ated a A Clinical Study of the Outcomes and Complications Associated with Maxillary Sinus Augmentation Antonio Barone, DDS, PhD'/Stetane Santini, DDS, MD!/Ludovica Sbordone, DDS, MD2/ Roberto Crespi, MD"/Ugo Covani, DDS, MD Purpose: Te wim ofthis study was 10 evawvate the sate of complications v mawillary Sinus augment Yon surgery and the impact of complications on subsequent mplant treatment i a patient population vith severe inaxilary atropty scheduled for treatnent under generel anesthesia, Materlals and Meth. ‘os: The sity population consisted of £0 patients (124 sinuses) with severe maxillary atrophy who underwent mexitary sinus augmentation, Sixteen patients were schcouled to have a unilateral proce. dure and 54 patients a bietera! procedure. Sinus auginentaton was performed with autogenous bone alone in 98 sinuses; 9 BE sinuses, 4 1:1 riixjure of autoganous bone and corticocanceslous pig bone particles was used. Tentysis of 124 procedures involved both Sirus augmentation and autogenous biock yrafting for the treacnent of severely ayvounic maxilae. Results: The most comoion intraopera tive compsication was ihe perforation OF the snus membrane, Which was observed in 3. sinuses (25%). Seven (5.6%) sinuses in T palents exnibived suppuration of tne mraxilary sines. Five of the 7 patients wth sinus infection were smokers, snowing a prevatence of compilcations signiticantty greater i smokers coMMarEd (0 AonSIMOKerS. Moreaver, the USe OF an onky bore Ara! Jn eonjurcbOn wih sinus auginentation aopearect io significantly herease the rate of inrective complications. infec ons were weated by drainage ard tne aumuinistration of systemic ankibioves. Iwo clinical cases Shaw ‘ing porsistent sigs uf infection required an endascapie inspection of the maxtiary sinus Discussion ‘and Conctuston; In the present stusy sinus membrane perforatian was nat shown to be @ significant actor in the rete of implant complications. Hoaexer, he conibination of smoking an onlay bone graft ‘ing coutd synifcanty Increase the rate of pastoperathee infection following sinus grarting, Wt J ONAL Muxione hietants 2006;24:81-85 Key words: nraniary sinus compreations, manilary situs yratts, maxillary sinus surgery he placement of dental implants requires a suffi- cient quality and quantity of alveolar bone to support implantation. Furthermore, proximity of the mazillary sinus often poses a clinical problem for the placement of implants in the posterior area of 3agsistam Pressor Deparment of Bophysieal, Mesa! and Dental Sciences and Technolgies, Medical Scheo, Universty of Genova, ta *rotesscr ard Ghai of Pelodontology and inplantcloge Deparment of sup01y Urwerty OF Pisa, Hay Yhecktare Proteesor Department ef Bephysia, Metical and ‘Donal Sciences are Tenn, Mahe Schoo, Una of Genova, tal: Pvate Pracice, Busto Bar, ay ‘Onniman of ral Patclow: Department of Glopysieal, Meal and Derval Soiences and octroegies, Mecca School Unver tyof Genor, talPrivate Practice, Camere, tly, Cerespondoace to: D:Aotonio Barare, Plaza Dia 10 5504 Ca maior (t,t, Fax: +39 0584985393, Ema brosurgahbnro the maxilla. Sinus augmentation surgery has had to, be evaluated! and subsequently modified to over- come this problem, Maxillary sinus grafting has become routine treaiment over the last 10 years. It allows the placement of dental implants using simul taneous of staged procedures in sites in the posie- rior maxilla that were previously considered unsuit- able for implant placement because of insufficient bone volume. Several studies have reported excellent long term survival rates for implants placed into augmented mavillary sinuses. Most of these studies have shown a correlation between the success of the bone graft and the success of dental implants; the assumption made wes that implant integration was possible because the grafted bone remained viable. The sinus lift is generally considered to be a safe sur- gical procedure with a low prevalence of complica- tions.’ However, all suigical procedures have the potential to develop complications, leading to addi The ternational Journal of Oral & Mauillolacil plants 8Barone otal tional surgery, prolonged hospital recovery, fatigue, and nutritional disorders, which markedly compro- rmise quality of life!” ‘The occurrence of complications with manillary sinus augmentation procedures may in fact jeopar- ize the final outcomes of bone grafting and implant pplacement, The most common intraoperative compli cation seems to be schneiderian membrane perfora- tion, which occurs in 7% to 44% of procedures.'"