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Sinus Pathology and Anatomy in Relation

to Complications in Lateral Window
Sinus Augmentation
Hsun-Liang Chan, DDS,* and Hom-Lay Wang, DDS, MS, PhD

axillary sinus augmentation

via a lateral window approach (SALW) is an effective procedure to gain bone height for
implant placement in an atrophic posterior maxilla.1,2 This technique was
first published by Boyne and James3 in
1980. According to them, a bony window was made on the lateral sinus
wall and a space was created between
the Schneiderian membrane and the
sinus walls, where a grafting material
was placed. One key advantage of this
approach is gaining direct access to
the sinus. However, despite the high
success rate, complications do occur.4
The most frequently encountered surgical complication is perforation of the
Schneiderian membrane.5 Other complications include massive bleeding,
infection, implant displacement into
the sinus, etc.1 More than often these
complications are related to the sinus
anatomy and preexisting antral pathologies. Knowledge about common sinus diseases and variations in sinus
anatomy would greatly reduce the occurrence of these complications.
Therefore, this article aimed at reviewing antral diseases and anatomy
that might predispose to surgical complications in SALW. A treatment

*Resident, Graduate Periodontics, School of Dentistry,

University of Michigan, Ann Arbor, MI.
Professor and Director, Graduate Periodontics, School of
Dentistry, University of Michigan, Ann Arbor, MI.

Reprint requests and correspondence to: Hom-Lay

Wang, DDS, MS, PhD, 1011 North University Avenue,
Ann Arbor, MI 48109-1078, Phone: (734) 763-3383,
Fax: (734) 936-0374, E-mail: homlay@umich.edu
ISSN 1056-6163/11/02006-406
Implant Dentistry
Volume 20 Number 6
Copyright 2011 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e3182341f79

Antral pathoses and anatomical

variations increase the risk of surgical
complications during a lateral window sinus augmentation procedure.
Therefore, an understanding of maxillary sinus diseases and anatomies is
imperative. In the first part of this article, common sinus diseases will be
reviewed, which include acute/chronic
rhinosinusitis, mucoceles, pseudocysts, retention cysts, and odontogenic
diseases of the maxillary sinus. In addition, a treatment strategy will be
proposed toward the management of

these antral diseases. In the second

part, anatomical variations of the
maxillary sinus, for example, the
septum and artery that is in approximation to the osteotomy site will be
discussed. Knowledge of diagnosing
and managing sinus pathoses and
anatomies could assist surgeons in
reducing the incidence of sinus augmentation complications. (Implant
Dent 2011;20:406 412)
Key Words: maxillary sinus, sinus
pathology, sinus anatomy, sinus
augmentation, dental implants

proposal aiming at managing antral diseases was introduced. In addition, the

management of these surgical complications was discussed.

pressure in the sinus, eventually giving rising to symptoms, such as palpation pain around infraorbital region
and headache. Many of the sinus diseases and some complications resulting from SALW are associated with
the inability of the maxillary sinus to
drain mucin.
Sinus diseases and abnormities
are prevalent (40%) in patients scheduled for sinus lift procedures and the
presence of those conditions is significantly correlated with a history of indicative symptoms.8 In addition, their
presence might increase the difficulties in performing the surgery and the
risk of developing postoperative complications.9 11 As a result, maxillary
sinus diseases should be recognized
and managed with care before a sinus
augmentation procedure. Many of
them could be identified via a thorough medical and dental history evaluation, with a special focus on any
signs and symptoms that might suggest a concern in the sinus.8 A careful

MAXILLARY SINUS DISEASES

One of the main functions of the
maxillary sinus is to humidify and filter the air inhaled in the nose. It is
achieved by a layer of specialized respiratory epithelium, classified as
ciliated pseudostratified columnar epithelium.6 The main components of
this epithelial layer are basal cells,
goblet cells, and ciliated cells.7 Basal
cells own the ability to proliferate and
differentiate into the other 2 cell types.
Goblet cells are secretory cells that
produce mucin. The ciliated cells are
columnar epithelial cells that possess
cilia. They function by moving the
mucin toward the ostium, an opening
connecting the maxillary sinus to the
middle meatus in the nasal cavity.
Blockage of this pathway could lead to
accumulation of mucin and antral

IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011

407

Table 1. Common Maxillary Sinus Diseases and Their Managements for SALW
Diagnosis
Disease
ARS

CRS

Pseudocyst

Clinical Symptoms
Duration up to 4 wk
Anterior or posterior
mucopurulent drainage
Nasal congestion
Facial pain/pressure
Decreased sense of smell
Duration longer than 812 wk
Anterior or posterior
mucopurulent drainage
Nasal congestion
Facial pain/pressure
Decreased sense of smell
Usually none

Etiology

Histological Findings

Opacification or air-fluid level

Radiographic Findings

Bacterial/viral/fungal infection

Infiltration of neutrophils and

macrophages

ENT consultation

Thickening of the sinus lining

more or less in even width

Mainly inflammation from

low-grade infection or
allergy

Infiltration of lymphocytes,
plasma cells, and
macrophages

Prevalence: 1.5%10%
Dome-shaped radiopacity
Commonly located on the floor
of the sinus

Focal accumulation of
inflammatory exudate

No epithelial lining
Exudates accumulation
Inflammatory infiltration

Blockage and dilatation of

ducts of the
seromucinous glands
Blockage of ostium due to
trauma or other diseases

With epithelial lining

Mucin accumulation

ENT consultation: with

symptoms or thick
membrane 1/3
sinus height
Otherwise, proceed
with SALW
ENT consultation: with
symptoms or closer
to medial wall
Otherwise, enucleation
via lateral window
Proceed with SALW

Retention
cyst

Usually none

Mostly too small to be detected

Commonly found around ostium

Mucocele

Very rare, more commonly

found in frontal sinuses
May include headache,
diplopia, visual impairment,
and/or nasal obstruction

Initial stage: cloudy sinus cavity

Later stage: thinner sinus wall

dental and periodontal examination

especially for those teeth that are in
the vicinity of the sinus should be executed to rule out any odontogenic
lesions. Common sinus diseases that
might interfere with the performance
of SALW include acute/chronic rhinosinusitis, sinusitis of odontogenic origin, odontogenic cysts, pseudocysts,
mucoceles, and retention cysts. The
clinical and radiographic features of
each of them was discussed in below
and summarized in Table 1.
Rhinosinusitis

The term rhinosinusitis has replaced sinusitis because of the close

interrelationship between the 2 diseases.12 Rhinosinusitis is defined as
inflammation of the nose and paranasal sinuses. 13 Acute rhinosinusitis
(ARS) is usually infectious and lasts
up to 4 weeks, whereas chronic rhinosinusitis (CRS) is more inflammatory
and has a minimal duration of either 8
or 12 weeks.12 Apart from their differences in the duration and pathogenesis, symptoms associated with the 2
diseases are similar. More than 2 of
the following symptoms are required
to establish the diagnosis for both
ARS and CRS: (1) anterior or posterior mucopurulent drainage, (2) nasal
congestion, (3) facial/pain pressure,

and (4) decreased sense of smell.13 In

addition, CRS may be diagnosed with
objective methods, for example, a rhinoscopic or radiographic examination
with a preference for computed tomography (CT). CRS can be further
categorized into 3 subtypes with distinct but overlapping clinical characteristics: CRS without nasal polyposis,
CRS with nasal polyposis, and allergic
fungal rhinosinusitis.13 Radiographically, ARS might present with an airfluid interface and CRS is associated
with thickening of the sinus lining and
radiopacity in the sinus.14
Odontogenic Sinus Diseases

Maxillary sinusitis of odontogenic

origin account for approximately one
tenth of total maxillary sinus diseases.15
Common dental diseases that can cause
sinusitis include periapical infection,
periodontal disease, and perforation of
the antral mucosa during tooth extraction. Other dental-related maxillary
diseases are odontogenic cysts, for example, the radicular and dentigerous
cyst.16 These earlier mentioned diseases
might serve as a reservoir for microbes,
which might contaminate the grafting
material and dental implants resulting
in treatment failure if left untreated.
As a result, before planning a SALW,
a thorough dental examination is re-

With epithelial lining (typical

respiratory epithelium or
squamous metaplasia)

Management

ENT consultation

quired to rule out the earlier mentioned diseases.

