document24

Sinus Pathology and Anatomy in Relationto Complications in Lateral Window

Sinus AugmentationHsun-Liang Chan, DDS,* and Hom-Lay Wang, DDS, MS, PhD

Maxillary sinus augmentationvia a lateral window ap-proach (SALW) is an effec-

tive procedure to gain bone height forimplant placement in an atrophic pos-terior maxilla.1,2 This technique wasfirst published by Boyne and James3 in1980. According to them, a bony win-dow was made on the lateral sinuswall and a space was created betweenthe Schneiderian membrane and thesinus walls, where a grafting materialwas placed. One key advantage of thisapproach is gaining direct access tothe sinus. However, despite the highsuccess rate, complications do occur.4

The most frequently encountered sur-gical complication is perforation of theSchneiderian membrane.5 Other com-plications include massive bleeding,infection, implant displacement intothe sinus, etc.1 More than often thesecomplications are related to the sinusanatomy and preexisting antral pathol-ogies. Knowledge about common si-nus diseases and variations in sinusanatomy would greatly reduce the oc-currence of these complications.Therefore, this article aimed at re-viewing antral diseases and anatomythat might predispose to surgical com-plications in SALW. A treatment

proposal aiming at managing antral dis-eases was introduced. In addition, themanagement of these surgical complica-tions was discussed.

MAXILLARY SINUS DISEASESOne of the main functions of the

maxillary sinus is to humidify and fil-ter the air inhaled in the nose. It isachieved by a layer of specialized re-spiratory epithelium, classified asciliated pseudostratified columnar ep-ithelium.6 The main components ofthis epithelial layer are basal cells,goblet cells, and ciliated cells.7 Basalcells own the ability to proliferate anddifferentiate into the other 2 cell types.Goblet cells are secretory cells thatproduce mucin. The ciliated cells arecolumnar epithelial cells that possesscilia. They function by moving themucin toward the ostium, an openingconnecting the maxillary sinus to themiddle meatus in the nasal cavity.Blockage of this pathway could lead toaccumulation of mucin and antral

pressure in the sinus, eventually giv-ing rising to symptoms, such as palpa-tion pain around infraorbital regionand headache. Many of the sinus dis-eases and some complications result-ing from SALW are associated withthe inability of the maxillary sinus todrain mucin.

Sinus diseases and abnormitiesare prevalent (40%) in patients sched-uled for sinus lift procedures and thepresence of those conditions is signif-icantly correlated with a history of in-dicative symptoms.8 In addition, theirpresence might increase the difficul-ties in performing the surgery and therisk of developing postoperative com-plications.911 As a result, maxillarysinus diseases should be recognizedand managed with care before a sinusaugmentation procedure. Many ofthem could be identified via a thor-ough medical and dental history eval-uation, with a special focus on anysigns and symptoms that might sug-gest a concern in the sinus.8 A careful

*Resident, Graduate Periodontics, School of Dentistry,University of Michigan, Ann Arbor, MI.Professor and Director, Graduate Periodontics, School ofDentistry, University of Michigan, Ann Arbor, MI.

Reprint requests and correspondence to: Hom-LayWang, DDS, MS, PhD, 1011 North University Avenue,Ann Arbor, MI 48109-1078, Phone: (734) 763-3383,Fax: (734) 936-0374, E-mail: [email protected]

ISSN 1056-6163/11/02006-406Implant DentistryVolume 20 Number 6Copyright 2011 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e3182341f79

Antral pathoses and anatomicalvariations increase the risk of surgicalcomplications during a lateral win-dow sinus augmentation procedure.Therefore, an understanding of maxil-lary sinus diseases and anatomies isimperative. In the first part of this ar-ticle, common sinus diseases will bereviewed, which include acute/chronicrhinosinusitis, mucoceles, pseudo-cysts, retention cysts, and odontogenicdiseases of the maxillary sinus. In ad-dition, a treatment strategy will beproposed toward the management of

these antral diseases. In the secondpart, anatomical variations of themaxillary sinus, for example, theseptum and artery that is in approx-imation to the osteotomy site will bediscussed. Knowledge of diagnosingand managing sinus pathoses andanatomies could assist surgeons inreducing the incidence of sinus aug-mentation complications. (ImplantDent 2011;20:406412)Key Words: maxillary sinus, sinuspathology, sinus anatomy, sinusaugmentation, dental implants

