Complications of Sinus Grafting and the Atrophic Maxilla

  • Ali Hassani
  • Omidreza Fazli salehi


Occlusal rehabilitation of the atrophic maxilla with dental implants poses a great challenge to both the surgeon and the prosthodontist. Disuse atrophy of the alveolar ridge might impede straight forward implantation, specifically in posterior maxilla where the quality of bone is of concern as well. Sinus grafting has been the go-to technique for placing dental implants in posterior maxilla when sinus pneumatization reduces the available alveolar bone height after tooth extraction. Also the advent of Zygomatic, pterygoid, trans-sinus, and ultrashort implants has enabled clinicians to entertain the possibility of immediate loading in edentulous maxilla as well as eliminating the need for grafting procedures. In the case of a severely atrophied maxilla and midface, bone augmentation using autogenous onlay and interpositional grafts might be the only solution if using zygomatic implants are hindered. Despite the significant success attained with the above mentioned techniques, each might lead to complications which the clinician should foresee and be prepared for.


Sinus elevation complications Membrane perforation Sinus infection Pseudocysts Zygomatic implants Implant migration 


  1. 1.
    Tatum H. Annual meeting of the Alabama Implant Study Group; 1977.Google Scholar
  2. 2.
    Brånemark PI, Gröndahl K, Öhrnell L. Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results. Scand J Plast Reconstr Surg Hand Surg. 2004;38:70–85.PubMedGoogle Scholar
  3. 3.
    Tulasne JF. Osseointegrated fixtures in the pterygoid region. In: Worthington P, Branemark PI, editors. Advanced osseointegration surgery: applications in the maxillofacial region. Chicago: Quintessence Publishing; 1992. p. 182–8.Google Scholar
  4. 4.
    Jensen OT, Cottam JR, Ringeman JL, Graves S, Beatty L, Adams MW. Angled dental implant placement into the vomer/nasal crest of atrophic maxillae for All-on-Four immediate function: a 2-year clinical study of 100 consecutive patients. Int J Oral Maxillofac Implants. 2014;29(1):e30–5.PubMedGoogle Scholar
  5. 5.
    Jensen OT, Cottam J, Ringeman J, Adams M. Trans-sinus dental implants, bone morphogenetic protein 2, and immediate function for all-on-4 treatment of severe maxillary atrophy. J Oral Maxillofac Surg. 2012;70(1):141–8.PubMedGoogle Scholar
  6. 6.
    Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implants. 2007;22(Suppl):49–70.PubMedGoogle Scholar
  7. 7.
    Misch CE. Contemporary implant dentistry. 3rd ed. St Louis: Mosby; 2008. p. 905–74.Google Scholar
  8. 8.
    Silvestre FJ, Perez-Herbera A, Puente-Sandoval A, et al. Hard palate perforation in cocaine abusers: A systematic review. Clin Oral Invest. 2010;14:621.
  9. 9.
    Moraschini, V., & Barboza E.dS.P. dS. P. (2016). Success of dental implants in smokers and non-smokers: a systematic review and meta-analysis. Int J Oral Maxillofac Surg, 45(2), 205–215.
  10. 10.
    Testori T, Drago L, Wallace S, Capelli M, Galli F. Prevention and treatment of postoperative infections after sinus elevation surgery: clinical consensus and recommendations. Int J Dentistry. 2012;2012:365809.Google Scholar
  11. 11.
    Kasabah S, Krug J, Simůnek A, Lecaro MC. Can we predict maxillary sinus mucosa perforation? Acta Med (Hradec Kralove). 2003;46(1):19–23.Google Scholar
  12. 12.
    Lin Y-H, Yang Y-C, Wen S-C, Wang H-L. The influence of sinus membrane thickness upon membrane perforation during lateral window sinus augmentation. Clin Oral Implants Res. 2015;27(5):612–7.PubMedGoogle Scholar
  13. 13.
    Cho SC, Wallace SS, Froum SJ, Tarnow DP. Influence of anatomy on Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis. Pract Proced Aesthet Dent. 2001;13(2):160–3.PubMedGoogle Scholar
  14. 14.
    Chan H-L, Monje A, Suarez F, Benavides E, Wang H-L. Palatonasal recess on medial wall of the maxillary sinus and clinical implications for sinus augmentation via lateral window approach. J Periodontol. 2013;84(8):1087–93. Scholar
  15. 15.
    Delilbasi C, Gurler G. Comparison of piezosurgery and conventional rotative instruments in direct sinus lifting. Implant Dent. 2013;22(6):662–5.PubMedGoogle Scholar
  16. 16.
    Ali SA, Karthigeyan S, Deivanai M, et al. Implant rehabilitation for atrophic maxilla: a review. J Indian Prosthodont Soc. 2014;14:196–207.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Nolan PJ, Freeman K, Kraut RA. Correlation between schneiderian membrane perforation and sinus lift graft outcome: a retrospective evaluation of 359 augmented sinus. J Oral Maxillofac Surg. 2014;72(1):47–52.PubMedGoogle Scholar
  18. 18.
    Fugazzotto PA, Vlassis J. A simplified classification and repair system for sinus membrane perforations. J Periodontol. 2003;74(10):1534–41.PubMedGoogle Scholar
  19. 19.
    Hassani A, Motamedi MHK, Saadat S, Moshiri R, Shahmirzadi S. Novel technique to repair maxillary sinus membrane perforations during sinus lifting. J Oral Maxillofac Surg. 2012;70(11):e592–7.PubMedGoogle Scholar
  20. 20.
    Proussaefs P, Lozada J. The “Loma Linda pouch”: a technique for repairing the perforated sinus membrane. Int J Periodont Restor Dent. 2003;23(6):593–7.Google Scholar
  21. 21.
    Solar P, Geyerhofer U, Traxler H, Windisch A, Ulm C, Watzek G. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res. 1999;10(1):34–44.PubMedGoogle Scholar
  22. 22.
    Danesh-Sani SA, Loomer PM, Wallace SS. A comprehensive clinical review of maxillary sinus floor elevation: anatomy, techniques, biomaterials and complications. Br J Oral Maxillofac Surg. 2016;54(7):724–30.PubMedGoogle Scholar
  23. 23.
    Kim S, Yun P, Kim Y. Clinical evaluation of sinus bone graft in patients with mucous retention cyst. Maxillofac Plast Reconstr Surg. 2016;38:35. Scholar
  24. 24.
    Gardner DG. Pseudocysts and retention cysts of the maxillary sinus. Oral Surg Oral Med Oral Pathol. 1984;58(5):561–7.PubMedGoogle Scholar
  25. 25.
    Mardinger O, Manor I, Mijiritsky E, Hirshberg A. Maxillary sinus augmentation in the presence of antral pseudocyst: a clinical approach. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2007;103(2):180–4.Google Scholar
  26. 26.
    Thio D, De S, Phelps PD, Bath AP. Maxillary sinus mucocele presenting as a late complication of a maxillary advancement procedure. J Laryngol Otol. 2003;117(5):402–3.PubMedGoogle Scholar
  27. 27.
    Kara İM, Küçük D, Polat S. Experience of maxillary sinus floor augmentation in the presence of antral pseudocysts. J Oral Maxillofac Surg. 2010;68(7):1646–50.PubMedGoogle Scholar
  28. 28.
    Chirilă L, Rotaru C, Filipov I, Săndulescu M. Management of acute maxillary sinusitis after sinus bone grafting procedures with simultaneous dental implants placement – a retrospective study. BMC Infect Dis. 2016;16(S1):94.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Sakakibara A, Suzuki H, Yamashita A, Hasegawa T, Minamikawa T, Furudoi S, Komori T. Facial emphysema after sinus lift. J Surg Case Rep. 2015;2015(6):rjv067.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Farina R, Zaetta A, Minenna L, Trombelli L. Orbital and periorbital emphysema following maxillary sinus floor elevation: a case report and literature review. J Oral Maxillofac Surg. 2016;74(11):2192.e1–7.Google Scholar
  31. 31.
