DENTAL IMPLANTS

J Oral Maxillofac Surg

66:1426-1438, 2008

Anatomical and Surgical Findings and

Complications in 100 Consecutive
Maxillary Sinus Floor
Elevation Procedures
Steven A. Zijderveld, DDS, MD,*
Johan P.A. van den Bergh, DDS, PhD,
Engelbert A.J.M. Schulten, DDS, MD, PhD, and
Christiaan M. ten Bruggenkate, DDS, MD, PhD
Purpose: To investigate the prevalence of anatomical and surgical findings and complications in

maxillary sinus floor elevation surgery, and to describe the clinical implications.
Patients and Methods: One hundred consecutive patients scheduled for maxillary sinus floor elevation were included. The patients consisted of 36 men (36%) and 64 women (64%), with a mean age of
50 years (range, 17 to 73 years). In 18 patients, a bilateral procedure was performed. Patients were
treated with a top hinge door in the lateral maxillary sinus wall, as described by Tatum (Dent Clin North
Am 30:207, 1986). In bilateral cases, only the first site treated was evaluated.
Results: In most cases, an anatomical or surgical finding forced a deviation from Tatums standard procedure. A thin or thick lateral maxillary sinus wall was found in 78% and 4% of patients, respectively. In 6%, a
strong convexity of the lateral sinus wall called for an alternative method of releasing the trapdoor. The same
method was used in 4% of cases involving a narrow sinus. The sinus floor elevation procedure was hindered
by septa in 48%. In regard to complications, the most common complication, a perforation of the Schneiderian membrane, occurred in 11% of patients. In 2%, visualization of the trapdoor preparation was compromised
because of hemorrhages. The initial incision design, ie, slightly palatal, was responsible for a local dehiscence in 3%.
Conclusion: To avoid unnecessary surgical complications, detailed knowledge and timely identification
of the anatomic structures inherent to the maxillary sinus are required.
2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:1426-1438, 2008
Maxillary sinus floor elevation with autogenous or
synthetic grafting material has proven to be a reliable
method that enables the insertion of endosseous implants in patients with a severely resorbed maxilla.
*Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery, Free University Medical Center/Academic Center
for Dentistry Amsterdam, Amsterdam, and St Antonius Hospital,
Nieuwegein, The Netherlands.
Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery, Free University Medical Center/Academic Center
for Dentistry Amsterdam, Amsterdam, and St Antonius Hospital,
Nieuwegein, The Netherlands.
Associate Professor, Department of Oral and Maxillofacial Surgery, Free University Medical Center/Academic Center for Dentistry Amsterdam, Amsterdam, The Netherlands.

The classical sinus floor elevation consists of a top

hinge door in the lateral maxillary sinus wall, as
invented by Tatum,1 but first described by Boyne
and James 1980.2 The variety of anatomical modalProfessor, Department of Oral and Maxillofacial Surgery,
Free University Medical Center, Academic Center for Dentistry
Amterdam, Amsterdam, and Rijnland Hospital, Leiderdorp, The
Netherlands.
Address correspondence and reprints requests to Dr Zijderveld:
Department of Oral and Maxillofacial Surgery, St Antonius Hospital,
Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; e-mail:
s.zijderveld@antonius.net
2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6607-0016$34.00/0
doi:10.1016/j.joms.2008.01.027

1426

1427

ZIJDERVELD ET AL

ities in the shape of the inner aspect of the maxillary sinus defines the surgical approach.3 Van den
Bergh et al described a number of anatomical considerations.3
Several studies described separate anatomical findings, such as blood supply to the lateral wall, sinus
shape, and sinus septa4-11 (Table 1). To the best of our
knowledge of the literature, this is the first prospective study with regard to most of the anatomical
findings during 100 consecutive maxillary sinus floor
elevation procedures. To avoid unnecessary surgical
complications, detailed knowledge and timely identification of the anatomic structures inherent to the
maxillary sinus are required. The aim of the present
study was to investigate the prevalence of different
anatomical findings and complications in maxillary
sinus floor elevation procedures, and to describe the
clinical implications.

Patients and Methods

For this prospective study, 100 consecutive patients scheduled for maxillary sinus floor elevation
were included. The patients consisted of 36 men
(36%) and 64 women (64%), with a mean age of 50
years (range, 17 to 73 years). In 18 patients, a bilateral
procedure was performed. All sinus floor elevations
were performed by the same surgeon.
Only the first unilateral site was evaluated according to the anatomical findings and complications. All
patients were treated in the Department of Oral and
Maxillofacial Surgery, Free University Medical Center
(Amsterdam, The Netherlands), or at the Rijnland
Hospital (Leiderdorp, The Netherlands). Directly after
each sinus floor elevation procedure, a standard
checklist was filled out, according to predefined criteria.
Patients were treated with a sinus floor elevation
technique according to Tatum, ie, an osteotomy of
the lateral wall of the maxillary sinus.1 Patients treated
with a less invasive surgical approach for maxillary
sinus elevation (the transalveolar approach, as described by Summers12) were excluded from this
study.
In cases with a bilateral procedure, it was decided
to evaluate only the first unilateral site. Patients were
evaluated according to anatomical findings, with surgical relevance related to the maxillary sinus floor
elevation, and to complications. Anatomical findings
such as septa or perforations could only be counted
once per patient. Surgical observations that called for
unforeseen and additional measurements, such as
membrane perforations or hemorrhages, were also
counted as complications, regardless of eventual healing. In regard to complications, the follow-up period
was restricted to an osseointegration time of 3

months after implant placement, and in this study, no

observations were performed subsequent to implant
failures.

