for an infective process within the antrum. Perforation of the Schneiderian membrane is most likely to happen at sharp angles and ridge lines, septae, and spines. Perforation of the Schneiderian membrane most often occurs when the lateral wall is being infractured, but it can also happen when the membrane is being elevated off the inferior and anterior bony aspect of the sinus and can occur due to irregularities of the sinus floor. It has also been suggested that previous sinus surgery and absence of alveolar bone are risk factors to a large rending of the maxillary sinus. In these cases, defects equal or smaller than 5 mm may heal spontaneously with normal blood clot formation and routine mucosal repair (and not regeneration). However, utilization of a resorbable barrier to cover and protect the defect during the initial stages of healing may be indicated. Primary closure is necessary if the defect is greater than 5 mm. I personally use a 5-0 Vicryl suture to close the perforation under magnification and then do my grafting at the same session.

Dr Jafari, well put. I especially like this quote. "large perforations pose an absolute contraindication to continuation of the surgery, especially if the graft material is in the form of granules or bone chips." Dr. Miller Im not sure what amazes you about the quotation. Pick up this months International Journal of Perio and restorative. The NYU team who probably has some of the most sinus experience out there quotes 30-50% sinus tears which is reduced to 7% with Piezo in thier latest article. You make this sound so second nature but in fact a large sinus perf if it gets infected can result in large problems. Im handling a case right now where the provided proceeded when he shouldnt have and now there is a large mess to clean up. Even Dr. Pikos lecture changes from meeting to meeting and depending on who his audience is. He said in the past that he used to remove the entire sinus membrane now he refrains from that. Ask him how many cases he has had to fix from providers not knowing what they are doing. Most ENT will tell you that when they used to treat sinus pathology it would be routine to get in there and remove all the membrane, now they dont do that. Once again Dr. Miller the readers of this blog range from having a 6 year residency to a one weekend CE please remember that.

Dr. Miller the last thing you want to do is remove the sinus membrane entirely. The Sinus membrane is cilated. It is well documented in the ENT literature that when you remove the sinus membrane as it heals the ciliated epithelium doesnt come back. You lose the cilia, so you would then be dooming a patient to Chronic Sinusitis for the rest of your life which is also well documented. But by all mean, advise people to do that, a ENT will love you for it.

I totally agree with Dr.Hattfield.There is much to loose and little to gain in grafting large tears. I also agreed that skill and knowledge of readers of this site varies vastly and so BIG NAMES should contain themselves from inciting less experienced clinicians from doing wrong/fancy/heroic things.

Pretty srong statement,Satish. Congratulations.

This is from my, for what its worth department…… Since the sinus membrane repairs itself so well and so fast, I do not hold to using a heavy Type I collagen membrane as part of the tent. I use a Type 2 membrane that resorbes in a month or less. Placing a membrane on the bone to use as a sack around the graft is contraindicated in my opinion. The most important aspect of a sinus lift is to get the sinus membrane off the floor of the sinus so the bone graft material can sit directly on bone. The covering over the top of the graft is to hold the graft material in place, passively. Colla Tape works well for this. The membrane we use needs to resorbe quickly, close to the rate the body repairs its own sinus membrane. At best, the sinus membrane is folded into itself, a very abnormal condition. Good antibiotics and primary closure of the incision are critical. Whether you use a Type I Collagen Membrane over the initial hole in the bone on the buccal, depends on how intact the periostium is. The size of the tear, (which, I believe, there are small tears nearly 100% of the time) is relatively unimportant. The type of graft material is important, and using PRP helps to form a solid fibrin clot within the graft material. PRP appears to alleviate quite a lot of post operative pain and speed up angiogenesis within the graft material. The platelets released within normal bleeding within the graft will help the clot to set up, so PRP is not mandatory to develop a nice finished product. It becomes more critical, the larger the sinus membrane tear. It appears to me, most of the actual evidence we have is empirical. We trust the hundreds of successful sinus grafts we have done and we shy away from doing things that have failed. One of my biggest problems with infection and foreign body response during the post operative stages of a sinus lift was caused, (in my opinion), because I used a Biomend Extend (long life) Type I Collagen Membrane over the top of my graft. I felt the body needed to reject and resorbe the collagen so it would be able to grow a new sinus membrane. With antibiotics, the green puss finally went away and most of the particulate graft material was saved. My experience has not been favorable with any HA including Pepgen P-15. You appear to get something hard that is somewhat brittle, that can hold implants, if it’s not too hard and/or brittle. I am not sure it ever is completely replaced by the bodies own bone. I prefer autogenous bone or whole bone from a donor source for sinus lifts.