    Barone A, Santini S, Sbordone L, Crespi R, Covani U. A clinical study of the outcomes and complications associated with maxillary sinus augmentation. Int J Oral Maxillofac Implants. 2006;21(1):81–5.PubMedGoogle Scholar
  32. 32.
    Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, Corrigan MD. Clinical practice guideline (update). Otolaryngol Head Neck Surg. 2015;152(4):598–609.PubMedGoogle Scholar
  33. 33.
    Manor Y, Mardinger O, Bietlitum I, Nashef A, Nissan J, Chaushu G. Late signs and symptoms of maxillary sinusitis after sinus augmentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2010;110(1):e1–4.Google Scholar
  34. 34.
    Pignataro L, Mantovani M, Torretta S, Felisati G, Sambataro G. ENT assessment in the integrated management of candidate for (maxillary) sinus lift. Acta Otorhinolaryngol Ital. 2008;28(3):110–9.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Chiapasco M, Felisati G, Zaniboni M, Pipolo C, Borloni R, Lozza P. The treatment of sinusitis following maxillary sinus grafting with the association of functional endoscopic sinus surgery (FESS) and an intra-oral approach. Clin Oral Implants Res. 2012;24(6):623–9.PubMedGoogle Scholar
  36. 36.
    Wen S-C, Lin Y-H, Yang Y-C, Wang H-L. The influence of sinus membrane thickness upon membrane perforation during transcrestal sinus lift procedure. Clin Oral Implants Res. 2014;26(10):1158–64.PubMedGoogle Scholar
  37. 37.
    Pommer B, Unger E, Sütö D, Hack N, Watzek G. Mechanical properties of the Schneiderian membrane in vitro. Clin Oral Implants Res. 2009;20(6):633–7.PubMedGoogle Scholar
  38. 38.
    Catros S, Montaudon M, Bou C, Da Costa Noble R, Fricain JC, Ella B. Comparison of conventional transcrestal sinus lift and ultrasound-enhanced transcrestal hydrodynamic cavitational sinus lift for the filling of subantral space: a human cadaver study. J Oral Implantol. 2015;41(6):657–61.PubMedGoogle Scholar
  39. 39.
    Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: a preliminary prospective study. Int J Oral Maxillofac Implants. 2002;17(4):557–66.PubMedGoogle Scholar
  40. 40.
    Ali S, Bakry SA, Abd-Elhakam H. Platelet-rich fibrin in maxillary sinus augmentation: a systematic review. J Oral Implant. 2015;41(6):746–53.Google Scholar
  41. 41.
    Chang T-P, Lin Y-W, Sung P-Y, Chuang H-Y, Chung H-Y, Liao W-L. Benign paroxysmal positional vertigo after dental procedures: a population-based case-control study. PLoS One. 2016;11(4):e0153092.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Sammartino G, Mariniello M, Scaravilli MS. Benign paroxysmal positional vertigo following closed sinus floor elevation procedure: mallet osteotomes vs. screwable osteotomes. A triple blind randomized controlled trial. Clin Oral Implants Res. 2010;22(6):669–72.PubMedGoogle Scholar
  43. 43.
    Von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman-Toker D. Benign paroxysmal positional vertigo: diagnostic criteria. J Vestibul Res. 2015;25(3–4):105–17.Google Scholar
  44. 44.
    Wolf JS, Boyev KP, Manokey BJ, Mattox DE. Success of the modified epley maneuver in treating benign paroxysmal positional vertigo. Laryngoscope. 1999;109(6):900–3.PubMedGoogle Scholar
  45. 45.
    Talaat HS, Kabel A-MH, Khaliel LH, Abuhadied G, El-Naga HAE-RA, Talaat AS. Reduction of recurrence rate of benign paroxysmal positional vertigo by treatment of severe vitamin D deficiency. Auris Nasus Larynx. 2016;43(3):237–41.PubMedGoogle Scholar
  46. 46.