Results
In most cases, an anatomical or surgical finding
forced a deviation from the standard procedure of
Tatum.1 A thin or thick lateral maxillary sinus wall
was found in 78% and 4% of patients, respectively.
In these cases, the initial trapdoor preparation differed. The lateral wall was defined as thin if, after
reflection of the mucoperiosteum, the Schneiderian
membrane already shone dark grayish-bluish through
the sinus wall. A maxillary sinus wall was considered
thick if it measured at least 2.3 mm, which was similar
to the diameter of the stainless steel burr.
In cases of strong convexity of the lateral maxillary
sinus wall, the inward and upward rotation of the
fractured door can easily lead to a mucosa tear at the
cranially placed trapdoor osteotomy. If the authors
observed this risk factor when releasing the trapdoor,
the lateral wall was scored as convex.
In 6% of patients, a strong convexity of the lateral
sinus wall called for an alternative method of releasing
the trapdoor. The same method was used in 4% of
patients with a narrow sinus. The prepared door was
converted into a hatch, mobilized on four sides and
carefully lifted upward. A wide sinus, observed in 7%
of patients, may lead to underfilling, so that the estimated bone height appears not to be the true bone
height, leading to perforation of the implant into the
sinus. The authors observed that the method of Tatum1
was hindered by septa in 48% of cases. Inversion of the
bone plate was complicated by these septa. The septa
were left intact, and the contour of the sinus was followed by making a W-shaped trapdoor preparation or 2
separated doors. In 5 cases, this alternative procedure
resulted in a membrane perforation at the location of the
septa. The perforations were then covered with a
resorbable barrier membrane, and because of this
proper surgical measurement, the perforations had no
negative effect on the eventual outcomes of the procedures. In all 5 cases, the healing was not compromised.
The prevalences of different anatomical findings are
listed in Table 2. We found no significant differences
with regard to gender or age.
With regard to complications, the most common
complication, perforation of the Schneiderian membrane, occurred in 11% of patients. As already mentioned, 5 perforations occurred in relation to septa, and
4 additional perforations were the result of extension
mesially when releasing the Schneiderian membrane,
because of poor visibility. The direct connection between the sinus and oral mucosa was the cause in one
case of a membrane perforation, occurring directly after

1428

Table 1. ANATOMICAL STUDIES AND FINDINGS IN RELATION TO SINUS FLOOR AUGMENTATION PROCEDURES

Reference
Ulm et al, 199516

Purpose

Study Design

41

Prevalence and localization of septa

Cadaver study

65
200

Prevalence of septa
Morphology of septa

Clinical examination
CT scan

Krennmair et al, 19999

194

Prevalence and location of septa

CT scan versus
panoramic x-ray

Velasquez-Plata et al, 200222

312

Prevalence and morphology of

septa

CT scan

Kim et al, 200620

100

Prevalence and morphology of

septa

CT scan

Cho et al, 200117

59

Influence of sinus anatomy on

membrane perforation

Proussaefs et al, 200427

24

Effect of repair on perforated sinus

membrane

Shlomi et al, 200425

73

Incidence of membrane perforation

and influence on clinical
outcomes
Significance of membrane
perforation
Examination of vascularization of
the lateral maxilla

CT scan in correlation
with experienced
perforation rate
Human study, splitmouth design,
histomorphometry
Clinical and
radiographic

Ardekian et al, 200628

110

Solar et al, 19995

18

Elian et al, 20054

50

Distribution of maxillary artery

Uchida et al, 19987

38

Measurement of sinus volumes for

bone grafting

Clinical
Cadaver study
CT scan, intraosseous
artery of lateral
maxilla
CT scan and sinus
floor simulation

Abbreviation: CT, Computed tomography.

Zijderveld et al. Complications in Maxillary Sinus Floor Elevation Procedures. J Oral Maxillofac Surg 2008.

