Pablo Galindo-Moreno Complications associated with implant

Miguel Padial-Molina
Gustavo Avila
migration into the maxillary sinus
Hector F. Rios cavity
Pedro Hernández-Cortés
Hom-Lay Wang

Authors’ affiliations: Key words: alveolar ridge augmentation, bone grafting, complications, dental implants,
Pablo Galindo-Moreno, Oral Surgery and Implant maxillary sinus, migration
Dentistry Department, School of Dentistry,
University of Granada, Granada, Spain
Miguel Padial-Molina, Hector F. Rios, Hom-Lay Abstract
Wang, Department of Periodontics and Oral
Medicine, School of Dentistry, University of
Background: Migration of dental implants into the maxillary sinus is an uncommon, but
Michigan, Ann Arbor, MI, USA increasingly reported complication. Implant migration may result from initial lack of primary
Gustavo Avila, Department of Periodontics, stability, intrasinusal and nasal pressure changes, autoimmune reaction to the implant or incorrect
University of Iowa College of Dentistry, Iowa City,
IA, USA distribution of occlusal forces. This retrospective study aims at analyzing the factors that may
Pedro Hernández-Cortés, Orthopedic Surgery Unit, influence implant migration into the maxillary sinus cavity.
San Cecilio Clinical Hospital, Granada, Spain Material and methods: Fourteen patients presenting a total 15 implants that migrated into the
Corresponding author: maxillary sinus were recruited. Diagnosis of this complication was based on imaging techniques,
Dr. Pablo Galindo-Moreno such as cone beam computerized tomography scan and panoramic radiography. Clinical data were
C/Recogidas, 39 5º Izq, 18005 Granada, Spain recorded in all cases and processed for statistical analysis.
Tel.: +34 958 520658
Fax: +34 958 520658 Results: ABH was below 6 mm in the majority of cases. However, almost 50% of the patients did
e-mail: [email protected]/[email protected] not receive any site preparation treatment prior to implant insertion. Five patients (33.3%) were
treated by osteotome techniques, but only one of them had bone grafting. Therefore, 73.3% of
sites did not receive any biomaterial to increase available bone height. The most common
complication-associated factors found on this study were related to implant design (cylindrical),
implant dimension (diameter), implant restoration/rehabilitation method (partial removable
denture), site-specific anatomy (initial residual bone height between 5 and 6.9 mm), demographics
(age), and biomaterials.
Conclusion: Patient selection and proper treatment planning, as well as the application of the
appropriate sinus augmentation technique, are critical aspects that should be controlled to
minimize the risk of implant migration into the maxillary sinus cavity. [Correction added after online
publication August 17 2011: The Conclusion was revised to provide better clarity to the reader.]

Occlusal rehabilitation of the edentulous bone resorption (Schropp et al. 2003). Resorp-
posterior maxilla with implant-supported tive processes are particularly dramatic in the
restorations represents a unique clinical chal- posterior maxilla, resulting in marked verti-
lenge. Posterior upper maxilla bone is typi- cal bone deficiency that may contraindicate
cally soft, due to its thin or non-existing conventional implant placement. Various
cortical and very spongiotic trabeculae, possi- therapeutic alternatives have been proposed
bly compromising implants′ primary stability to overcome this limitation. Sinus floor ele-
and, therefore, consecutively its implant fail- vation, also known as sinus augmentation, is
ure (Adell et al. 1990; Misch 1990a). To offset regarded as a predictable procedure for
this biomechanical disadvantage different implant site development in this region.
therapeutic strategies have been developed. Since it was first described (Boyne & James
Date: These include, but are not limited to, special 1980), this technique has proven its efficacy
Accepted 11 June 2011
drilling protocols, modified implant designs, and reliability in a variety of clinical scenar-
To cite this article: and the use of bone condensers (e.g. osteo- ios using different grafting materials, and
Galindo-Moreno P, Padial-Molina M, Avila G, Rios HF,
Hernández-Cortés P, Wang H-L. Complications associated tome-based implant placement). On the other modifications of the original surgical protocol
with implant migration into the maxillary sinus cavity.
hand, tooth loss typically triggers a cascade (Wallace & Froum 2003; Pjetursson et al.
Clin. Oral Impl. