J Oral Maxillofac Surg

70:e592-e597, 2012

Novel Technique to Repair Maxillary

Sinus Membrane Perforations During
Sinus Lifting
Ali Hassani, DDS,*
Mohammad Hosein Kalantar Motamedi, DDS,
Sarang Saadat, DDS, Roya Moshiri, DDS, and
Solaleh Shahmirzadi, DDS
After the first report of maxillary sinus lifting in an
atrophic maxilla by Boyne and James,1 sinus lifting for
implant placement progressed rapidly to become an
established procedure in implantology. It is a predictable method used when augmenting the bone in the
posterior maxilla is necessary. The increase in sinus
lifting procedures and bone grafting for the purpose
of implant placement in the posterior maxilla has in
turn increased the rate of complications. The most
common complication during open sinus lifting is
perforation of the sinus membrane during surgery; if
left untreated, this may result in loss of graft material
into the sinus cavity, sinus infection, oroantral fistula,
and impairment of the physiologic function of the
antrum.2-5 Fugazzotto and Vlassis6 classified sinus
membrane perforations based on their location into 3
groups (class I, class II, and class III), and the second
group had 2 subgroups as well (Table 1).7,8 The most
common location of perforation is the apical wall of
the cavity (class I), followed by the mesial surface of
the lateral wall (class II). Sinus membrane perforations are usually classified based on 2 factors: perforation size and site.

The rate of sinus membrane perforation has been

reported to be as high as 58%, and it is more common
in cases where the membrane is too thin or septa are
present.9,10 Thus a method to manage this complication during surgery is warranted. This article introduces a new, simple, feasible and effective method to
manage sinus membrane perforations during sinus
lifting. This retrospective assessment of a technique
used to manage a complication was exempted by our
institutional review board.

Technique
After the surgeon accesses the maxillary antrum
and inadvertent sinus membrane perforation occurs
during sinus lifting, the initial step is to evaluate the
perforation size and determine whether materials
are needed for repair. After the occurrence of moderate to severe perforation (class I or II) of the sinus
membrane (class II, mesial wall) during sinus lifting, if the quality of the sinus membrane is acceptable, the membrane margins are gently released.
Then, 2 holes are made 3 to 4 mm from one another
by use of a fissure bur in the lateral wall near the
access window for class II perforations or in the
apical wall for class I perforations. Next, a No. 4-0
absorbable suture with a round needle is passed
through 1 of the cortical holes from the outer
surface into the sinus and then passed through 2
locations in the membrane (to reduce tension and
prevent membrane tearing). The suture then passes
through the other hole, exiting from inside the
sinus outward, and the knot is tied outside the sinus
cavity with a horizontal mattress technique (Figs
1-6); the sinus membrane abuts the bone as a result
of the tension applied. This way, the perforation is
closed, the integrity of the maxillary sinus floor is
maintained, and sinus lift can be resumed by bone
grafting and insertion of biomaterial under the sinus
membrane as required. For large perforations, it is
prudent to place a membrane or biological barrier
after this phase to ensure closure and prevention of

*Associate Professor, Department of Oral and Maxillofacial Surgery,

Azad University of Medical Sciences Dental Branch, Tehran, Iran.
Professor, Department of Oral and Maxillofacial Surgery,
Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
Private Practice in Dentistry, Tehran, Iran.
Private Practice in Dentistry, Tehran, Iran.
Private Practice in Dentistry and Member, Young Researchers
Club, Tehran, Iran.
Address correspondence and reprint requests to Dr Motamedi:
Shariati St., Roumi Bridge, Sharifi-manesh St., Adjacent to Akhtar
Hospital, #34, 5th Floor, Apt. 17, Tehran, 19647 Iran; e-mail:
Motamedical@lycos.com
2012 American Association of Oral and Maxillofacial Surgeons

0278-2391/12/7011-0$36.00/0
http://dx.doi.org/10.1016/j.joms.2012.06.191

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HASSANI ET AL

Table 1. FUGAZZOTTO AND VLASSIS6

CLASSIFICATION OF PERFORATIONS

Type of
Perforation
Class I
Class IIA
Class IIB

Class III

Description of Perforation
Produced in the most apical part of the
window
Produced along the lateral or coronal wall
of the window; the sinus extends 4 to
5 mm proximal to the perforation
Differs from the previously mentioned
classes because the perforation is
located at the limit of the maxillary
sinus; therefore the osteotomy cannot
be enlarged to expose intact membrane
Produced in any part within the window
extension

Hassani et al. Maxillary Sinus Membrane Perforation. J Oral

Maxillofac Surg 2012.

graft material from migrating into the sinus cavity.

Alternatively, buccal fat can be used for perforation
closure or as a barrier between the sinus membrane
and graft material. This fixation method can be used
along with a variety of materials.

implant placement in an atrophic maxillary ridge. Like

every other conventional treatment, sinus lifting has
its own risks and complications. The most common
potential complication of open sinus lift surgery is
sinus membrane perforation during the procedure,
which may result in leakage of graft material into the
sinus, sinus infection, oroantral fistula, and impairment of the physiologic function of the sinus if left
untreated.2-5 The risk of sinus membrane perforation
has been reported to be as high as 58%, especially
when the membrane is very thin or bone septa are
present.9,10 The most common factor that can cause
sinus membrane perforation is use of excessive force
when attempting to elevate the sinus membrane or
uncontrolled pressure applied on the instrument on 1
side of the area that has undergone osteotomy without adequate reflection or release of the membrane
periphery.7 In addition, anatomic variations can increase the risk of complications.8 These anatomic
variations and the associated risk of sinus membrane
perforations are as follows: thin membrane, 28%;
presence of septa, 22%; membrane adhesion, 17%;
previous surgery, 17%; presence of scar tissue, 11%;
and presence of cyst, 5%.11