406 SINUS IN RELATION TO COMPLICATIONS IN LATERAL WINDOW SINUS AUGMENTATION CHAN AND WANG

dental and periodontal examinationespecially for those teeth that are inthe vicinity of the sinus should be ex-ecuted to rule out any odontogeniclesions. Common sinus diseases thatmight interfere with the performanceof SALW include acute/chronic rhino-sinusitis, sinusitis of odontogenic ori-gin, odontogenic cysts, pseudocysts,mucoceles, and retention cysts. Theclinical and radiographic features ofeach of them was discussed in belowand summarized in Table 1.

Rhinosinusitis

The term rhinosinusitis has re-placed sinusitis because of the closeinterrelationship between the 2 dis-eases.12 Rhinosinusitis is defined asinflammation of the nose and parana-sal sinuses.13 Acute rhinosinusitis(ARS) is usually infectious and lastsup to 4 weeks, whereas chronic rhino-sinusitis (CRS) is more inflammatoryand has a minimal duration of either 8or 12 weeks.12 Apart from their differ-ences in the duration and pathogene-sis, symptoms associated with the 2diseases are similar. More than 2 ofthe following symptoms are requiredto establish the diagnosis for bothARS and CRS: (1) anterior or poste-rior mucopurulent drainage, (2) nasalcongestion, (3) facial/pain pressure,

and (4) decreased sense of smell.13 Inaddition, CRS may be diagnosed withobjective methods, for example, a rhi-noscopic or radiographic examinationwith a preference for computed to-mography (CT). CRS can be furthercategorized into 3 subtypes with dis-tinct but overlapping clinical charac-teristics: CRS without nasal polyposis,CRS with nasal polyposis, and allergicfungal rhinosinusitis.13 Radiographi-cally, ARS might present with an air-fluid interface and CRS is associatedwith thickening of the sinus lining andradiopacity in the sinus.14

Odontogenic Sinus Diseases

Maxillary sinusitis of odontogenicorigin account for approximately onetenth of total maxillary sinus diseases.15

Common dental diseases that can causesinusitis include periapical infection,periodontal disease, and perforation ofthe antral mucosa during tooth extrac-tion. Other dental-related maxillarydiseases are odontogenic cysts, for ex-ample, the radicular and dentigerouscyst.16 These earlier mentioned diseasesmight serve as a reservoir for microbes,which might contaminate the graftingmaterial and dental implants resultingin treatment failure if left untreated.As a result, before planning a SALW,a thorough dental examination is re-

quired to rule out the earlier men-tioned diseases.

Pseudocyst, Retention Cyst,and Mucocele

A pseudocyst, as the name im-plies, is not a true cyst (without epi-thelium lining) while a retention cystis.17,18 A pseudocyst is believed to bean accumulation of inflammatory ex-udates between the bony wall andperiosteum. A retention cyst is formedwhen mucin is allowed to accumulatein a dilated seromucous duct that isblocked. Radiographically, a pseudo-cyst is characterized by its dome-shaped radiopaque structure and iscommonly found on the floor of themaxillary sinus. The prevalence ofpseudocysts ranges from 7.3%19 to14%20 on radiographs. On the otherhand, a retention cyst is not readilyseen on the x-ray because it is toosmall and if found, it is often aroundthe ostium. Under normal conditions,both lesions are usually asymptomaticand require no treatment. However,when a SALW is planned, a pseudo-cyst might complicate proceduresand risk the development of surgicalcomplications.