Pseudocyst, Retention Cyst,
and Mucocele

A pseudocyst, as the name implies, is not a true cyst (without epithelium lining) while a retention cyst
is.17,18 A pseudocyst is believed to be
an accumulation of inflammatory exudates between the bony wall and
periosteum. A retention cyst is formed
when mucin is allowed to accumulate
in a dilated seromucous duct that is
blocked. Radiographically, a pseudocyst is characterized by its domeshaped radiopaque structure and is
commonly found on the floor of the
maxillary sinus. The prevalence of
pseudocysts ranges from 7.3%19 to
14%20 on radiographs. On the other
hand, a retention cyst is not readily
seen on the x-ray because it is too
small and if found, it is often around
the ostium. Under normal conditions,
both lesions are usually asymptomatic
and require no treatment. However,
when a SALW is planned, a pseudocyst might complicate procedures
and risk the development of surgical
complications.
A mucocele, on the contrary, is
invasive in nature. The pressure generated from the fluid in the mucocele

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may resorb the bony walls of the sinus. It is also much larger in size and
may fill the entire sinus thus creating
sinus symptoms. The blockage of the
ostium is believed to be responsible
for this pathosis.18
Management of Maxillary Sinus Diseases

A proposed treatment strategy is

summarized in Figures 1 and 2 for
patients who are diagnosed with maxillary sinus diseases and at the same
time planned for SALW. From a medicolegal and preventive standpoint,
dental surgeons should collaborate
closely with an otorhinolaryngologist
in managing maxillary sinus diseases.
The general goal is to alleviate sinusrelated symptoms, eliminate the lesion
and regain sinus membrane health before sinus augmentation. The procedures to achieve this goal may include
a nonsurgical or a surgical approach or
a combination of both.
More specifically, a mucocele
should be removed first because of its
aggressive nature and large size. If
diagnosed during the sinus augmentation surgery, the pathologic tissue can
be removed with a Caudwll-Luc procedure and the augmentation procedure is
aborted.21 CRS should be referred, when
it is symptomatic or if the sinus membrane thickness is greater than one third
of the height of the sinus. For maxillary
sinus diseases of odontogenic origin,
the lesion should resolve itself after
dental procedures, which might include endodontic therapy, periodontal
treatment, and extraction.22 The retention cyst is often small, symptomless,
and near the ostium. Therefore, no
specific treatment is warranted.
The management of the pseudocyst
is somewhat controversial and different
approaches have been reported in several case reports.19,21,23,24 Sinus augmentation was performed with the presence
of a pseudocyst in 2 cases.23 One case
developed an abscess postoperatively
and was controlled by antibiotics, after
which the implants had been followed
for 7 months without further complications. In another study,19 8 cases
with a pseudocyst were treated with a
standard SALW. Postoperative acute
sinusitis and membrane perforation
occurred in one and 2 cases, respec-

Fig. 1. A proposed treatment strategy for common antral diseases before SALW.

Fig. 2. A proposed treatment strategy for common antral diseases during and after SALW.

tively. The authors concluded that a

sinus lift procedure can be performed
safely even when a pseudocyst is present; however, in cases of unclear diagnosis or if the cyst is large, further
evaluation is recommended. On the
other hand, Lin et al24 suggested removing the pseudocyst routinely before SALW. In their case report, a 5
mm round window was created on the
lateral wall of the sinus, from where
the cyst was enucleated. The SALW
was performed 3 months after the removal of the cyst. The authors claimed
that this procedure allowed for elimination of the cyst and shortening of

treatment time (a Caldwell-Luc procedure or an endoscopic surgery for cyst

removal normally requires 6 months
healing). The pseudocyst should be removed before sinus augmentation because of the following reasons. First,
histopathologic examination can be
performed to rule out any possible malignancy. Second, the healed sinus
membrane after elimination of the cyst
would be healthier, and thus facilitate
the sinus elevation procedure. Third,
the long-term effect of the pseudocyst
on the grafting material and implants
are not known. Whether the enucleation procedure is referred depends on

IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011

409

Table 2. Summary of Articles Studying the Prevalence, Size, Location, and Orientation of Maxillary Septa
N
(Subjects)
Ulm et al32

41

Krennmair
et al27

165

Kim et al26

100

Shibli et al31

1024

Neugebauer
et al28

1029

Rosano
et al30
Park et al29

30

200

Dental Status

Septum
Definition

Prevalence/Sinus (%)

Location (%)

Cadavers

Edentulous

2.5 mm

31.7

Clinical
examination
and CT
CT

Both

NA

Edentulous

2.5 mm

Panoramic
radiographs
CBCT

Edentulous

NA

Clinical: 27.7; CT: 16;

dentate: 13.2;
edentulous: 26.8
Total: 26.5;
edentulous: 31.8;
dentate: 22.6
21.6

Premolars: 73.3; 1st molar:

19.9; 2nd molar: 6.6
NA

Both

NA

33.2

Cadavers

Edentulous

CT

Edentulous

Methods

3 mm

NA

33.3

27.7

Direction

2nd premolar: 25.4; 1st

and 2nd molars: 50.8;
3rd molar: 23.7
NA
1st molar: 31.6; 2nd molar
: 27.6; 2nd premolar:
17.1
2nd premolar-1st molar:
30; 1st-2nd molar: 40;
distal to 3rd molar: 30
1st and 2nd premolar:
22.5; 1st and 2nd
molar: 45.9; 3rd molar:
31.5

Size (mm)

NA

7.9

NA

6.8 (clinical), 8.1 (CT)

NA

1.63 (lateral), 3.55 (middle),

5.46 (medial)

NA

NA

Medial-lateral: 74.7; 7.3 (mesiodistal); 11.7

anterior-posterior:
(anterior-posterior)
25.3
Medial-lateral: 30;
8.72
anterior-posterior:
70
Medial-lateral: 96.3;
7.8
anterior-posterior:
3.6

CT, computed tomography; CBCT, cone-beam computed tomography.

the presence of symptoms and the location of the cyst. When the cyst is
symptomatic or is medially located, an
endoscopic surgery might be indicated
and therefore should be referred to an
otorhinolaryngologist.
Intraoperatively, the outcome of
sinus augmentation is influenced by
several factors, such as the presence of
a membrane perforation, size of the
perforation, presence of unexpected
infection, and the ability to clean the
infection. The presence of pus/exudate
requires a debridement procedure and
if the debridement could not be completed, the sinus augmentation should
be aborted. If the size of the perforation is larger than 10 mm, the procedure generally should be terminated
too. Postoperatively, decongestant
medications and antibiotics should be
prescribed and the patients should be
informed about the possibility of having higher incidence of developing
complications.

VARIATIONS IN THE ANATOMY

COULD PREDISPOSE
TO COMPLICATIONS
Sinus Septum and Membrane Perforation

The internal structures of the maxillary sinus have been described a hundred years ago.25 It was not until the
introduction of the SALW did these
internal anatomies regain attention,
and in particular, the septum. Articles
related to the maxillary sinus septum

are summarized in Table 2. A septum

is a bony projection with various sizes,
locations, and orientations, most commonly arising from the floor of the
maxillary sinus. The prevalence of the
septum ranges from 16% to 33.3%,
depending on ethnicity, methods used
to identify a septum and the dentate
status, etc.26 32 The septum has been
found more commonly in edentulous
than dentate status because of the presence of the secondary septum.27 It was
hypothesized that after tooth loss, a
selective bony resorption of the sinus
floor resulted in areas of protrusion
and depression. The protrusive bony
spike formed the secondary septum, in
comparison with the primary septum,
which was formed along with the development of the maxillary sinus. This
theory was further supported by the
fact that a primary septum is higher in
size and may split a sinus into 2 compartments, whereas a secondary septum
is considerably shorter. The septum was
most commonly found at the molar
area,26,2830 where a sinus augmentation
procedure is commonly performed. The
height of the septum varies greatly
among studies, ranging from 1.6326 to
11.7 mm.28 A septum can be found more
commonly in a mediolateral direction,
partially separating the sinus into an anterior and posterior compartment,28,29
although a septum in the transverse
and sagittal directions could also be
found. To summarize, a septum, vary-