Dr.G I had the same problem during my residency and I closed the lateral wall with a Biomend Extend (for no other reason than that is what we had avaialble at the program). I went back in after six weeks ( a rather large perf, basically the whole size of the window was perfed). During the reflection of the flap I noticed that the membrane and the flap were fused togeher. A sharp disection allowed me to reflect the flap and the reflect the membrane. I was able to finish the sinus lift and place the implant at the same time. The case was restored in 6 months. If you are not an expereinced periodontist or an Oral Surg. with imlplant experiece, please do not try this again. It make you look bad infornt of your patient. The tear was probably due to a small window size. I agree with the rest of the comments as to repair when the tear is small and abandon if large. You can make a clinical decision when it is in between. Antibiotic coverage is also very important. AMOX qid, or AUG bid or lastly Levoquinn.

Dr G, Never perform a surgery if ou are not capable of handling complications, especially an obvious one such as a sinus perforation. You are doing a procedure where sinus perfs are common. Patients desrves more. It is one thing to find a complication that you are trained to handle but still find difficulty where you may need outside help. It is another issue if you you don't know the prescribed protocol for a perf. Tread carefully as this issue is definitely not a practice builder. Good luck Dr G.

Dr. G, Please note closely the post from Paul; I vigorously indorse his comments. I teach in a graduate perio/implant program and one of my major goals is to insure that my residents have a full understanding of the potential complications for a specific procedure ( to hopfully avoid them)and then to be able deal with those complications that do occur. I am not aware of your level of training but to attempt a procedure to which you are not fully capable of handling in all respects, won't make either your insurance carrier or lawyer very happy. Advanced surgery and bone grafting are not limited to periodontists or oral surgeons, as the early proponents for implants and advanced surgery were knowledgable and skilled GP's. If you want to become skilled in these areas, either find a local mentor to guide you or attend one of the accredited programs that usually consist of a long weekend, once a month for one or two years. These programs's normally provide for bringing in your own patient's to be treated by you under the supervision of experienced and skilled faculty. Good Luck Dr G

I agree with some of the posts that say tears can be managed with a membrane and also with others that say DO NOT curette out the entire lining. What is most important is that the clinician should be well versed in the technique and also have a thorough basic knowledge of the surgical aspect. When I say thorough knowledge I mean starting right from the basics of incision making till the last suture coz each n every small part goes a long way in affecting the success rates.

I read the post by Dr Miller. He is wrong about nevi being considered premalignant by many pathologists. There are a variety of nevi (or moles as they are commonly known) most of which are very benign. Those that are considered premalignant are the so called junctional nevi; when malignant cells have penetrated further into the connective tissue then it is considered a melanoma. Melanomas do occur in the mouth and also are found in the GI tract, eye etc.

Hi I was at Steve Wallace's NYU based Sinus surgery review course at the Greater NY dental Meeting this past week. They have clinical studies and reviews of clinical trials going back 15years. At this point they have very solid evidence that contrary to popular believe the gold standard in sinus surgery is xenograft. It would take a while to explain why, but this is based on clinical research and histology. He did present a study of 100 sinus lifts in a row using piezosurgery that had little or no perforations. (experianced surgeons including some who ar eon this thread) He did suggest membrane repair when there is a perf and showed how to do it. That being said I have done a few hundred lateral lifts and I do not repair perfs greater than 7mm or so. Of course others will, and that is OK. However I think that controlling the graft position after repair is not so predictable.. Best Sheldon

Sheldon Great post. Still never got a response from Dr. Miller to my response to Dr Millers absurd suggestion on removing the entire sinus membrane. I agree large perfs should not be grafted. NYU has published the a study on the piezo. The study shows perforations are reduced from 30% to 7%. Most of the perfs didnt happen until they switched from piezo to hand instruments.