A mucocele, on the contrary, isinvasive in nature. The pressure gen-erated from the fluid in the mucocele

Table 1. Common Maxillary Sinus Diseases and Their Managements for SALW

Disease

Diagnosis

Etiology Histological Findings ManagementClinical Symptoms Radiographic Findings

ARS Duration up to 4 wkAnterior or posterior

mucopurulent drainageNasal congestionFacial pain/pressureDecreased sense of smell

Opacification or air-fluid level Bacterial/viral/fungal infection Infiltration of neutrophils andmacrophages

ENT consultation

CRS Duration longer than 812 wkAnterior or posterior

mucopurulent drainageNasal congestionFacial pain/pressureDecreased sense of smell

Thickening of the sinus liningmore or less in even width

Mainly inflammation fromlow-grade infection orallergy

Infiltration of lymphocytes,plasma cells, andmacrophages

ENT consultation: withsymptoms or thickmembrane 1/3sinus height

Otherwise, proceedwith SALW

Pseudocyst Usually none Prevalence: 1.5%10%Dome-shaped radiopacityCommonly located on the floor

of the sinus

Focal accumulation ofinflammatory exudate

No epithelial liningExudates accumulationInflammatory infiltration

ENT consultation: withsymptoms or closerto medial wall

Otherwise, enucleationvia lateral window

Retentioncyst

Usually none Mostly too small to be detectedCommonly found around ostium

Blockage and dilatation ofducts of theseromucinous glands

With epithelial liningMucin accumulation

Proceed with SALW

Mucocele Very rare, more commonlyfound in frontal sinuses

May include headache,diplopia, visual impairment,and/or nasal obstruction

Initial stage: cloudy sinus cavityLater stage: thinner sinus wall

Blockage of ostium due totrauma or other diseases

With epithelial lining (typicalrespiratory epithelium orsquamous metaplasia)

ENT consultation

IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011 407

may resorb the bony walls of the si-nus. It is also much larger in size andmay fill the entire sinus thus creatingsinus symptoms. The blockage of theostium is believed to be responsiblefor this pathosis.18

Management of Maxillary Sinus Diseases

A proposed treatment strategy issummarized in Figures 1 and 2 forpatients who are diagnosed with max-illary sinus diseases and at the sametime planned for SALW. From a med-icolegal and preventive standpoint,dental surgeons should collaborateclosely with an otorhinolaryngologistin managing maxillary sinus diseases.The general goal is to alleviate sinus-related symptoms, eliminate the lesionand regain sinus membrane health be-fore sinus augmentation. The proce-dures to achieve this goal may includea nonsurgical or a surgical approach ora combination of both.

More specifically, a mucoceleshould be removed first because of itsaggressive nature and large size. Ifdiagnosed during the sinus augmenta-tion surgery, the pathologic tissue canbe removed with a Caudwll-Luc proce-dure and the augmentation procedure isaborted.21 CRS should be referred, whenit is symptomatic or if the sinus mem-brane thickness is greater than one thirdof the height of the sinus. For maxillarysinus diseases of odontogenic origin,the lesion should resolve itself afterdental procedures, which might in-clude endodontic therapy, periodontaltreatment, and extraction.22 The reten-tion cyst is often small, symptomless,and near the ostium. Therefore, nospecific treatment is warranted.

The management of the pseudocystis somewhat controversial and differentapproaches have been reported in sev-eral case reports.19,21,23,24 Sinus augmen-tation was performed with the presenceof a pseudocyst in 2 cases.23 One casedeveloped an abscess postoperativelyand was controlled by antibiotics, afterwhich the implants had been followedfor 7 months without further compli-cations. In another study,19 8 caseswith a pseudocyst were treated with astandard SALW. Postoperative acutesinusitis and membrane perforationoccurred in one and 2 cases, respec-

tively. The authors concluded that asinus lift procedure can be performedsafely even when a pseudocyst is pres-ent; however, in cases of unclear di-agnosis or if the cyst is large, furtherevaluation is recommended. On theother hand, Lin et al24 suggested re-moving the pseudocyst routinely be-fore SALW. In their case report, a 5mm round window was created on thelateral wall of the sinus, from wherethe cyst was enucleated. The SALWwas performed 3 months after the re-moval of the cyst. The authors claimedthat this procedure allowed for elimi-nation of the cyst and shortening of

treatment time (a Caldwell-Luc proce-dure or an endoscopic surgery for cystremoval normally requires 6 monthshealing). The pseudocyst should be re-moved before sinus augmentation be-cause of the following reasons. First,histopathologic examination can beperformed to rule out any possible ma-lignancy. Second, the healed sinusmembrane after elimination of the cystwould be healthier, and thus facilitatethe sinus elevation procedure. Third,the long-term effect of the pseudocyston the grafting material and implantsare not known. Whether the enucle-ation procedure is referred depends on

Fig. 1. A proposed treatment strategy for common antral diseases before SALW.

