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Wilcko et al
Background: Sinus lift procedures are con-
sidered safe and predictable procedures for
the rehabilitation of the athrophic upper pos-
terior maxilla. The presence of sinusal neo-
formation, highly reported in the literature,
could represent a problem for sinus lifts. The
removal of these lesions is recommended in
order to limit intra- and post-operative com-
plications. The aim of this prospective study
is to describe the surgical removal of sinusal
cyst concurrently with sinus lift procedures.
Methods: 10 patients, 7 male and 3 female,
presenting edentulism of the posterior maxilla
associated with severe pneumatization of the
maxillary sinus and presence of an antral cyst,
were enrolled in the study. 14 sinus lift pro-
cedures were performed following aspiration
of the liquid contained within the cyst. Radio-
graphic exams were performed before, imme-
diately after, and six months after the surgery.
Results: All patients showed successful inte-
gration of the implants and the survival rate
was 100% at the most recent recall. Intraop-
erative complications were rare and included
minor membrane perforations in 3 cases. In
11 cases the CT scan examination revealed
no sign of presence of the lesion after 6
months. In 3 cases the total volume of the
lesion was significantly reduced. 4 patients
presented thickening of the Scheiderian mem-
brane up to 2 mm with no sign of inflammation.
Conclusions: This study proposes a modi-
fied surgical approach to drain the endolu-
minal liquid during the sinus lift procedure.
The new proposed technique allows the
reduction of the surgical morbidity thanks
to the elimination of one surgical phase in
case of staged approach. The Authors con-
sider this technique safe and predictable.
Sinus Lift Procedure in Presence of Mucosal Cyst:
A Clinical Prospective Study
C. Maiorana1 • M. Beretta1 • M. Benigni1 • M. Cicciù2 • E. Stoella1 • GB Grossi1
1. Department of Dental Implants, Fondazione IRCCS Cà Granda, University of Milan,
Ospedale Maggiore Policlinico, Milan, Italy
2. Human Pathology Department, University of Messina University of Messina School of Dentistry
Abstract
KEY WORDS: Maxillary sinus lift, cyst, dental implant, bone augmentation
The Journal of Implant & Advanced Clinical Dentistry • 53
54 • Vol. 4, No. 5 • November/December 2012
INTRODUCTION
Implant therapy in the posterior maxilla can be
complicated by the qualitative and quantitative
limitations of the residual bone, often interrelated
with the pneumatization of the maxillary sinus.1
The sinus lift is a predictable surgical technique,
strongly supported in the literature2,3 for many
decades, providing a safe and stable base for
endosseous implant placement.4 Some authors
have stated that the presence of an antral cyst
would be a contraindication for the predictabil-
ity of the sinus lift procedure in these particular
patients5 while other studies assess that pseu-
docysts do not affect the possibility to perform
a sinus grafting procedure.6 The aim of this pro-
spective study is to evaluate, by means of clini-
cal and radiological examination (CT scan), the
effectiveness of a modified sinus lift procedure
in case of severe pneumatization of the maxil-
lar sinus associated with presence of antral cyst.
MATERIALS AND METHODS
Patients
10 patients, 7 male and 3 female, presenting
edentulism of the posterior maxilla associated
with severe pneumatization of the maxillary sinus
and presence of an antral cyst, were enrolled
in the study. Fourteen sinus lift procedures
were performed. The group had a mean age
of 45.3 years, ranging from 27 to 73 years.
Demographic data, medical and dental health
history and smoking habits were registered.
General inclusion criteria for oral surgery proce-
dures were considered. Patients were excluded
from the study if they had a medical history of
any systemic disease that would impair wound
healing, such as non-controlled diabetes melli-
tus, immunosuppressive drugs and heavy smok-
ing (more than 10 cigarettes per day). Each
patient received a comprehensive dental exami-
nation and a periodontal chart was filled, in order
to determine the periodontal and dental status.
Radiographic examination included Panoramic
exam, coronal and axial CT scans. Assessment
of maxillary sinus anatomy, vertical dimension of
the sinus floor and an evaluation of any patho-
logic findings were carried out on each patient.
All patients with a radiographic finding of a
dome-shaped radiopacity compatible with an
antral pseudocyst were included in the study
(Figures 1-3). Patients with a lesion less
than 1 cm² with diffuse mucosal thickening
or irregular calcifications were excluded. Cri-
teria for sinus augmentation were a maxil-
lary vertical dimension of less than 8 mm
with al least 1 mm of residual bone height.
All patients were referred to a otorhinolaryn-
gologist in order to perform sinus examination and
an endoscopic procedure (FESS) when required.