Prevalence 31.7%
Most septa (73.3%) in bicuspid region
Prevalence 27.7%
Prevalence 16.0%
Significantly greater dimension of septa in nonatrophic
maxillary regions
Prevalence significantly greater in atrophic maxillae than
in dentate regions
Panoramic x-ray less sensitive and specific than CT scan
Prevalence 24%, prevalence significantly greater in
edentulous maxillas; most in middle region, at mean
heights of 7.59, 5.89, and 3.54 mm in lateral, middle,
and medial areas, respectively
Prevalence, 26.6%; 50.8% in the middle region; mean
heights of 1.63, 2.44, and 5.46 mm in lateral, middle,
and medial areas, respectively
Perforation most frequently in narrow sinus
Perforated sites result in reduced bone formation in
relation to nonperforated sites (33.5% vs 14.1%), and
reduced implant survival rates (69.5% vs 100%)
Incidence of 28%, no statistically significant difference in
survival rate (90% vs 91% in control group) and ridge
height pre- and postsurgery
Incidence of 32%, more frequently with low height of
residual ridge, no difference in success rates
Prevalence of intraosseous artery lateral maxilla, 100%;
mean distance between intraosseous anastomosis in
lateral maxilla and alveolar ridge, 19 mm
Prevalence of 52%, mean distance of 16 mm from
alveolar crest
Mean volume of inferior portion of the sinus, 4.02 cm3
for 15-mm lifting, and 6.19 cm3 for 20-mm lifting

COMPLICATIONS IN MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

Krennmair et al, 199718

Conclusions

1429

ZIJDERVELD ET AL

Table 2. ANATOMIC FINDINGS IN 100

CONSECUTIVE MAXILLARY SINUS FLOOR
ELEVATION PROCEDURES

Thin lateral sinus wall

Thick lateral sinus wall
Convex lateral sinus wall
Connection of Schneiderian membrane and
oral mucosa
Narrow sinus
Wide sinus
Sinus septa
Longitudinal sinus septum
Root-shape configurations

78%
4%
6%
2%
4%
7%
48%
2%
4%

Zijderveld et al. Complications in Maxillary Sinus Floor Elevation

Procedures. J Oral Maxillofac Surg 2008.

reflection of the mucoperiosteum. Fortunately, this perforation remained relatively small. In 1 perforation, no
anatomical explanation could be given. The perforations
were all covered with a barrier membrane, and the
eventual healing was uneventful.
In 2% of patients, visualization of the trapdoor preparation was compromised because of hemorrhages. In
our study group, only 1 patient developed postoperative maxillary sinusitis. This patient had no preoperative risk factors, such as sinus pathology in the past,
nor a perioperative perforation of the Schneiderian
membrane.
The initial incision design, ie, slightly palatal, was
responsible for local dehiscence in 3% of patients. In 2
patients with local wound dehiscence, graft infection
was observed along with a purulent discharge, and was
treated by antibiotic therapy and local debridement. The
dehiscence healed by secondary granulation.
At the time of implantation in 1 patient, the sinus
cavity was reached after drilling to a depth of 8 mm,
indicating a partial loss of the graft. This patient
showed no signs of infection, and in particular, no
maxillary sinusitis in the time of healing after elevation. As an alternative explanation for this finding, the
Schneiderian membrane was probably not elevated as
far as the medial wall, resulting in underfilling with
graft material of the created space.

FIGURE 1. Pneumatization of maxillary sinus after tooth loss,

probably caused by reinforcement of osteoclastic activity of the
Schneiderian membrane.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

In 4 different patients, 4 implants were lost during

the osseointegration period of 3 months. In a total of
243 implants placed, this was equivalent to 1.6%. We
could not find any relationship to the remaining crest

Table 3. COMPLICATIONS IN 100 CONSECUTIVE

MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

Perforation of Schneiderian membrane

Perioperative hemorrhages
Postoperative hemorrhages
Postoperative maxillary sinusitis
Local wound dehiscences
Graft infections
Loss of graft
Loss of implants

11%
2%
0%
1%
3%
2%
1%
4%

FIGURE 2. A, In cases of a thin maxillary sinus wall, after reflection of the mucoperiosteum, the Schneiderian membrane already
shines a dark grayish-bluish through the lateral sinus wall. B, The
lateral door preparation is made directly with a round diamond
burr, without use of a stainless-steel burr.

Zijderveld et al. Complications in Maxillary Sinus Floor Elevation

Procedures. J Oral Maxillofac Surg 2008.

Zijderveld et al. Complications in Maxillary Sinus Floor Elevation

Procedures. J Oral Maxillofac Surg 2008.

1430

COMPLICATIONS IN MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

FIGURE 3. Schematic drawing of the thinning out of a thick lateral

wall for the purpose of a good visualization of the inner aspect of
the bony sinus.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

of the native maxilla. In none of these patients did any

other complication, as mentioned in this study, occur.
Complications are listed in Table 3.