Fig. 2. A proposed treatment strategy for common antral diseases during and after SALW.


the presence of symptoms and the lo-cation of the cyst. When the cyst issymptomatic or is medially located, anendoscopic surgery might be indicatedand therefore should be referred to anotorhinolaryngologist.

Intraoperatively, the outcome ofsinus augmentation is influenced byseveral factors, such as the presence ofa membrane perforation, size of theperforation, presence of unexpectedinfection, and the ability to clean theinfection. The presence of pus/exudaterequires a debridement procedure andif the debridement could not be com-pleted, the sinus augmentation shouldbe aborted. If the size of the perfora-tion is larger than 10 mm, the proce-dure generally should be terminatedtoo. Postoperatively, decongestantmedications and antibiotics should beprescribed and the patients should beinformed about the possibility of hav-ing higher incidence of developingcomplications.

VARIATIONS IN THE ANATOMYCOULD PREDISPOSETO COMPLICATIONSSinus Septum and Membrane Perforation

The internal structures of the max-illary sinus have been described a hun-dred years ago.25 It was not until theintroduction of the SALW did theseinternal anatomies regain attention,and in particular, the septum. Articlesrelated to the maxillary sinus septum

are summarized in Table 2. A septumis a bony projection with various sizes,locations, and orientations, most com-monly arising from the floor of themaxillary sinus. The prevalence of theseptum ranges from 16% to 33.3%,depending on ethnicity, methods usedto identify a septum and the dentatestatus, etc.2632 The septum has beenfound more commonly in edentulousthan dentate status because of the pres-ence of the secondary septum.27 It washypothesized that after tooth loss, aselective bony resorption of the sinusfloor resulted in areas of protrusionand depression. The protrusive bonyspike formed the secondary septum, incomparison with the primary septum,which was formed along with the de-velopment of the maxillary sinus. Thistheory was further supported by thefact that a primary septum is higher insize and may split a sinus into 2 com-partments, whereas a secondary septumis considerably shorter. The septum wasmost commonly found at the molararea,26,2830 where a sinus augmentationprocedure is commonly performed. Theheight of the septum varies greatlyamong studies, ranging from 1.6326 to11.7 mm.28 A septum can be found morecommonly in a mediolateral direction,partially separating the sinus into an an-terior and posterior compartment,28,29

although a septum in the transverseand sagittal directions could also befound. To summarize, a septum, vary-

ing in size, location, and orientation iscommonly present in the maxillary si-nus. Its presence may increase the riskof a sinus membrane perforation dur-ing the surgery.

A membrane perforation is themost commonly encountered compli-cation.1 The mean prevalence of sinusperforation during sinus elevation pro-cedures is 19.5%, with a range of 0%to 58.3%.1 The highest perforation rateis associated with single tooth replace-ment.27 It might be possible that thelimited access had significantly in-creased the perforation rate. Whethermembrane perforation incurs morepostoperative complications andhigher implant failure rate is debat-able. Barone et al33 found that the useof an onlay graft and/or smoking andnot the membrane perforation is asso-ciated with higher postoperative infec-tion rate. Becker et al34 also suggestedthat with proper treatment, a perfora-tion of the membrane did not elevatethe risk for implant loss, infection, ordisplacement of grafting material.Schwartz-Arad et al5 concluded that amembrane perforation significantlyincreased postoperative complicationsbut it did not result in more implantfailures. On the other hand, Cho-Leeet al35 found that the implant survivalrate was lower (81%) when surgicalcomplications, membrane exposure orpostoperative sinusitis occurred, com-pared with no complications (97.6%).

