A novel technique to close large perforation of sinus membrane

SUMMARY

Maxillary sinus floor elevation is generally accepted as a regenerative procedure to facilitate dental implants placement in the posterior atrophic maxilla. Although the sinus lift procedure is relatively safe, some potential problems could be occur. The most prevalent intraoperative complication is perforation of sinus membrane, which can lead to graft infection and early failure.

The Aim of this work

Is to present a new technique to repair large perforation of sinus membrane.

This case report

Is focused on a 10 mm perforation of sinus membrane occurred during preparation of the sinus window. The obliteration of the perforation was obtained by means of suturing sinus membrane with a resorbable material to the bone directly lateral to the osteotomy site. Sinus augmentation procedure could complete and the insertion of a graft was permitted.

Introduction

Maxillary sinus floor elevation is a well-documented technique and it is generally accepted as a regenerative procedure to facilitate dental implants placement in the posterior atrophic maxilla (1, 2). Freeing the membrane during sinus surgery is a delicate procedure, and perforation of membrane could be occur very frequently (from 11% to 56%) (3). A tear of shneiderian membrane results in direct comunication between the graft material and the contaminated sinus cavity; this event can cause infection and chronic sinusitis, which can lead to loss of graft volume (4). Perforation of the shneiderian membrane most often occurs when the lateral wall is being in fractured, but it can also happen when the membrane is being elevated off the inferior and anterior bony aspect of the sinus or it can occur due to irregolarities of the sinus floor (5–8). It has also be suggested that previous sinus surgey is a risk factor to perforations of the maxillary sinus, which tend to be large in those cases.

When the perforation is small and located in an area where the elevated mucosa is folded together, it will be healed by itself (9, 10). 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 (9, 10). In such these cases sinus floor is usually managed by use of a collagenous membrane, fibrin adhesive, use of a block graft or, at least, one have to abandon the procedure (9, 10).

If adequately repaired, perforations have no effect on the ultimate survival of the implants placed in the affected sinuses (5).

The main purpose of this report was to present a novel technique to repair a large perforation of sinus membrane by means of adsorbable suture, when a collagen membrane is not available.

Case Report

A 40 year-old women was referred to our department for an implant-supported prosthesis in a partially edentulous maxilla. Radiographic exams revealed not only an insufficient bony support but also a residual root apex in the region where implant should be programmed (Figs. 1, 2).

Figure 1.

Radiographic exams (coronal images) revealed not only an insufficient bony support but also a residual root apex in the region of the first upper molar where implant should be programmed.

Figure 2.

Radiographic exams (parasagittal images) also revealed not only an insufficient bony support and the residual root apex in the palatal side.

It was decided to remove the root before starting the regenerative procedure. During the exctraction, a perforation of sinus membrane occurred (Fig. 3). It was located in the mid superior aspect of the osteotomy, extending mesiodistally for two-thirds of the dimension of the total osteotomy site. Because of a collagen membrane wasn’t available, the obliteration of the perforation was obtained through suturing sinus membrane with a resorbable material to the bone directly lateral to the osteotomy site (Fig. 4A, B), giving the chance to not abort sinus augmentation procedures and to place the graft material (Fig. 5). Finally detached sutures were positioned (Fig. 6).

Figure 3.

During the extraction, a perforation of sinus membrane occurred.

Figure 4.

A) The obliteration of the perforation was obtained through suturing sinus membrane with a resorbable material to the bone directly lateral to the osteotomy site. B) The obliteration of the perforation was obtained through suturing sinus membrane with a resorbable material to the bone directly lateral to the osteotomy site.

Figure 5.

Graft material placement.

Figure 6.

Detached sutures.

Post operative medications were prescribed and after fifteen days sutures were removed.

The clinical checks done at 15 days, 1 months, 3 months and 6 months showed a postoperative course without complications. No serious infections, no signs of sinus membrane inflammation or hypertrophy were detected. Radiographic exams after 6 months revealed a good quantity of bone to receive an implant, so an osseointegrated implant was placed (Fig. 7) and the patient was rehabilited with a PFM crown (Fig. 8). The intraoral radiographic control (Fig. 9).

Figure 7.

The placement of a osseointegrated implant.

Figure 8.

The rehabilitation with a PFM crown.

Figure 9.

The intraoral radiographic control.

This technique resulted useful to obtain the closure of a large perforation providing the clinician safe for the placement of the planned regenerative materials and for the following scheduled therapies.