Discussion
ANATOMICAL FINDINGS

Thin or Thick Lateral Maxillary Sinus Wall

After loss of the maxillary teeth and reduction of the
masticatory forces acting on the maxilla, the sinus wall
gradually becomes thinner as a result of the increased
size (or volume) by pneumatization of the maxillary
sinus.13 The duration of edentulism is decisive for the
extent of alveolar-ridge resorption and antral pneumati-

zation of the alveolar process.14 Increased antral pneumatization starting after tooth loss seems to result especially from the basal bone loss caused by a
reinforcement of osteoclastic activity of the Schneiderian membrane (Fig 1).15 In extreme cases, only a paperthin lamella of bone separates the maxillary sinus from
the oral cavity after long-term edentulism.16
In cases of a very thin maxillary sinus wall, careful
reflection of the mucoperiosteum is recommended,
while the Schneiderian membrane already shines dark
grayish-bluish through the sinus wall (Fig 2A). Reflection of the mucoperiosteum with sharp instruments
can already cause a perforation of the sinus wall and
the Schneiderian membrane. In the present study,
after reflection of the mucoperiosteum, this transparent, dark aspect was observed in 78% of cases. Because of the risk of perforation of the Schneiderian
membrane during lateral door preparation in these
cases, it is advised not to begin the lateral door preparation with a round stainless-steel burr, but to use a
round diamond burr directly, and thus reduce the risk
of a membrane perforation (Fig 2B).
If the lateral wall consists of thick bone, the whole
lateral wall should be thinned out (Fig 3). When the
stainless-steel burr, with a diameter of 2.3 mm, totally
filled the lateral osteotomy (Fig 3), this alternative
procedure was followed. Otherwise, it would be extremely difficult to mobilize the Schneiderian membrane from the inner aspect of the bony sinus, because instruments cannot reach this tissue due to a
deep cleft-like approach.3
Convex Lateral Sinus Wall
In 6% of the patient population in this study, the
convexity of the lateral maxillary sinus wall called for

FIGURE 4. A profound convexity of the maxillary sinus wall sometimes required an alternative trapdoor preparation.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation Procedures. J Oral Maxillofac Surg 2008.

ZIJDERVELD ET AL

1431

FIGURE 7. Absence of the lateral maxillary sinus wall, because of

previous sinus surgery (a Caldwell-Luc procedure). This is a contraindication for sinus floor elevation. R, right; P, posterior.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

FIGURE 5. A, Patient with a convexity of the lateral sinus wall. B,

The prepared door was mobilized on 4 sides and lifted upward.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

an alternative trapdoor luxation (Fig 4). In normal

cases, the procedure consists of the preparation of a
top hinge door in the lateral maxillary sinus wall. In
cases of a convex lateral sinus wall, the inward and
upward rotation of the fractured door can easily lead
to a mucosa tear at the cranially placed trapdoor

FIGURE 6. Perforation immediately after reflection of the mucoperiosteum, because of direct contact of the sinus mucosa with the
oral mucosa.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

osteotomy. Therefore, in cases of profound convexity

of the maxillary sinus wall, an alternative approach is
advisable, in which the prepared door is converted to
a hatch, mobilized on 4 sides and carefully lifted
upward to a horizontal position in the maxillary sinus
(Figs 5A,B). Alternatively, the trapdoor preparation
can be placed medial to the convexity of the lateral
sinus wall, tunneling farther in a distal direction, although this creates a higher risk of perforating the
Schneiderian membrane.
Connection Between the Schneiderian
Membrane and Oral Mucosa
When the alveolar bone is totally absent in some
places (because of resorption or traumatic bone loss
after tooth extraction, eg, sinus perforation), the sinus
mucosa may be in immediate contact with the oral
mucosa. This is a very difficult condition, in which the
Schneiderian membrane cannot usually be kept intact
(Fig 6). It may lead to large perforations at very difficult sites, making any further preparation impossible.3
Previous sinus surgery (eg, a Caldwell-Luc procedure) sometimes constitutes a contraindication for
maxillary sinus floor elevation, because anatomical
disconfigurations do not allow for the preparation of
intact, healthy mucosal tissue (Fig 7). In cases of
previous sinus operations, a preoperative computed
tomography (CT) scan can be helpful in demonstrating this condition.
The Narrow and Wide Sinus
Until the eruption of permanent teeth, the sinus
cavities are insignificant in size. The development of
the maxillary sinus is a dynamic, active procedure
when 2 conditions apply: a slight, positive intrasinus
pressure, and good physiology of the mucosal sinus