    Stambolieva K, Angov G. Effect of treatment with betahistine dihydrochloride on the postural stability in patients with different duration of benign paroxysmal positional vertigo. Int Tinnitus J. 2010;16(1):32–6.PubMedGoogle Scholar
  47. 47.
    Galindo-Moreno P, Padial-Molina M, Avila G, Rios HF, Hernández-Cortés P, Wang H-L. Complications associated with implant migration into the maxillary sinus cavity. Clin Oral Implants Res. 2011;23(10):1152–60.PubMedGoogle Scholar
  48. 48.
    Gonzalez-Garcia A, Gonzalez-Garcia J, Diniz-Freitas M, Garcia-Garcia A, Bullon P. Accidental displacement and migration of endosseous implants into adjacent craniofacial structures: a review and update. Med Oral Patol Oral Cir Bucal. 2012;17(5):e769–74.PubMedPubMedCentralGoogle Scholar
  49. 49.
    Kluppel LE, Santos SE, Olate S, Freire Filho FWV, Moreira RWF, de Moraes M. Implant migration into maxillary sinus: description of two asymptomatic cases. Oral Maxillofac Surg. 2009;14(1):63–6.Google Scholar
  50. 50.
    Chiapasco M, Felisati G, Maccari A, Borloni R, Gatti F, Di Leo F. The management of complications following displacement of oral implants in the paranasal sinuses: a multicenter clinical report and proposed treatment protocols. Int J Oral Maxillofac Surg. 2009;38(12):1273–8.PubMedGoogle Scholar
  51. 51.
    Lim D, Parumo R, Chai MB, Shanmuganathan J. Transnasal endoscopy removal of dislodged dental implant: a case report. J Oral Implantol. 2017;43(3):228–31.PubMedGoogle Scholar
  52. 52.
    Higuchi KW. The zygomaticus fixture: an alternative approach for implant anchorage in the posterior maxilla. Ann R Australas Coll Dent Surg. 2000;15:28–33.PubMedGoogle Scholar
  53. 53.
    Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, et al. Extrasinus zygomatic implants: three year experience from a new surgical approach for patients with pronounced buccal concavities in the edentulous maxilla. Clin Implant Dent Relat Res. 2010;12(1):55–61.PubMedGoogle Scholar
  54. 54.
    Aparicio C. A proposed classification for zygomatic implant patients based on the zygoma anatomy guided approach (ZAGA): a cross-sectional survey. Eur J Oral Implantol. 2011;4(3):269–75.PubMedGoogle Scholar
  55. 55.
    Chrcanovic BR, Albrektsson T, Wennerberg A. Survival and complications of zygomatic implants: an updated systematic review. J Oral Maxillofac Surg. 2016;74(10):1949–64.PubMedGoogle Scholar
  56. 56.
    Peñarrocha M, Carrillo C, Boronat A, Martí E. Level of satisfaction in patients with maxillary full-arch fixed prostheses: zygomatic versus conventional implants. Int J Oral Maxillofac Implants. 2007;22(5):769–73.PubMedGoogle Scholar
  57. 57.
    Sartori EM, Padovan LEM, de Mattias Sartori IA, Ribeiro PD, Gomes de Souza Carvalho AC, Goiato MC. Evaluation of satisfaction of patients rehabilitated with zygomatic fixtures. J Oral Maxillofac Surg. 2012;70(2):314–9.PubMedGoogle Scholar
  58. 58.
    Molinero-Mourelle P, Baca-Gonzalez L, Gao B, Saez-Alcaide L, Helm A, Lopez-Quiles J. Surgical complications in zygomatic implants: a systematic review. Med Oral Patol Oral Cir Bucal. 2016;21(6):e751–7.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Bidra AS, Huynh-Ba G. Implants in the pterygoid region: a systematic review of the literature. Int J Oral Maxillofac Surg. 2011;40(8):773–81.PubMedGoogle Scholar
  60. 60.