ing in size, location, and orientation is

commonly present in the maxillary sinus. Its presence may increase the risk
of a sinus membrane perforation during the surgery.
A membrane perforation is the
most commonly encountered complication.1 The mean prevalence of sinus
perforation during sinus elevation procedures is 19.5%, with a range of 0%
to 58.3%.1 The highest perforation rate
is associated with single tooth replacement.27 It might be possible that the
limited access had significantly increased the perforation rate. Whether
membrane perforation incurs more
postoperative complications and
higher implant failure rate is debatable. Barone et al33 found that the use
of an onlay graft and/or smoking and
not the membrane perforation is associated with higher postoperative infection rate. Becker et al34 also suggested
that with proper treatment, a perforation of the membrane did not elevate
the risk for implant loss, infection, or
displacement of grafting material.
Schwartz-Arad et al5 concluded that a
membrane perforation significantly
increased postoperative complications
but it did not result in more implant
failures. On the other hand, Cho-Lee
et al35 found that the implant survival
rate was lower (81%) when surgical
complications, membrane exposure or
postoperative sinusitis occurred, compared with no complications (97.6%).

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Table 3. Summary on Managements of Sinus Membrane Perforation

Management by the Size of the Perforation

References
Shlomi et al

38

Ardekian et al36

Becker et al34

Hernandez-Alfaro
et al37

Total No. of
Augmentations

Total No.
of Implants

73

253

110

201

474

Perforation
Rate (%)
28

221

425

1166

Implant
Placement Timing
Staged

Simultaneous

20.4

25.15

Both

Simultaneous

Perforation Size
(mm)
No. of perforations
Repair technique
Postoperative
complications
(%)
Implant survival
rate (%)
No. of perforations
Repair technique
Postoperative
complications
(%)
Implant survival
rate (%)
No. of perforations
Repair technique
Postoperative
complications
(%)
Implant survival
rate (%)
No. of perforations
Repair technique

Postoperative
complications
(%)
Implant survival
rate (%)

10

510

20
DFDLB sheet
0

90 (NSS from NP group)

Collagen membrane
5.7 (0 in NP group)

94.4 (NSS from NP group)

28
Collagen
membrane

6
Collagen membrane
suture
4.8 (1 in NP group)

4
Discontinue the
procedure

98 (NSS from NP group)

56
Suturing, or
resorbable
collagen
membrane

28
Lamellar bone
resorbable collagen
membrane

20
Lamellar bone, lamellar
bonebuccal fat
pad, or bone block
graft

97.1

91.9

74.1

NSS, not statistically significant; NP, nonperforation; DFDLB, demineralized freeze dried human lamina bone.

Regardless of the controversies in the

potential effect of membrane perforation on postoperative complications
and implant failure, this intraoperative
complication absolutely increase surgical difficulty and lengthen surgical
time. It is, therefore, preferable to prevent the occurrence of a membrane
perforation. Of equal importance is the
management of a perforation once
identified during the procedure.
Management of Sinus
Membrane Perforation

Table 3 summarized methods

used to repair a membrane perforation
of different sizes. A perforation 5
mm is generally repaired with a collagen membrane alone or sutures.34,36,37
A perforation size between 5 and 10
mm might be treated with a collagen
membrane alone,36 in combination
with sutures34 or lamina bone harvested from the lateral wall after osteotomy.37 It might be corrected with a
demineralized freeze-dried human lamellar bone sheet.38 Attempts were

made to repair a larger perforation

(10 mm), including a demineralized
freeze-dried human lamellar bone
sheet,38 lamina bone alone, combined
with buccal fad pad, or the use of a
block graft.37 On the contrary, it was
suggested to abandon the surgery.34
From these clinical evidences, small to
medium perforations might be repaired, after which the augmentation
procedure could be completed without
jeopardizing implant survival rate.
However, when a large perforation occurs, the surgery should be terminated
because lower implant survival rate was
found in cases with a 10 mm perforation and a repair was attempted.37
Distributions of Blood Vessels and
Massive Hemorrhage

