Title	Maxillary Sinus Membrane Perforation May Affect Implant Survival
Clinical Question	In patients who undergo maxillary sinus augmentation, does perforation of the sinus membrane increase the risk for implant failure?
Clinical Bottom Line	For patients who undergo maxillary sinus augmentation, there is conflicting data as to whether or not membrane perforation has an effect on future implant survival.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 30168884 Al-Moraissi/2018 58 studies/2947 patients Systematic review and meta regression analysis Key results Implant loss was higher when sinus membrane perforation was present (RR = 2.17, CI: 1.52-3.10, P = 0.001). There was also a positive correlation between the number of intraoperative sinus membrane perforations and implant failure (P = 0.005). 34250560 Diaz-Olivares/2021 7 studies/1162 patients Systematic review and meta-analysis Key results There was no significant difference between the survival rate of implants placed in perforated sites (97.68%) and non-perforated sites (98.88%) (p=0.229). The most frequent post-op complication after sinus membrane perforations was infection.
Evidence Search	(sinus membrane perforation) AND (implants)
Comments on The Evidence	Both studies are systematic reviews and meta-analyses, which represent the highest level of available evidence. However, different outcomes were observed. Both studies had well designed and clearly defined search and selection strategy. Al-Moraissi et al. (2018) included RCTs and non-randomized studies, of which 17 showed an unknown or high risk of bias. Included studies had data from both lateral and vertical sinus augmentation procedures, and procedures using piezoelectric and/or rotary instruments. Possible confounding factors were present including surgeon experience, size of membrane perforation, etc. and there was no discussion about perforation repair. The regression model also showed that sinus membrane perforation could only account for 52% of variation, meaning that 48% of implant failure may be due to other reasons. Diaz-Oliveras et al. (2021) included seven retrospective cohort studies (lower level of evidence), of which only 1 showed increased risk of bias. The cohort studies examined only lateral sinus augmentation procedures and presented data on membrane repair methods and post-op complications.
Applicability	Sinus augmentation is a common procedure that is performed to allow for implant placement in the posterior maxilla. Perforation of the sinus membrane is the most common complication of this procedure. Although there are conflicting conclusions about the effect of intraoperative maxillary sinus membrane perforation on implant failure, it is important to note several key trends. Based on these two studies, both size (Diaz-Olivares et al., 2021) and number of perforations (Al-Moraissi et al., 2018) may have a significant effect on future implant survival. It is crucial that surgeons performing maxillary sinus lifts begin with thorough planning and use careful surgical technique to avoid intraoperative complications. However, when complications do arise, appropriate management and repair may minimize adverse future outcomes.
Specialty	(Oral Surgery) (Periodontics) (Prosthodontics) (Restorative Dentistry)
Keywords	Maxillary Sinus, Sinus Lift, Sinus Augmentation, Sinus Membrane Perforations, Implant
ID#	3497
Date of submission	11/19/2022
E-mail	milesc@uthscsa.edu
Author	Claire Miles, DMD
Co-author(s)	Jason Nguyen, DDS
Co-author(s) e-mail	nguyenj16@livemail.uthscsa.edu
Faculty mentor	Angela Palaiologou-Gallis, DMD, MS
Faculty mentor e-mail	palaiologoua@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available