The endoscopic and radiographic examination (CT
scan) by the otorhinolaryngologist had the aim to
exclude pathological conditions such as: chronic
sinusitis with retention of mucous secretions in the
sinus, ostium stenosis or obstruction, presence of
bony destruction and communication with dental
roots. All subjects were informed regarding the
treatment sequence and the procedures involved
and were provided a signed informed consent.
Surgical Procedure
Sinus augmentation was performed following the
guidelines stressed by Tatum.3 After antibiotic pro-
phylaxis by means of 2 grams of amoxicillin 1 hour
before the surgery, anesthesia was obtained by
local infiltration of Ecocain 1:50,000 and 4 mg of
dexamethasone were infiltrated locally. A crestal
Maiorana et al
The Journal of Implant & Advanced Clinical Dentistry • 55
Maiorana et al
incision slightly palatal to the crest in order to pre-
serve a band of keratinized attached mucosa and
two vertical release incisions were carried out to
reflect a mucoperiosteal flap. The lateral wall of the
maxillary sinus was exposed and an osteotomic
window was performed using a round bur7 (Fig-
ure 4). A perforation through the vestibular wall of
the maxillary sinus was made 5 mm over the upper
side of the bony window using a 2 mm round
bur (Figure 5). This procedure was performed
to allow a direct access to the mucosal cyst in
order to suck out the liquid contained in the neo-
formation by means of a syringe inserted into this
communication (Figure 6). The liquid extraction
consented to reduce the internal pressure of the
cyst, thus diminishing the dimension of the lesion
and the risk of laceration during the lifting of the
scheiderian membrane. The sinus membrane was
then gently lifted from the bony floor by means
of an antral curette. The created sub-antral cav-
ity was then grafted with anorganic bovine bone
(Bio-oss Geistlich, Wolhusen, CH) (Figure 7).
In 9 procedures the vertical residual bone
height was sufficient to allow the primary stability
of implants inserted at the same time of the sinus
lift procedure. In 5 procedures a staged procedure
Figure 1: Panoramic exams showing a neoformation on the
floor of the maxillary sinus.
Figure 2: Panoramic exams showing a neoformation on the
floor of the maxillary sinus.
Figure 3: CT scan exam shows the presence of a
neoformation in the right maxillary sinus.
56 • Vol. 4, No. 5 • November/December 2012
Maiorana et al
with delayed implant placement because of the
insufficient residual bone was performed. Thirty
four implants were placed, 25 in single proce-
dure and 9 in staged approach. The graft material
was covered by a resorbable collagen membrane
(Biogide Geistlich, Wolhusen, CH) and a pri-
mary closure wound healing was obtained with
a 4-0 non resorbable suture (Figure 8).
Post-operative management included sys-
temic antibiotics (1 gram Amoxicillin 3 times a
day for 7 days), application of decongestant
nasal spray, chlorohexidine 0.20% mouthwash (3
times a day for 15 days) and analgesic. Patients
were instructed to avoid use of any removable
appliance for the first 2 weeks postoperatively.
Clinical and Radiographic Follow-Up
The patients were seen once a week for the
first post-op month, and then once a month for
the following 5 months. Suture removal was
Figure 4: Crestal incision with two vertical release and
exposure of the lateral wall of the maxillary sinus.
Figure 5: A perforation was made 5 mm above the upper
side of the bony window to allow the suction of the liquid
inside the cyst.
Figure 6: Enucleation of the cyst. Figure 7: The sinus wall was grafted with anorganic
bovine bone. (Bio-oss Geistlich, Wolhusen, CH).
The Journal of Implant & Advanced Clinical Dentistry • 57
Maiorana et al
performed 15 days post-operatively. Radio-
graphic examinations were made at the
time of surgery (panoramic exam) and after
6 months (panoramic exam and CT scan).
RESULTS
Mean follow-up was 28 months ranging from
12 to 40 months. All the patients showed suc-
cessful integration of the implants and the sur-
vival rate was 100% at the most recent recall.
Figure 8: The graft material was covered by a resorbable
collagen membrane. (Biogide Geistlich, Wolhusen, CH).
FIgure 9: in 3 cases a laceration of the schneiderian
membrane occurred.
Figure 10: Panoramic exam shows implant integration in
the right and left maxillary sinus.
Figure 11: Cross sections show good implants integration
in the sinus graft 6 months after the surgery.
58 • Vol. 4, No. 5 • November/December 2012
Maiorana et al
Intraoperative complications were rare and
included minor membrane perforations in 3
cases. The lacerations were in an area where
the membrane was thin and far from the per-
foration created to drain the liquid from the cyst
(Figure 9). No complications, such as infection
of the grafted material or acute sinusitis were
registered during the postoperatively period
and during the follow-up recall in all the surgi-
cal sites. Six month radiologic follow-up (CT
scan) showed good integration of the graft-
ing material in all the patients (Figures 10, 11).
