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Effect of Mmebrane Perforation During Sinus Grafting on Implant Survival rate: retrospective study


Sarah Bukhari, BDS, MS – Fellow (Advanced Education Program in Implant Dentistry), LLU

Yueh-Ling Chao, DDS – Fellow (Advanced Education Program in Implant Dentistry), LLU


Purpose of the Study: Maxillary sinus augmentation is a predictable procedure with high success and low complication rates.1-3 The most common complication of with maxillary sinus augmentation is perforation of the Schneiderian membrane ranging from 10-55%.4-9 The incidence of perforation has been attributed to several factors; the anatomy of the sinus, the presence of septa, the thickness of the membrane, operator error, overfilling of the sinus.6,7 10Evidence in the literature is contradicting in regard to the correlation between sinus membrane perforation (SMP) and post-operative complications. The aim of this retrospective study is to evaluate the correlation between SMP and post-operative complication; graft failure, implant failure, bone formation. Taking into consideration operator experience, perforation size and location, sinus anatomy and repair technique.

Methods: Patient Selection This retrospective study was approved by the institutional review board of Loma Linda University. The treatment records of patients who underwent sinus augmentation (lateral approach) and subsequence implant placement between June 2012 and June 2018 were reviewed. Inclusion Criteria: Potential subjects for exposure rate comparison must meet ALL of the following criteria: Be over 18 years old at the beginning of treatment. Have sinus augmentation (lateral approach) procedure without implant placed simultaneously. Additional criteria for implant survival rate comparison: Receive implant placement after sinus graft is healed and have a record of more than 1-year follow-up after implant placement. Data collection Patient demographics (age and gender), tobacco usage (smoking or non-smoking), date of sinus augmentation, augmented site, initial bone height, membrane perforation, perforation size, perforation management, graft outcome, and sinusitis. Perforation rates were reported in the following categories: Surgeons’ surgical experience: >5 years (E) or <5 years (LE) Smoking habit Cross-sectioned images were measured using CBCT (i-CAT, Imaging Science Internation, Hatfield, PA) before sinus augmentation (T0), right after sinus augmentation (T1), and before or right after implant placement (T2). The CBCT were transferred and opened using an implant planning software program (InVivo 6, Anatomage Dental, San Jose, CA). Superimposition function was used to measure the same area from T0-T1-T2. A preplanned implant position (P1) was selected as point of measurement based on radiographic template. Additional implant positions were selected 1mm mesial (P2) and distal (P3) to P1. After points of measurement were obtained, the area-measuring tool in InVivo 6 was used to measure cross-sectioned images at P1, P2, and P3 of images T0, T1, and T2. Average value of P1, P2, and P3 from each CBCT images (T0, T1, and T3) were calculated to obtain the height before sinus augmentation (mm), height right after sinus augmentation (mm), and height after healing (mm). After obtain the height of the three images (T0, T1, T2), quantitative height of grafted bone placed (QGBP), quantitative height of grafted bone remained (QGBR), quantitative grafted bone height loss (QGBDL) and Percentage grafted bone height loss (PGBDL) were calculated using these formulas: Quantitative height of grafted bone placed (B1) = height right after GBR – height before GBR Quantitative height of grafted bone remained (B2) = height after healing – height before GBR Quantitative grafted bone height loss (B3) = height right after GBR – height after healing Percentage Grafted Bone height Loss = (B3/B1) x 100 The mean QGBP, QGBR, and PGBDL of the perforated and non-perforated groups were calculated for each type of membranes. Statistical Analysis The sinus membrane perforation rates associated with each recorded parameter were represented using descriptive statistics. PGBDL of perforated groups and non-perforated groups among each barrier were compared using independent samples Mann-Whitney U PGBDL among perforated membrane was compared by independent-sample Kruskal-Wallis test. Intra-examiner reliability was tested using SPSS® intraclass correlation coefficient (ICC) and was considered adequate at 0.90. The level of statistical significance was set at P < 0.05. The methodology was reviewed and approved by an independent statistician.



Articles: References: 1. Ulm, C.W., Solar, P., Krennmair, G., Matejka, M. & Watzek, G: Incidence and suggested surgical management of septa in sinus-lift procedures. Int J Oral Maxillofac Implants. 1995;10: 462–465. 2. Khoury, F. Augmentation of the sinus floor with mandibular bone blocks and simultaneous implantation: a 6-year clinical investigation Int J Oral Maxillofac Implants. 1999;14: 557–564. 3. Vlassis, J.M. & Fugazzotto, P.A. (1999) A classification system for sinus membrane perforations during augmentation procedures with options for repair. Journal of Periodontology 70: 692–699. 4. Misch CE: The maxillary sinus lift and sinus graft surgery, in Misch CE, (ed). Contemporary Implant Dentistry. St Louis, MO: CV Mosby, 1999, pp. 469–495. 5. Pikos MA: Maxillary sinus membrane repair: Update on tech- nique for large and complete perforations. Implant Dent 17: 24, 2008 6. Schwartz-Arad D, Herzberg R, Dolev E: The prevalence of surgi- cal complications of the sinus graft procedure and their impact on implant survival. J Periodontol 75:511, 2004. 7. Bergh van den JPA, Bruggenkate ten CM, Disch FJM, et al: Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 11:256, 2000 8. Shlomi B, Horowitz I, Kahn A, et al: The effect of sinus mem- brane perforation and repair with Lambone on the outcome of the maxillary sinus floor augmentation: A radiographic assess- ment. Int J Oral Maxillofac Implants 19:559, 2004. 9. Timmenga NM, Raghoebar GM, Boering G, et al: Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 55:936, 1997. 10. Marin S, Kirnbauer B, Rugani P, Payer M, Jakse N. Potential risk factors for maxillary sinus membrane perforation and treatment outcome analysis. Clinical implant dentistry and related research. 2019 Feb;21(1):66-72.

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