1432

COMPLICATIONS IN MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

membrane, which should be supple and easy to expand, as well as capable of bone resorption and thinning the sinus wall. This is in line with the presence
of osteoclasts found in the maxillary sinus, as the
osteoclastic activity is jointly responsible for the resorption and thinning of the sinus wall.15
There is a wide range in sizes and shapes of maxillary sinuses. In a study by Uchida et al,7 maxillary
sinus volumes were measured using CT images of 38
sinuses and a 3-dimensional reconstruction system.
The average total maxillary sinus volume was 13.6
6.4 cc. The minimum maxillary sinus volume was 3.5
cc, and the maximum was 31.8 cc.7
The size of the sinus, and especially the angulation
between the medial and lateral walls of the maxillary
sinus, seemed to exert a large influence on the incidence of membrane perforation during maxillary sinus floor elevation. The sharper angles observed at
the inner walls of the sinus at the sites of the second
upper bicuspid presents a higher risk of perforation.
The angulation will influence the feasibility of the
sinus floor during elevation. Group 1 of Cho et al17
consisted of specimens with an angle of 30 or less,
group 2 consisted of specimens with angles between
31 and 60, and group 3 consisted of specimens with
angles of 61 or greater. The different groups demonstrated significant correlation with the observed perforations. The perforation rates were 37.5% (group 1),
28.6% (group 2), and 0% (group 3).17 The sites of the
first upper molars are the least difficult areas.8,17 In
the present study, 4 patients had a narrow maxillary
sinus that required an alternative surgical approach.
The most reliable method in terms of being preoperatively informed about the size and shape of the
maxillary sinus is a CT scan. With a preoperative CT
scan, a narrow maxillary sinus can be anticipated.
One way to circumvent the problem of a narrow sinus
is by performing an antrostomy in the lateral wall
instead of a door preparation. In this situation, however, the sturdy bone support and a new floor of the
sinus will be absent, and the one bone-inductive element for the bone graft will fail. Alternatively, the
prepared door can be converted into a hatch, mobilized on all 4 sides and carefully lifted (pedunculated
only to the sinus mucosa) upward to a higher position
in the maxillary sinus, where the lateral sinus dimensions are larger (Figs 8A,B).3 In such cases, it is advised to make an all-around preparation, to minimize
the risk of perforating the Schneiderian membrane. In
all 4 cases in the present study, this alternative surgical method was chosen.
In cases of a wide maxillary sinus, it is recommended to make a large door preparation, and lift the
door to a high position cranially. However, without a
preoperative CT scan, the surgeon is mostly uninformed about this possibility. Especially in a wide

FIGURE 8. Axial computed tomography scan (A) and schematic

drawing (B) of the narrow maxillary sinus. The prepared door can
be converted into a hatch, mobilized on all 4 sides, and carefully
lifted (pedunculated only to the sinus mucosa) to a higher position
in the maxillary sinus. Arrows indicate the direction in which the
trapdoor should be displaced.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

sinus, there is a risk of underfilling the recipient site

with grafting material if elevation of the membrane
has not been continued as far as the medial wall. This
underfilling might lead to later complications, if the
estimated bone height appears not to be the true
bone height during implant surgery, leading to perforation of the implant into the sinus (Fig 9).
Maxillary Sinus Septa
The presence of septa increases the risk of sinus
membrane perforation during sinus floor elevation
procedures. This anatomic variation was first described by Underwood in 1910,11 and therefore is
sometimes referred to as Underwoods septa. In an
anatomical study, Underwood11 found 30 septa in 90

ZIJDERVELD ET AL

1433
bony wall into an anterior and a posterior part of the
hinge door, and inverted both trapdoors.
The present authors suggest following the contour
of the sinus floor by making a W-shaped preparation
in smaller septa, or 2 separate doors (Figs 11A-C).3
Another option would involve an antrostomy approach.24

FIGURE 9. In a wide sinus, seen on this axial computed tomography scan, there is a risk of underfilling if the elevation of the
membrane has not been continued as far as the medial maxillary
sinus wall.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

maxillary sinuses, showing a prevalence of 33%. The

incidence of antral septa varies between 16% and
58%.9 The prevalence of septa was significantly
greater in atrophic edentulous regions than in dentate
regions. Krennmair et al9,18 hypothesized that if teeth
are gradually lost, atrophy begins at different times in
different regions. They classified septa into primary
(which arise from the development of the maxilla)
and secondary (which arise from irregular pneumatization of the maxillary sinus floor after tooth loss).
Because maxillary molars are often lost earlier than
are premolars, the different phases of maxillary sinus
pneumatization result in the formation of antral septa.
Hence Krennmair et al9,18 stated that 70% of antral
septa were found in the anterior region. Stover criticized these conclusions, stating a greater prevalence
of septa in the posterior segments results from remnant interradicular bone between adjacent maxillary
molars.19
The prevalence of primary septa was found to be
significantly higher.9,20-22
The average height of medial insertions was greater
than that of the lateral insertions. In other words,
septal height increased from lateral to medial insertions. This can complicate the inversion of the bone
plate or lateral door.
Panoramic radiography has less sensitivity and
specificity than CT scanning for the detection of sinus
septa (Fig 10). Krennmair et al9 reported a falsepositive or negative diagnosis regarding the presence
of antral septa in 21.3% of cases.
In instances where septa are encountered on the
sinus floor, Boyne and James2 recommended cutting
them with a narrow chisel and removing them with a
hemostat, so that the bone graft can be placed over
the entire antral floor. Tidwell et al23 subdivided the

Longitudinal Septum
Elevation of the Schneiderian membrane is a timeconsuming procedure. In most cases, upon reaching
the floor of the maxillary sinus, visibility improves,
accelerating the procedure.
However, in 2 cases, a horizontal and longitudinal
rim was encountered, in mesiodistal or sagittal direction instead of the usual transversal septa, halfway
between the sinus floor and medial wall. Because of
this unexpected rim, there was a risk of perforating
the membrane while shooting out with an elevation
instrument. In contrast to a root-shape configuration,
this rim is located along the full length of the sinus
floor (Fig 12).
Root-Shape Configurations
Root-shape configurations, found in 4 patients of
the study group, can be expected when teeth have
been extracted recently (Fig 13). In 2 of 4 cases, the
separation of the Schneiderian membrane caused a
perforation at this particular location. If possible, sinus floor elevation should be delayed for at least 6
months after extraction of the teeth when root-tip
expressions in the maxillary sinus are clearly visible
on a panoramic radiograph.