!? Less common complications can also occur in the postoperative phase, for example, sinus infection and barrier membrane or graft exposure.” The aim of the present study was to evaluate the surgical complication rate of maxillary sinus aug- mentations performed uncer general anesthesia and the impact on subsequent implant treatment in a patient population diagnosed with a severe maxil lary atrophy. MATERIALS AND METHODS: Patient Selection The study sample comprised 70 patients (32 men and 38 women} ranging in age from 35 to 68 years (median age 51,2 years). Forty-two of the patients were partially edentulous in the posterior maxilla, and 28 were completely edentulous, All patients were selected as suitable cancidates for maxillary sinus augmentation prior to implant surgery. All patients were healthy and had previously undergone complete intraoral and radiographic examination, Preoperative radiographic assessment included care {ul evaluation of any pathologic conditions of the sinus using orthopantomograms and computed tomography. The inclusion criteria were as follows: the need for sinus lifting and grafting; the presence of severe ‘maxillary bone atrophy rated class ¥ according to the Caivood and Howell classification"; a residual maxil lary sinus floor less than 3 mm high, and healthy sys: temic conditions, including the absence of any dis ease that would contraindicate surgery under general anesthesia, The exclusion criteria were as follows: severe ill ness, unstable diabetes, uncontrolled periodontal disease, a history of head and neck radiation, chemotherapy, and 2 history of drug abuse. in add tion, patients smoking more than 10 cigarettes per day were excluded from the study; patients smoking less than 10 cigarettes per day were advised to refrain from smoking, However, there was no mont toring of patient compliance, ‘A total of 21 patients were smokers; 49 were non- smoker, 82. Yowune 21, wunver 1, 2006 ‘The patients were informed of the surgical tech nique, and oraland written consent were obtained. ‘\ total of 124 maxillary sinus augmentation pro- cedures were performed: 16 patients were planned for a unilateral procedure and 54 patients for a bilateral procedure, Surgical Technique Maxillary sinus floor lifting and grafting were per formed under general anesthesia in all clinical cases The preoperative treatment regime consisted of intravenous antibiotic (2 ¢ cephalosporine) and cor ticosteroids (8 mg dexamethasone}. A local anes thetic agent with vasoconstrictor (2% xylocaine, 150,090) was injected into the vestibule and into the palate, First, a crestal incision was made, A mucope Fiosteal flap was raised, and an osteotomy was then performed on the lateral wall of the maxillary sinus Using a round steel bur under cooling with sterile saline solution to prepare a bony window. The sinus mucosa was carefully dissected and elevated using ‘mucosal sinus elevators, and the bony wall wes gent tly pushed inside the sinus cavity forming the root for the bone transplant. It small perforations appeared in the sinus membrane they were repaired with a collagen membrane, The doner sites for bone harvesting included the mandibular symphysis or the antero-superior border of the iliac crest,'®" Sinus augmentation was performed in 93 sinuses ‘with autogenous bone alone and in 31 sinuses with a 1 mixture of autogenous bone and corticocancel lous pig bone particles (Qsteobiok Tecnoss, Coazze, Italy) (Table 1). The particles were about 600 ym ‘wide. The bony sinus windows were covered with 3 resorbable collagen membrane. Finally, the mucope- riosteal flap was replaced and sutured using vertical intertupted mattress sutures, Postoperative Management All patients received antibiotics (cephalosporine 2g/day) for 5 days following suigery,a corticosteroid (dexamethasone 4 mg/day) for 2 days following surgery, and chlorhexidine mouthwash twice daily for 21 days following surgery. All patients were advised to avoid physical stress, blowing theit noses, orsneezing for a period of 3 weeks, The sutures were removed after 10 days. Dentures were not allowed to be worn until they had been adjusted and refitted not sooner than 2 weeks after surgery. During the postoperative healing petiod the occurrence of clinical complications such as acute or chronic sinus Infection, bleeding, and onlay bone graftexposure or mobility were recorded or implant Therapy ‘nealing pete 12 | atiowed before dt Tmplantation pro implant manwfactl i Martina, P22, to heal ovata pet | oaaing- the il ima in bent an | statistical Mett The comparison perfoxmes wih Maney ble aa ofP= 05) RESULTS. A vot of 124 fro paves. Voxh snus rattan he watt ered 0 Membrane M sinuses (25%) ‘en me Scot pert conn dues pro Sos ee these 78 ote ine Sinton Tansmok ‘pov sation Sbsered bone 98 ouronlImplant Therapy A healing period ranging from 4 to 6 months was allowed before dental implant placement. the implantation procedure took into account the implant manufacturer's recommendations (Sweden & Martina, Padova, Italy). The implants were allowed to heal over a period of 6 months before prosthetic loading, The implants placed ranged from 11 to 15 ‘mm in length and from 3,75 to § mm in diameter Statistical Methods The comparison between the different groups was performed with the chi square