Sinus Perforation after tooth extraction or sinus perforation during implant placement?

Sinus perforation is a known and fairly common complication for tooth extractions in the maxilla and for dental implant placement there as well.

Test for sinus perforation.

Sometimes with proper magnification and lighting you can visually see the perforation or perhaps during the surgery you saw the perforation occur. If not you can use the valsalva maneuver. To be successful you need some sort of fluid to be in the extraction socket. Often times this fluid is blood; however, if the socket is dry you need to either add a small amount of saline or agitate the soft tissue to elicit some bleeding.

Inform the patient that you need to check if the sinus membrane is patent by having them try to blow through their nose while you plug it. They won’t know what you are talking about but that is fine for now. Then firmly plug their nose and ask them to try to blow air out their nose.  While this is occurring check the tooth socket for bubbles. Tell them to stop blowing before you let go of their nose so you don’t end up with snot all over the place. Bubbles mean there is a perforation; however, no bubbles does not necessarily mean that there was not a perforation.

Sinus perforation protocol for tooth extractions.

Small sinus perforation is 1-2mm.

• You can usually simply allow the blood clot to close the perforation.
• Place a gelfoam or something similar in the socket.
• Suture the extraction site.
• Patient is to follow standard sinus precautions
• Place the patient on amoxicillin 500mg tid 7 days and Sudafed or Claritin-D
• Consider Omnicef/cefdinir

Large sinus perforation – consider referral to someone comfortable with lateral sinus lifts

• Primary Closure with longer lasting suture like PTFE
• Place a gelfoam or something similar in the socket.
• Patient is to follow standard sinus precautions
• Place patient on amoxicillin 500mg tid 7 days and Sudafed or Claritin-D

Sinus perforation during implant placement

There are several schools of thought on this from abort procedure to ignore and place the dental implant. If you can do a lateral window then repair the sinus perforation with a large collagen membrane, this is Pikos method. Pathological changes, such as mucosal thickening and antral pseudocycsts, in the schneiderian membrane reduce risk of perforation and do not have a negative impact on implant survival according to Fang 2022 JOI review.

Standard sinus precautions for a sinus perforation.

1. DO NOT rinse with anything today.  Starting tomorrow, gently rinse with a warm saltwater solution 2-3 times daily for the next week.
2. DO NOT eat anything hot (temperature), spicy, and/or coarse/hard foods for the next week.  Eat a soft diet and chew on the opposite side as much as possible.
3. NO SMOKING for one week; at least decrease amount or frequency as much as possible.
4. When brushing your teeth, avoid the surgical area(s) and especially the gums. Do NOT use a waterpik for 3 weeks.
5. For the next week.  DO NOT spit, DO NOT drink from a straw, and, DO NOT “suck” on the wound site or candy.
6. DO NOT blow your nose and DO NOT sneeze through your nose, rather if the urge to sneeze arises, sneeze with your mouth open.
7. You can NOT play any wind instrument for one week.