FIGURE 10. The coronal computed tomography scan has a high

sensitivity and specificity for the detection and localization of sinus
septa.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

1434

COMPLICATIONS IN MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

FIGURE 11. A, B, The suspected sinus septa on the antral floor is left in situ and visualized by making 2 trapdoors. C, When elevated, the
Schneiderian membrane is at risk of being torn, particularly at the cranial edge of the septum. A membrane is placed to cover the perforation.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation Procedures. J Oral Maxillofac Surg 2008.

SURGICAL FINDINGS

Maxillary Sinus-Membrane Perforation

Sinus-membrane perforation is the most prevalent
complication of sinus floor elevation procedures (10%
to 60%).25-28 Anatomic as well as technical factors
have been implicated in membrane perforation. The
integrity of the sinus membrane is essential in maintaining the healthy, normal function of the maxillary
sinus. The mucociliary apparatus protects the sinus
against infection by removing organisms trapped in
mucus through the ostium. The membrane also acts
as a biologic barrier, and an increased chance of
infection results if the biologic barrier (the membrane) perforates because a greater number of bacteria can invade the graft. Possible causes of perforation
include tearing of the membrane during window osteotomy or with an infracture of the bony window,
elevation of the membrane, the presence of septa,
and overfilling with graft material.26 Documented risk
factors include irregularities of the sinus floor, root
formations, previous sinus surgery (scar tissue), and
a lower height of the residual alveolar crest.3,28
Ardekian et al28 reported that in residual ridges of 3
mm, a perforation of the sinus membrane occurred
in 85% of cases, whereas in residual ridges of 6 mm,

a perforation was observed in 25% of cases. In most

studies, no statistical difference was observed in
the success rates of implants placed with sinus
bone grafting in patients whose Schneiderian membrane was perforated versus those patients in
whom the membrane remained intact. However, a
histomorphometric study according to a split-mouth
design, and with regard to sinus perforation during
surgery, suggested that repairing the perforated site
of the sinus membrane with a resorbable collagen
membrane may result in reduced bone formation and
a reduced implant survival rate.25 When the perforation is small (2 mm) and located in an area where
the elevated membrane is folded together, it will heal
by itself. However, even with a small perforation or a
very thin Schneiderian membrane, the present authors prefer to use a resorbable collagen membrane to
cover and support the weak spot. Larger perforations
are almost always managed by the use of a barrier
membrane. In the present study, a freeze-dried human
lamellar bone sheet (Lambone; Pacific Coast Tissue
Bank, Los Angeles, CA) was applied after it was
shaped and cut for proper fit. The large size of a sheet
is chosen to provide a customized fit within the bony
sinus walls. The corners are rounded off, and the

ZIJDERVELD ET AL

FIGURE 12. Schematic drawing of a longitudinal or sagittal septum, instead of the usual transversal septum, of the antral floor.
Because of this unexpected rim, there is a risk of perforating the
membrane while shooting out with an elevation instrument.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

membrane is rehydrated before placement in the

maxillary sinus (Figs 14A-C). Other treatment options
include the use of an autogenous block graft instead
of a cancellous graft, suturing, or abandonment of the
surgical procedure.
With regard to the prevention of a perforation, the
present authors make some additional small holes in
the suction device, to diminish the suction power.
Furthermore, the prevention of direct contact of the
suction device with the Schneiderian membrane can
be achieved by placing an elevation instrument between them.
Hemorrhages
Knowledge of the blood supply to the maxillary
sinus is of importance in sinus floor elevation procedures, in terms of both vascularization of the sinus
graft and the location of that blood supply relative to
the position of the required lateral osteotomy. The
surgical severance of one of the vessels may not be a
life-threatening event, but may complicate the procedure, because of the more difficult visualization of the
Schneiderian membrane. Although the maxilla is very
densely vascularized in young and dentate populations, the blood supply to the bone is permanently
reduced with age and progressing atrophy, and the
number of vessels and their diameters decrease, while
tortuosity increases.4 Three arteries supply the maxillary sinus: the posterior superior alveolar, infraorbital, and posterior lateral nasal arteries, all of which