test with a contin: gency table analysis (statistically significant at a level of P=.05). RESULTS A total of 124 sinus lift procedures were performed in 70 patients. Twenty-six of 124 procedures included both sinus augmentation ané autogenous block graft to treat severely atrophic maxillae (Table 1). The most common intraoperative complication observed was the tearing or perforation of the sinus membrane, Membrane perforation was observed in 31 sinuses (250%), In these clinical cases, resorbable colla gen membrane was trimmed and used to overlap the site of perforation prior to insertion of the graft material Seven (5.6%) maxillary sinus augmentation proce: dures performed in 7 pationts exhibited suppuration 3 to S weeks after surgical treatment (Table 2).Five of these 7 patients were smokers. The prevalence of Boron ot a conjunction with maxillary sinus auigmentation pro- duced a significantly greater rate of infective compli ‘ations (P < 05). Complications following maxillary sinus augmentation were significantly greater in patients who smoked and received onlay bone grafts (50%) compared to patients who did not smoke and did not receive onlay bone grafts (2.5%) |P < 05) Once the infection iwas confirmed by clinical and radiographic examination, the sinuses were drained, and systemic antibiaties were administered, Two clin ical cases showed persistent signs of infection lespite drainage and required an endoscopic inspec- tion through the nasal cavity to enlarge and to liber ate the maxillary osteum. Five of 7 patients with sup- purated sinuses received additional sinus augmentation using corticocancellous pig bone par tiles 4 to 6 months subsequent to the sinus suppu- ration, No further complications were abserved. Implants were placed at a later stage according to the initial treatment planning. Two of 7 patients who developed sinus infections refused any additional surgical treatment. Absence of adequate bone volume was observed in 1 patient with a bilateral sinus augmentation: the patient was 2 smoker, Additional surgery was per- formed by elevating the schneiderian membrane while simultaneously placing the implants, Once sat~ isfactory clinical stability of the implants had been achieved, the sinuses were subsequently filled with deproteinized pig bone particles. A total of 287 implants were placed in the aug mented areas, acute infection following the sinus it operation was SENSE significantly greaterin smokers (142%), compared to. (Ube eae nonsmokers (2.2%), Moreover, 4 of the 7 patients showing acute sinus infection were treated with an Fling additional onlay bone graft. Acute infection was mateta! observed in 15.39% of patients treated with onlay tae bone bone grafts compared to 3% of patients treated with- _MiecboneandQsteoiol 3 Bc ds ‘out onlay bone grafis. The use of onlay bone grafts in Th 2. Postoperative Complica Mombraro ‘Associated onlay Patient perforation Complication material Smoking bone graft ‘treatment 1 No Infeion —Autoginous Yes Havzontal_ Drange ard antivotes 2 Yes Infection Autogonaus No = Drainage ara ative 3 No tneaion Mie Yes Honeental—_brologe ard antivoues 4 No tioxtion —Autogzneus Yes = Drolnge ard ontivotes 5 Yee Infection Autogonous No. Horzental_—_rainage ard antivoies 6 No ection Mie Yes Hvizntal ahaa ard anttvois + 1" 7 No Infection _Autogsreus Yes Drainage ar antibatis E laws 4171 rice oa toganovs bone and darren a ne arils (Ostet The Inernstional journal of oral Mawiotest Implans 83DISCUSSION The sinus lft procedure is an internal augmentation of the maxillary sinus; the aim of this procedure is to increase the bone volume in the lateral maxilla to make use of dental implants possible. The dental implants can either be placed simuliangously when there is sufficient bone height, or be placed in a sec- ond procedure postaugmentation, ‘The principle and technique of sinus elevation is relatively straightforward; however, the possibility of| postoperative complications exists and should be considered. The aim of this study was to evaluate in a popula- tion of patients with severe maxillary atiophy the prevalence of complications associated with maxi lary sinus augmentation. This study was carried out within a patient population scheduled to be treated under general anesthesia, All the patients selected for this study showed severe maxillary atrophy (class V using the Cawood and Howell classification: Twenty-six sinus lift procedures needed additional bone augmentation by autogenous onlay graft to ‘obtain better sagittal and/or vertical relationships and create more favorable conditions for the implant prosthetic rehabilitation. In 93 surgical pre cedures, sinus augmentation was performed with autogenous bone alone; in the remaining 31 proce: dures. a 1:1 mixture of autogenous bone and cortico: cancellous pig bone particles was used. Perforation of the sinus membrane has often been reported as the most comman