Dealing with complications

Case 1: Large perforation of the sinus membrane during sinus augmentation

It has been reported that membrane perforations are the most frequently encountered surgical complication when performing sinus augmentation procedures. Small perforations can usually be successfully managed using resorbable membranes (fig 1). However, large perforations are difficult to treat (fig 2). According to the literature, when perforations are larger than 10mm, implant survival rate drops significantly, from 97 to 74% (Hernández-Alfaro et al., 2008).

The speaker described the sinus augmentation procedure, during which they encountered a large perforation (20x20mm) when lifting the membrane. It appears that membrane elevation is the most critical step of these procedures (Stacchi et al., 2015). The speaker reflected that an inadequate osteotomy design made the surgical access more challenging, and this may be what ultimately lead to the tear in the delicate Schneiderian membrane.

Conventional treatment guidelines dictate that we suture the membrane. However, this is a difficult procedure and in fact often results in the tearing of the membrane and new perforations. However, the speaker described the technique of making a hole in the lateral bony wall near the surgical window. The hole is used as a window through which to pull the membrane with a suture thread, and thus reduce the size needing to be covered with a collagen membrane. With this technique, there is no need to suture the perforation completely, thereby avoiding inadvertently causing additional damage to the Schneider membrane. Compared with the conventional procedure (suturing the two sides of the membrane), the bony hole reduces the tension and facilitates suturing (fig 3–4).