1435
are ultimate branches of the maxillary artery. The
posterior superior alveolar artery supplies the lining
of the antrum, posterior teeth, and superficial
branches to supply the maxillary gingivae and mucoperiosteum. The dental branch of this artery courses
intraosseously, halfway up the lateral sinus wall, and
forms a horizontal anastomosis with the infraorbital
artery. The infraorbital artery runs through the infraorbital canal and, before emerging from the infraorbital foramen, it gives off 1 or 2 branches that
course caudally along the anterior antral wall.29 An
intraosseous anastomosis was found in all specimens
in an anatomic study of cadavers, and was visualized
in 53% of the CT scans in a radiographic study.4,5 In
the 2 studies, the mean distance of the intraosseous
anastomosis to the alveolar crest was 19 mm and 16
mm, respectively. If the goal is to place implants 12
mm in length, the superior osteotomy cut will be
made approximately 14 mm from the alveolar crest.
According to CT scan data, 80% of the arteries are
located more than 15 mm from the crest, and are at
no risk regarding a potential surgical complication.4
But in cases where the alveolar ridge has been severely resorbed, the vessel will be closer to the crest
than the reported average.
In the present study, a hemorrhage during preparation of the trapdoor was encountered in 2 patients
(Fig 15). In both patients, it reduced the visualization
and hindered the surgical procedure, but had no negative influence on the treatment outcome. Bleeding can
usually be controlled by pressure with a mist gauze pad.

FIGURE 13. Schematic drawing of dental root-shape configuration that makes preparation of the membrane difficult.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

1436

COMPLICATIONS IN MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

FIGURE 14. A, Patient with a perforation of the Schneiderian membrane. B, A freeze-dried human lamellar bone sheet was applied after
being shaped and cut for proper fit. C, The recipient side was filled with a particulated autogenous bone graft from the retromolar trigonum.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation Procedures. J Oral Maxillofac Surg 2008.

Electrocautery should be avoided, because there is a risk

of perforating the Schneiderian membrane.
Solar et al5 reported on an extraosseous anastomosis of the same arteries mentioned in 44% of the cases.
It is located at a mean distance of 23 mm from the
alveolar ridge. The anastomosis is in close contact
with the bone. Vertical incisions should therefore
extend cranially as little as possible, and the periosteum should be prepared with the utmost care, to
minimize vascular trauma.
In addition to anastomosis in the lateral wall of the
maxillary sinus, a third artery can be a potential risk
for severing an intraosseously located artery during a
vigorous curettage for sinus elevation in the posterior
medial wall of the sinus. The posterior lateral nasal
artery can be found close to, or within, the medial
wall of the sinus, and because of the proximity of the
sphenopalatine artery, it may produce a problematic
flow of blood if severed.6
Another form of perioperative or postoperative
bleeding that can occur is an epistaxis, indicating a
membrane perforation.
Postoperative Maxillary Sinusitis
The rather low complication rate of 1% for postoperative maxillary sinusitis is somewhat surprising. A

transient or persisting effect on the ciliated antral

mucosa would be expected as a result of maxillary
sinus floor elevation raising the Schneiderian membrane. When the maxillary sinus is filled with blood, a
delay of maxillary sinus clearance is thought to occur,
because it is generally assumed that a reduction of the
patency of the osteomeatal unit creates a potential

FIGURE 15. Hemorrhages during preparation of the trapdoor

reduced the visualization and hindered the surgical procedure.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

1437

ZIJDERVELD ET AL

mance of all procedures by 1 skilled surgeon. In

maxillary sinus floor elevation procedures, it is essential to have good knowledge of the different anatomical and surgical findings, to minimize perioperative
and postoperative complications. The results of this
study contribute to a better understanding of this
preimplant procedure.

References

FIGURE 16. A, The horizontal incision on top of the crest was

made slightly palatal. B, Postoperatively, a local wound dehiscence occurred.
Zijderveld et al. Complications in Maxillary Sinus Floor Elevation
Procedures. J Oral Maxillofac Surg 2008.

risk for the development of maxillary sinusitis. However, the results of a human study by Timmenga et al30
in regard to the effects of maxillary sinus floor elevation
on maxillary sinus physiology suggest that the maxillary
sinus mucosa is capable of adapting adequately to the
changes induced by elevation procedures, especially
in cases of noncompromised sinus clearance.
Local Wound Dehiscences
In 3 cases, a local wound dehiscence occurred in
the first 2 weeks postoperatively. This was probably
because, in the first treated patients, the incision on
the top of the crest was made slightly palatal (Figs
16A,B). The main course of the supplying arteries is
from posterior to anterior, the main vessels run parallel to the alveolar ridge in the vestibulum, and the
crestal area of the edentulous alveolar ridge is covered by an avascular zone with no anastomoses
crossing the alveolar ridge. This argues in favor of
midline incisions on the alveolar ridge and avoidance
of incisions crossing the alveolar ridge, hence eliminating the risk of cutting anastomoses or cutting out
avascular areas of the mucosa.31
The relatively low rate of complications in this
patient group was probably attributable to the perfor-