intraoperative compl: cation in ease studies.!2”"4 Although the membrane perforation could represent a window for bacterial penetration and invasion into the grafted area, the authors did not find any correlation between the treat ment outcome and the subsequent implant failure fate. More recently, other authors” have suggested that a sinus membrane perforation laiger than 2 min coulel be associated with reduced bone formation and implant success compared to sites where the sinus membrane was not perforated. On the contrary, within the limits of this study population, the 31 sinuses with membrane perforation did not show any significant complications during the healing peried or at the time cof implant placement. It should be taken into consider ation that the current study was based on a radi graphic evaluation and prevalence of complications No comparative analysis was performed on the basis of histologic evaluation and implantsurvival rate. Cigarette smoking can now be strongly linked to several oral pathologies such as oral cancer, perio. dontal disease, leukoplakia, and stomatitis.20-22 Smoking has been shown not only to represent a sig nificant risk factor for periodontal diseace® but also 84 Volume 21, Number 1, 2008 to be anegative influence on healing following pet odontal and dental implant procedures.**?* Unil auly, the toxic effects of smoking were largely assigned 10 nicotine, However, some studies have suggested that other major components of cigarette light play a more important role than nico tine in mediating the deleterious effecis of smoking ‘on maiginal bone loss and, consequently, an per: ‘odontal health.” In spite of the number of studies showing the link between smoking and oral patholo gies.the biologic mechanisms by which cigarette use influences the pathogenesis of oval disease and the healing process are not yet fully understood. The findings of the present study ceaffirm that cigarette smoking Isa deleterious factor in oral surgery, since a greater rate of complications following maxillary sinus lifting was observed in smokers compared 10 onsmokers. In audition, It was also observed that the onlay bone graft procedure combined with the sinus fit operation significantly increased the rate of postoperative infective complications in the present population, Moreover, smoking and onlay bone graft treatment together were associated with a signif: cantly increased rate (P < .05) of complications fol lowing maxillary sinus augmentation, The present study does not provide any analysis of the mecha: nisms telated to complications in patients who smoke or receive onlay bone giafts; however, it could be speculated that factors such as systemic vasocon: striction, reduced blood flow, and polymorphons- clear leukocyte dysfunction are involved, ‘The present research showed no significant corre: lations between the occurrence of complications ard the type of filing material adopted in the maxillaty sinus augmentetion. Furthermore, it was observed that new bone formation took place within 6 montis of the sinus lift operation, No radiographic discrep: ancies in the amount of bone regenerated were observed between sinuses where only autogenous bone was used and those where a 1:1 mixture of autogenous bone and corticacancellous pig bone particles was used Cases of acute sinus infection were treated using drainage through the bony window and administra tion systemic antibiotics.In the 2 clinical cases where signs of infection persisted despite this treatment, the patients subsequently underwent an endoscopic inspection via the nasal cavity, which indicated a maxillary osteum obstruction, The obsteuction wos cleared with endoscopy, and a drainage was ‘obtained, As a result of this treatment, both patients made afullrecovery. The sinus lift operation has been generally consi ered to be a safe treatment with a low rate of compli: cations. Indeed, data from this study have shown a smoke surviv sinusei tion an The rer there Ince needed the ccc able car will und Finally designed evaluate REFERE 1. Boynep utogen 2 ent rating ra 3. un Gin Nor 4 Boma study en aie Ont 8. rong 0,0 fori essen 4 Curngha infection in Sur 20441 9. PoatheroM tateof tans |, amssee 10, Niedergetn camption | tolsavscoure- 1s and villary erved nth screp: ‘were enous ure of ‘bone using nistra- where ment. scopic ated a mn was e was atients onsid- ompli- own a survival tate of 94.3%, Of the 7 patients with infected sinuses, 5 underwent subsequent sinus augmenta- tion, and implant placement proceeded as planned. ‘The remaining 2 clinical patients declined any fur ther treatment. In conclusion, longer-term clinical studies are needed to identify the potential factors involved in the occurance of complications. Preselection of sult- able candidates for maxillary sinus augmentation will undoubtedly help reduce the incidence rate. 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