    Balshi TJ, Wolfinger GJ, Slauch RW, Balshi SF. Brånemark system implant lengths in the pterygomaxillary region. Implant Dent. 2013;22(6):610–2.PubMedGoogle Scholar
  61. 61.
    Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation of the atrophic posterior maxilla with pterygoid implants: a review. J Oral Implantol. 2012;38(S1):461–6.PubMedGoogle Scholar
  62. 62.
    Choi J, Park H-S. The clinical anatomy of the maxillary artery in the pterygopalatine fossa. J Oral Maxillofac Surg. 2003;61(1):72–8.PubMedGoogle Scholar
  63. 63.
    Testori T, Mandelli F, Mantovani M, Taschieri S, Weinstein RL, Del Fabbro M. Tilted trans-sinus implants for the treatment of maxillary atrophy: case series of 35 consecutive patients. J Oral Maxillofac Surg. 2013;71(7):1187–94.PubMedGoogle Scholar
  64. 64.
    Jensen OT, Adams MW, Smith E. Paranasal bone: the prime factor affecting the decision to use transsinus vs zygomatic implants for biomechanical support for immediate function in maxillary dental implant reconstruction. Int J Oral Maxillofac Implants. 2014;29(1):e130–8.PubMedGoogle Scholar
  65. 65.
    Maló P, de Nobre M, Lopes A. Immediate loading of 'All-on-4′ maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol. 2013;6(3):273–83.PubMedGoogle Scholar
  66. 66.
    Yan Q, Wu X, Su M. Short implants (≤6mm) versus longer implant with sinus floor elevation in atrophic posterior maxilla: a systematic review and meta-analysis. BMJ Open. 2019;9:e029826.PubMedPubMedCentralGoogle Scholar
  67. 67.
    Atieh MA, Zadeh H, Stanford CM, Cooper LF. Survival of short dental implants for treatment of posterior partial edentulism: a systematic review. Int J Oral Maxillofac Implants. 2012;27(6):1323–31.PubMedGoogle Scholar
  68. 68.
    Carinci F, Farina A, Zanetti U, Vinci R, Negrini S, Calura G, Laino G, Piattelli A. Alveolar ridge augmentation: a comparative longitudinal study between calvaria and iliac crest bone grafts. J Oral Implantol. 2005;31(1):39–45.PubMedGoogle Scholar
  69. 69.
    Aghaloo T, Misch C, Lin G-H, Iacono V, Wang H-L. Bone augmentation of the edentulous maxilla for implant placement: a systematic review. Int J Oral Maxillofac Implants. 2017;31:s19–30.Google Scholar
  70. 70.
    Donovan MG, Dickerson NC, Hanson LJ, Gustafson RB. Maxillary and mandibular reconstruction using calvarial bone grafts and branemark implants: a preliminary report. J Oral Maxillofac Surg. 1994;52(6):588–94.PubMedGoogle Scholar
  71. 71.
    Sudhakar KN. Evaluation of donor site morbidity associated with iliac crest bone harvest in oral and maxillofacial, reconstructive surgery. J Clin Diagn Res. 2017;11(6):ZC28–33.PubMedPubMedCentralGoogle Scholar
  72. 72.
    Putters TF, Wortmann DE, Schortinghuis J, van Minnen B, Boven GC, Vissink A, Raghoebar GM. Morbidity of anterior iliac crest and calvarial bone donor graft sites: a 1-year randomized controlled trial. Int J Oral Maxillofac Surg. 2018;47(11):1474–80.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Ali Hassani
    • 1
  • Omidreza Fazli salehi
    • 2
  1. 1.Department of Oral and Maxillofacial Surgery, Head of Dental Implant Research CenterTehran Dental Branch, Tehran Medical Sciences, Islamic Azad UniversityTehranIran
  2. 2.DDS, Resident at Department of Oral and Maxillofacial SurgeryTehran Dental Branch, Buali Hospital, Islamic Azad UniversityTehranIran

Personalised recommendations