TRANSCRIPT:

When performing sinus lifts, you will encounter complications. The most common complication that you need to be prepared for and understand how to manage is a sinus membrane perforation. Keep in mind that the sinus membrane is only about one to two millimeters thick in the absence of sinus pathology, so it's not a very thick soft tissue structure and that's why it's prone to perforation when manipulated.

We can classify sinus perforations based on their size. Sizes are usually classified as a three-millimeter or less perforation, a three to six-millimeter perforation, and then six millimeters or greater. In perforations that are less than three millimeters, many advocate that you don't need to do much of anything at all, that the sinus perforation is inconsequential. However, I feel like this is a little bit risky.

In my hands, anytime I see or notice a perforation, I do cover it, even a perforation less than three millimeters. When you have a perforation less than three millimeters, you will get some coverage of the perforation by the membrane itself, and what I mean by that is when you elevate and lift the membrane, the membrane will somewhat fold in on itself, and that redundancy can help cover the perforation that was created. However, I still like to cover that to prevent any graft material from spilling out.

As we've touched on, graft spilling out of the membrane can lead to many complications, including blockage of the osteomedial complex, so keeping that membrane intact is of vital importance in my opinion. So when I encounter a perforation less than three millimeters, in my practice, I cover the perforation with PRF. I feel that the PRF is adhesive, adheres easily to the perforation, covers it adequately, and prevents graft from spilling out.

Other options are covering it with collotape or even a collagen membrane. For perforations that are three to six millimeters, it is indicated that these have some type of coverage to prevent graft from spilling out. Most practitioners utilize a collagen membrane for this purpose. I also utilize a collagen membrane, but I will also utilize platelet-rich fibrin as well. Typically, I line the perforation itself with PRF and layer collagen membrane or collotape on top of that if needed.

If a perforation is larger than six millimeters, this is where things can become complicated and difficult. As the perforation increases in size, often up to a centimeter or more, the ability to wall that off and protect your graft from spilling out of the perforation becomes much more difficult and relies on a number of things, including the materials you have at hand and mostly your experience and comfort level with managing that level of a perforation.

My advice to new practitioners performing this procedure is that when your perforation gets much larger than six millimeters, you consider covering that with PRF, if available, as well as a collagen membrane, but stepping back and potentially stopping the procedure at that point, closing up shop, allowing that membrane to heal, and coming back and re-accessing the site in approximately six weeks and attempting the procedure again with an intact membrane.

If you're an experienced provider, there are options. Dr. Picos has an article for one that discusses repair of membrane perforations all the way up to 1.5 centimeters. I will say that his technique does take a lot of skill to perform and is not recommended for the beginning practitioner. However, there are options, depending on your skill level, that you can assess and research to develop the skill set needed to handle those sizes of perforations.

Even with as many sinus lifts as I perform, when I do have a situation where I have a large tear or a very large rip in the membrane, I myself cover that with PRF, a collagen membrane if needed, and I abort, and either don't perform the sinus lift and look for another option, or I come back in six weeks and retry with an intact membrane. It is difficult to repair those large membrane perforations, and you have to weigh the risk to benefit, as we know, of graft getting spilled outside the membrane.

We know that that complication can lead to many greater complications, blockage of the osteo-medial complex, sinusitis, and acute infection that just causes failure of the graft and inability to perform future implants. So keep those things in mind, but you will, I promise, encounter some level of membrane perforation, and you should become adept and comfortable with managing the small perforations intraoperatively so that you can confidently continue your graft.

Lesson Summary

When performing sinus lifts, it is common to encounter complications. The most common complication is a sinus membrane perforation. The sinus membrane is very thin, about 1 to 2 millimeters thick, making it prone to perforation when manipulated.

Sinus perforations can be classified based on their size:

• Three millimeters or less
• Three to six millimeters
• Six millimeters or greater

For perforations that are less than three millimeters, some advocate that no treatment is needed. However, it is recommended to cover the perforation to prevent graft material from spilling out. Options for covering include PRF, collotape, or a collagen membrane.

Perforations that are three to six millimeters should have some type of coverage to prevent graft spilling. A collagen membrane is commonly used, but platelet-rich fibrin (PRF) can also be used.

Perforations larger than six millimeters can be more difficult to manage. It is important to have experience and the proper materials on hand. If a perforation is very large, it may be necessary to abort the procedure, allow the membrane to heal, and attempt the procedure again with an intact membrane after approximately six weeks.

Repairing large membrane perforations can be challenging and carries risks. If a large tear or rip in the membrane occurs, covering it with PRF and a collagen membrane is recommended, and then deciding whether to continue the procedure or come back later. Graft material spilling outside the membrane can lead to complications such as blockage of the osteo-medial complex, sinusitis, and acute infection.

It is important to become adept and comfortable with managing small perforations intraoperatively to continue the graft confidently.