Table 2. Summary of Articles Studying the Prevalence, Size, Location, and Orientation of Maxillary Septa

N(Subjects) Methods Dental Status

SeptumDefinition Prevalence/Sinus (%) Location (%) Direction Size (mm)

Ulm et al32 41 Cadavers Edentulous 2.5 mm 31.7 Premolars: 73.3; 1st molar:19.9; 2nd molar: 6.6

NA 7.9

Krennmairet al27

165 Clinicalexaminationand CT

Both NA Clinical: 27.7; CT: 16;dentate: 13.2;edentulous: 26.8

NA NA 6.8 (clinical), 8.1 (CT)

Kim et al26 100 CT Edentulous 2.5 mm Total: 26.5;edentulous: 31.8;dentate: 22.6

2nd premolar: 25.4; 1stand 2nd molars: 50.8;3rd molar: 23.7

NA 1.63 (lateral), 3.55 (middle),5.46 (medial)

Shibli et al31 1024 Panoramicradiographs

Edentulous NA 21.6 NA NA NA

Neugebaueret al28

1029 CBCT Both NA 33.2 1st molar: 31.6; 2nd molar: 27.6; 2nd premolar:17.1

Medial-lateral: 74.7;anterior-posterior:25.3

7.3 (mesiodistal); 11.7(anterior-posterior)

Rosanoet al30

30 Cadavers Edentulous 3 mm 33.3 2nd premolar-1st molar:30; 1st-2nd molar: 40;distal to 3rd molar: 30

Medial-lateral: 30;anterior-posterior:70

8.72

Park et al29 200 CT Edentulous NA 27.7 1st and 2nd premolar:22.5; 1st and 2ndmolar: 45.9; 3rd molar:31.5

Medial-lateral: 96.3;anterior-posterior:3.6

7.8

CT, computed tomography; CBCT, cone-beam computed tomography.


Regardless of the controversies in thepotential effect of membrane perfora-tion on postoperative complicationsand implant failure, this intraoperativecomplication absolutely increase sur-gical difficulty and lengthen surgicaltime. It is, therefore, preferable to pre-vent the occurrence of a membraneperforation. Of equal importance is themanagement of a perforation onceidentified during the procedure.

Management of SinusMembrane Perforation

Table 3 summarized methodsused to repair a membrane perforationof different sizes. A perforation 5mm is generally repaired with a colla-gen membrane alone or sutures.34,36,37

A perforation size between 5 and 10mm might be treated with a collagenmembrane alone,36 in combinationwith sutures34 or lamina bone har-vested from the lateral wall after os-teotomy.37 It might be corrected with ademineralized freeze-dried human la-mellar bone sheet.38 Attempts were

made to repair a larger perforation(10 mm), including a demineralizedfreeze-dried human lamellar bonesheet,38 lamina bone alone, combinedwith buccal fad pad, or the use of ablock graft.37 On the contrary, it wassuggested to abandon the surgery.34

From these clinical evidences, small tomedium perforations might be re-paired, after which the augmentationprocedure could be completed withoutjeopardizing implant survival rate.However, when a large perforation oc-curs, the surgery should be terminatedbecause lower implant survival rate wasfound in cases with a 10 mm perfora-tion and a repair was attempted.37

Distributions of Blood Vessels andMassive Hemorrhage

Accidently injuring the blood ves-sels in the maxillary sinus might causemassive hemorrhage during an aug-mentation surgery. Therefore, it is im-portant to understand the distributionsand variations of these arteries. Theartery that is located on the lateral wall

where an osteotomy will be performedis especially important. It is the anas-tomosis of the posterior superior alve-olar artery and infraorbital artery. Incadaver studies, this anastomosiscould always be found39,40; however,from CT images only 50% to 60%could be identified.4042 Its location inrelation to the alveolar crest was onaverage 11.25,40 16.4,41 18.0,42 and 19mm.39 Because of its location, it wasestimated that 20% of normally posi-tioned lateral window osteotomiesmight come across this artery, poten-tially causing major bleeding.41 Theuse of a piezoelectric machine for os-teotomy might preserve the integrityof this artery because it only cuts hardtissue.43 With regard to its relationshipwith the lateral sinus bony wall, it wasfound to be intraosseous39,41 or par-tially intraosseous.40,42 If it is locatedbetween the interior side of the bonywall and the Schneiderian membrane(partially intraosseous), care shouldalso be taken not to tear it when ele-

Table 3. Summary on Managements of Sinus Membrane Perforation

ReferencesTotal No. of

AugmentationsTotal No.

of ImplantsPerforationRate (%)