1. Tatum OH: Maxillary and sinus implant reconstructions. Dent

Clin North Am 30:207, 1986
2. Boyne P, James RA: Grafting of the maxillary sinus with
autogenous marrow and bone. J Oral Maxillofac Surg 38:113,
1980
3. van den Bergh JPA, Bruggenkate CB, Disch FJM, et al: Anatomical aspects of sinus floor elevation. Clin Oral Implant Res
11:256, 2000
4. Elian E, Wallace S, Cho S, et al: Distribution of the maxillary
artery as it relates to sinus floor augmentation. Int J Oral
Maxillofac Implants 20:784, 2005
5. Solar P, Geyerhofer U, Traxler H, et al: Blood supply to the
maxillary sinus relevant to sinus floor elevation procedures.
Clin Oral Implant Res 10:34, 1999
6. Flanagan D: Arterial supply of the maxillary sinus and potential
for bleeding complication during lateral approach sinus elevation. Implant Dent 14:336, 2005
7. Uchida Y, Goto M, Katsuki T, et al: Measurement of maxillary
sinus volume using computerized tomographic images. Int
J Oral Maxillofac Implants 13:811, 1998
8. Velloso GR, Vidigal GM, Freitas MM de, et al: Tridimensional
analysis of maxillary sinus anatomy related to sinus lift procedure. Implant Dent 15:192, 2006
9. Krennmair G, Ulm C, Lugmayr H: Maxillary sinus septa: Incidence, morphology and clinical implications. J Craniomaxillofac Surg 25:261, 1997
10. Ulm CW, Solar P, Krennmair G, et al: Incidence and surgical
management of septa in sinus-lift procedures. Int J Oral Maxillofac Implants 10:462, 1995
11. Underwood AS: An inquiry into the anatomy and pathology of
the maxillary sinus. J Anat Physiol 5:354, 1910
12. Summers RB: The osteotome technique. Less invasive methods
of elevating the sinus floor. Compend Contin Educ Dent 15:
698, 1994
13. Jensen OT: The sinus bone graft. Carol Stream, IL, Quintessence
Publishing, 1999
14. Tallgren A: The continuing reduction of the residual alveolar
ridges in complete denture wearers: A mixed longitudinal
study covering 25 years. J Prosthet Dent 27:120, 1972
15. Chanavaz M: Maxillary sinus: Anatomy, physiology, surgery and
bone grafting related to implantology. J Oral Implantol 16:199,
1990
16. Ulm CW, Solar P, Gsellmann B, et al: The edentulous maxillary
alveolar process in the region of the maxillary sinusA study
of physical dimensions. Int J Oral Maxillofac Surg 24:279, 1995
17. Cho SC, Wallace SS, Froum SJ: Influence of anatomy on Schneiderian membrane perforations during sinus floor elevation surgery: Three dimensional analysis. Pract Periodont Aesthet Dent
13:160, 2001
18. Krennmair G, Ulm CW, Lugmayr H, et al: The incidence,
location and height of maxillary sinus septa in the edentulous
and dentate maxilla. J Oral Maxillofac Surg 57:667, 1999
19. Stover JD: Discussion: The incidence, location and height of
maxillary septa in the edentulous and dentate maxilla. J Oral
Maxillofac Surg 57:671, 1999
20. Kim M, Jung U, Kim C, et al: Maxillary sinus septa: Prevalence,
height, location and morphology. A reformatted computed tomography scan analysis. J Periodontol 77:903, 2006
21. Lungmayr H, Krennmair G, Holzer H: Morphologie und Inzidenz
von Kieferhhlensepten. Fortschr Rontgenstr 165:452, 1996

1438

COMPLICATIONS IN MAXILLARY SINUS FLOOR ELEVATION PROCEDURES

22. Velasquez-Plata D, Hovey LR, Peach CC, et al: Maxillary sinus

septa: A three dimensional computerized tomographic scan
analysis. Int J Oral Maxillofac Surg 17:854, 2002
23. Tidwell JK, Blijdorp PA, Stoelinga PJ, et al: Composite grafting of the maxillary sinus for placement of endosteal implants. Int J Oral Maxillofac Surg 21:204, 1992
24. Bruggenkate CB, van den Bergh JPA: Maxillary sinus floor
elevation a valuable pre-prosthetic procedure. Periodontology
17:176, 2000
25. Shlomi B, Horowiz I, Kahn A, et al: The effect of sinus membrane
perforation and repair with Lambone sheet on the outcome of
maxillary sinus floor augmentation: A radiographic assessment. Int
J Oral Maxillofac Implants 19:559, 2004
26. Pikos M: Maxillary sinus membrane repair: Report of a technique for large perforations. Implant Dent 8:29, 1999

27. Proussaefs P, Lozada J, Kim J, et al: Repair of the perforated

sinus membrane with a resorbable collagen membrane: A human study. Int J Oral Maxillofac Impl 19:413, 2004
28. Ardekian L, Oved-Peleg E, Mactei E, et al: The clinical significance of sinus membrane perforation during augmentation of the maxillary sinus. J Oral Maxillofac Surg 64:277,
2006
29. Traxler H, Windisch A, Geyerhofer U, et al: Arterial blood
supply to the maxillary sinus. Clin Anat 12:417, 1999
30. Timmenga NM, Raghoebar GM, Liem RSB, et al: Effects of
axillary sinus floor elevation surgery on maxillary sinus physiology. Eur J Oral Sci 111:189, 2003
31. Kleinheinz J, Buchter A, Kruse B, et al: Incision design in
implant dentistry based on vascularization of the mucosa. Clin
Oral Implant Res 16:518, 2005