In 11 cases the CT scan examination
revealed no sign of presence of the lesion after
6 months. In 3 cases the total volume of the
lesion was significantly reduced. Four patients
presented thickening of the Scheiderian mem-
brane up to 2 mm with no sign of inflammation.
DISCUSSION
The presence of cyst-like opacity in the maxil-
lary sinus is commonly asymptomatic and diag-
nosed on routine radiographic examination taken
for other reasons, such as dental rehabilitation,
impacted teeth, or to assess the alveolar ridge
for implant rehabilitation. The literature reported
two different values of antral cyst prevalence
depending on the type of radiological examina-
tions: between 1.4% and 9.6% in case of Pan-
oramic exam9 and 12.4% in case of CT scan.10
Sinus augmentation is associated with sev-
eral complications, with postoperative sinus-
itis and bone graft infection as the most serious.
The development of sinusitis following sinus
augmentation can be directly related to drain-
age disturbances, mainly as a result of septal
deviation and allergy, combined with oversized
inferior and middle turbinates. The presence of
antral pseudocyst reduces the size of the maxil-
lary antrum. Therefore, it can be speculated that
lifting the maxillary mucosal lining in this case
would further reduce the sinus size and postop-
erative edema of the Schneiderian membrane. The
ostium opening may be blocked causing stasis
of fluids, which when contaminated, could lead
to sinusitis. Nevertheless, because of the high
position of the ostium relative to the sinus floor,
especially in a large antrum, the reported preva-
lence of sinusitis following sinus augmentation
in the absence of any pathology is about 3% to
20% of the cases reported in the literature11-13
Differential diagnosis of an antral pseudo-
cyst from other sinus lesions is crucial for treat-
ment planning. As the maxillary sinuses may
become involved with several types of dis-
eases, including chronic rhinosinusitis, benign
and malignant neoplasms, or even dental disor-
ders, appropriate diagnosis is mandatory prior
to any intervention.14,15 In particular radiologi-
cal evaluation (Panoramic exam and CT scan)
and ENT examination with endoscopic approach
are necessary to determine benign or malig-
nant nature of the lesion.16 Ostium stenosis has
been strongly associated with chronic maxil-
lary sinusitis and nasal polyps/cysts.17 The risk
of ostium stenosis is highly augmented in case
of sinus lift procedure in presence of antral cyst
which can lead to the iatrogenic closure of the
nasal meatus during the surgical procedure.18
The patency of the sinonasal ostium is funda-
mental to guarantee the possibility for the sinus
to drain the physiological mucus thanks to the
mucociliar flux reducing the risk of sinusitits.
In particular the sinus lift procedure leads
to a major quantity of mucus to be drained, due
to the surgical insult or an eventual migration of
The Journal of Implant & Advanced Clinical Dentistry • 59
Maiorana et al
the grafting material in the antral cavity in case
of perforation of the Schneiderian membrane.19
The literature suggests a surgical-endoscopic
approach to remove the intrasinusal lesion, in
order to consent the possibility to perform the
sinus lift procedure and the implant insertion.20, 21
CONCLUSION
The Authors propose a modified surgical
approach to drain the endoluminal liquid during
the sinus lift procedure. The new proposed tech-
nique allows the reduction of the surgical morbid-
ity thanks to the elimination of one surgical phase
in case of staged approach. Furthermore, a pseu-
docyst of the maxillary sinus is not a contraindica-
tion for sinus augmentation. The low frequency
of sinus membrane perforation and postsurgical
sinusitis makes the operation safe.6 Neverthe-
less, in patients with large lesions and where the
diagnosis is not clear, further evaluation should
be made before sinus augmentation is scheduled.
It is mandatory for the surgeon to be famil-
iar with the anatomy and pathology of the
maxillary sinus to avoid any unnecessary com-
plications. For this reason, pre - surgical radio-
graphic evaluation of the maxillary sinus by a
trained surgeon is mandatory to avoid unneces-
sary complications. Most cases of antral pseu-
docyst are directly related to the severity of
periodontal disease and odontogenic infections. ●
Correspondence:
Dr. Carlo Maiorana
Clinica Odontostomatologica,
Ospedale Maggiore Policlinico,
Via della Commenda n. 10 20132
Milano, Italy
Phone: 0039335602527;
Email: carlo.maiorana@unimi.it
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60 • Vol. 4, No. 5 • November/December 2012
Maiorana et al
Disclosure
The authors report no conflicts of interest with
anything mentioned in this article.
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Maiorana et al