ImplantPlacement Timing

Management by the Size of the Perforation

Perforation Size(mm) 5 510 10

Shlomi et al38 73 253 28 Staged No. of perforations 20Repair technique DFDLB sheetPostoperative

complications(%)

0

Implant survivalrate (%)

90 (NSS from NP group)

Ardekian et al36 110 221 Simultaneous No. of perforations Repair technique Collagen membrane Postoperative

complications(%)

5.7 (0 in NP group)


94.4 (NSS from NP group)

Becker et al34 201 425 20.4 Both No. of perforations 28 6 4Repair technique Collagen

membraneCollagen membrane

sutureDiscontinue the

procedurePostoperative

complications(%)

4.8 (1 in NP group)


98 (NSS from NP group)

Hernandez-Alfaroet al37

474 1166 25.15 Simultaneous No. of perforations 56 28 20Repair technique Suturing, or

resorbablecollagenmembrane

Lamellar boneresorbable collagenmembrane

Lamellar bone, lamellarbonebuccal fatpad, or bone blockgraft

Postoperativecomplications(%)


97.1 91.9 74.1

NSS, not statistically significant; NP, nonperforation; DFDLB, demineralized freeze dried human lamina bone.


vating the membrane. The diameter ofthis artery was 1 mm in 55.3%, 1 to2 mm in 40.4%, and 2 to 3 mm in4.3% of cases.40 When a large diameterblood vessel (3 mm) is encountered, itmay be wise to ligate it to preventmassive bleeding.44

Location of the Ostium andSinus Obliteration

The ostium is located 40 mmabove the antral floor.45 A case wasreported for a patient who complainedabout frequent headache, sinus con-gestion, and discharge after a sinusaugmentation procedure.46 CT re-vealed that the grafting material occu-pied 80% of the maxillary sinus andwas just below the ostium. It was pos-sible that the grafting material hadblocked the normal fluid movement inthe maxillary sinus and symptoms de-veloped. Therefore, maxillary sinusshould not be overpacked.

Migration of the Implant

Displacement of implant into si-nus was reported sporadically in theliterature.47,48 the incidence of thiscomplication is currently unknownand believed to be rare. The timing ofits occurrence varies from several daysafter implant placement,49 at abutmentconnection surgery,50 or even severalyears after function.51 The exact causeis not clear; however, 3 essential con-ditions must be present for this unfor-tunate incident to occur, these are alack of osseointegration, membraneperforation, and a pushing force on theimplant toward sinus. It is generallyagreed that once the displacement isdiagnosed, the implant should be re-moved as early as possible. Three mainrescue therapies have been discussedand the treatment protocol has been de-veloped, which comprises of intraoralapproach (modified Caldwell-Luc pro-cedure), functional endoscopic sinussurgery (FESS), and the combinationof both.47 According to their protocol,an intraoral approach is chosen whenno symptoms of sinusitis are presentand the ostium is patent, whereas aFESS is selected when there is ob-struction of maxillary ostium withoutoroantral communications. The FESSis combined with an intraoral ap-

proach when sinusitis, obstruction ofthe ostium, and oroantral communica-tions are all present. A high successrate (26 of 27 patients recovered com-pletely) following this protocol suggeststhat this is an effective approach. Nev-ertheless, the best way is probably toprevent this complication from happen-ing. Because of rare occurrence, it wasdifficult to identify the risk factors. Pos-sible predisposing factors include inad-equate residual ridge height, poor bonequality, and simultaneous implant place-ment with sinus augmentation.

CONCLUSIONSThe occurrence of surgical compli-

cations during SALW is most likely re-lated to the presence of maxillary sinuspathoses and anatomical variations.Management strategies for antral dis-eases before, during and after the aug-mentation procedure were proposed. Inaddition, maxillary sinus anatomies, inparticular the maxillary septum, ostium,and artery in the vicinity of the osteot-omy site and their clinical significancewere discussed. Correct diagnosis andmanagement of sinus diseases and theknowledge of sinus anatomies couldgreatly reduce the incidence of surgicalcomplications.

DISCLOSUREThe authors claim to have no finan-

cial interest in any company or any ofthe products mentioned in this article.

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