Repair
Discussion
The growing popularity of implant treatment runs
hand in hand with procedural complications. One
example is sinus membrane perforation during treatment of the atrophic posterior maxilla, which makes
implant placement difficult. In 1980, Boyne and
James1 performed the first sinus lift procedure. Since
then, sinus lifting has been the treatment of choice for

In perforations smaller than 5 mm, the hole can

usually be readily closed by applying a direct suture, covering it with a collagen membrane, or
using fibrin tissue sealant with no extra measures.12-14 However, management of larger perforations requires application of other techniques. Various methods have been suggested in this regard,
such as use of fibrin tissue sealant, suturing the

FIGURE 1. Perforation of sinus membrane during sinus lift surgery.

Hassani et al. Maxillary Sinus Membrane Perforation. J Oral Maxillofac Surg 2012.

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MAXILLARY SINUS MEMBRANE PERFORATION

FIGURE 2. By use of a blunt instrument, the membrane is carefully and gently released. Two holes are made 3 to 4 mm from one another
with a fissure bur.
Hassani et al. Maxillary Sinus Membrane Perforation. J Oral Maxillofac Surg 2012.

hole, and placing a membrane to cover it.13-18 Some

researchers recommend to abort the procedure and
postpone it 6 to 9 months to let the sinus membrane heal.19 In contrast, many others believe that
the perforation can be managed efficiently using
graft materials placed at the same time of repair.20
Shin and Sohn21 repaired sinus membrane perforations by using fibrin adhesive simultaneous with
implant placement. Application of such substances
is indicated only for small perforations and not for
medium or large perforations. Pikos5 offered a
method for repair of sinus perforations. He created

4 notches in 4 corners of the membrane, adapted it

into the cavity, and used a tag to stabilize the
membrane. Testori et al10 introduced a method for
repair of large sinus perforations. They applied a
few stitches on the sinus wall and created a strut for
placement of membrane. However, membrane was
not attached to these sutures, and the stitches only
worked as a strut.
In general, suturing the 2 edges of the perforated
membrane inside the sinus or keeping them close
to each other for use of fibrin adhesive is not an
easy task. In contrast, fixing the perforated mem-

FIGURE 3. The suture enters through the first hole from outside, toward inside the cavity, and traverses the membrane. Suture passes through
another part of the membrane to reduce pressure.
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HASSANI ET AL

FIGURE 4. The suture exits through the second hole. After tension is applied, the membrane is placed adjacent to the bone.
Hassani et al. Maxillary Sinus Membrane Perforation. J Oral Maxillofac Surg 2012.

brane to the sinus wall is much easier because the

main part of the suturing will be performed outside
the sinus cavity and the margins of the perforated
membrane will be fixed to the bony sinus wall. In
our study 14 patients in whom perforations of maxillary sinus membrane developed and who were
treated using our technique were assessed; perforations developed after sinus lifting in 10, after
removal of impactions in 3, and after cyst removal
in 1. There were 6 perforation sites on the apical
part of the window (class I), 6 on the lateral part
(class II), and 2 within the window extension (class
III). Patients were followed up for a mean of 13.7

months (range, 12-18 months). Complications were

minor (Table 2).
Our technique is an easy, accessible, and predictable method used for sinus membrane perforations.
This technique helps the surgeon to easily manage the
situation.
Sinus membrane perforation is a common event
during sinus lift surgeries. Other operations not
related to implant placement may also be associated
with this complication. In such situations it is necessary to use a simple applicable method for the
management of this condition. Using the double
hole and suturing fixation method allows for safe

FIGURE 5. Suture is tied and the knot is tightened on the external sinus wall. The perforation has been completely closed.
Hassani et al. Maxillary Sinus Membrane Perforation. J Oral Maxillofac Surg 2012.

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MAXILLARY SINUS MEMBRANE PERFORATION

FIGURE 6. Sinus membrane augmented with buccal fat pad.

Hassani et al. Maxillary Sinus Membrane Perforation. J Oral Maxillofac Surg 2012.

Table 2. DISTRIBUTION OF PATIENTS TREATED FOR SINUS MEMBRANE PERFORATIONS

No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Perforation Type
I
I
I
I
I
I
II, mesial
II, mesial
II, mesial
II, mesial
II, mesial
II, distal
III
III

Cause of Perforation

Follow-Up

Complications

Sinus lifting process

Sinus lifting process
Sinus lifting process
Sinus lifting process
Removal of impact maxillary premolar
Removal of impact maxillary third
molar
Sinus lifting process
Sinus lifting process
Second maxillary molar extraction
Sinus lifting process
Sinus lifting process
Cyst
Sinus lifting process
Sinus lifting process

13 mo
14 mo
14 mo
18 mo
7 mo
7 mo

Sinusitis controlled using antibiotics

13 mo
12 mo
8 mo
13 mo
14 mo
12 mo
16 mo
12 mo

Hemorrhage from nose 1 d after surgery

Hassani et al. Maxillary Sinus Membrane Perforation. J Oral Maxillofac Surg 2012.

grafting, the use of membranes, and/or simultaneous implant placement without added complications.

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