Accidently injuring the blood vessels in the maxillary sinus might cause
massive hemorrhage during an augmentation surgery. Therefore, it is important to understand the distributions
and variations of these arteries. The
artery that is located on the lateral wall

where an osteotomy will be performed

is especially important. It is the anastomosis of the posterior superior alveolar artery and infraorbital artery. In
cadaver studies, this anastomosis
could always be found39,40; however,
from CT images only 50% to 60%
could be identified.40 42 Its location in
relation to the alveolar crest was on
average 11.25,40 16.4,41 18.0,42 and 19
mm.39 Because of its location, it was
estimated that 20% of normally positioned lateral window osteotomies
might come across this artery, potentially causing major bleeding.41 The
use of a piezoelectric machine for osteotomy might preserve the integrity
of this artery because it only cuts hard
tissue.43 With regard to its relationship
with the lateral sinus bony wall, it was
found to be intraosseous39,41 or partially intraosseous.40,42 If it is located
between the interior side of the bony
wall and the Schneiderian membrane
(partially intraosseous), care should
also be taken not to tear it when ele-

IMPLANT DENTISTRY / VOLUME 20, NUMBER 6 2011

vating the membrane. The diameter of

this artery was 1 mm in 55.3%, 1 to
2 mm in 40.4%, and 2 to 3 mm in
4.3% of cases.40 When a large diameter
blood vessel (3 mm) is encountered, it
may be wise to ligate it to prevent
massive bleeding.44
Location of the Ostium and
Sinus Obliteration

The ostium is located 40 mm

above the antral floor.45 A case was
reported for a patient who complained
about frequent headache, sinus congestion, and discharge after a sinus
augmentation procedure. 46 CT revealed that the grafting material occupied 80% of the maxillary sinus and
was just below the ostium. It was possible that the grafting material had
blocked the normal fluid movement in
the maxillary sinus and symptoms developed. Therefore, maxillary sinus
should not be overpacked.
Migration of the Implant

Displacement of implant into sinus was reported sporadically in the

literature.47,48 the incidence of this
complication is currently unknown
and believed to be rare. The timing of
its occurrence varies from several days
after implant placement,49 at abutment
connection surgery,50 or even several
years after function.51 The exact cause
is not clear; however, 3 essential conditions must be present for this unfortunate incident to occur, these are a
lack of osseointegration, membrane
perforation, and a pushing force on the
implant toward sinus. It is generally
agreed that once the displacement is
diagnosed, the implant should be removed as early as possible. Three main
rescue therapies have been discussed
and the treatment protocol has been developed, which comprises of intraoral
approach (modified Caldwell-Luc procedure), functional endoscopic sinus
surgery (FESS), and the combination
of both.47 According to their protocol,
an intraoral approach is chosen when
no symptoms of sinusitis are present
and the ostium is patent, whereas a
FESS is selected when there is obstruction of maxillary ostium without
oroantral communications. The FESS
is combined with an intraoral ap-

proach when sinusitis, obstruction of

the ostium, and oroantral communications are all present. A high success
rate (26 of 27 patients recovered completely) following this protocol suggests
that this is an effective approach. Nevertheless, the best way is probably to
prevent this complication from happening. Because of rare occurrence, it was
difficult to identify the risk factors. Possible predisposing factors include inadequate residual ridge height, poor bone
quality, and simultaneous implant placement with sinus augmentation.

CONCLUSIONS
The occurrence of surgical complications during SALW is most likely related to the presence of maxillary sinus
pathoses and anatomical variations.
Management strategies for antral diseases before, during and after the augmentation procedure were proposed. In
addition, maxillary sinus anatomies, in
particular the maxillary septum, ostium,
and artery in the vicinity of the osteotomy site and their clinical significance
were discussed. Correct diagnosis and
management of sinus diseases and the
knowledge of sinus anatomies could
greatly reduce the incidence of surgical
complications.

DISCLOSURE
The authors claim to have no financial interest in any company or any of
the products mentioned in this article.

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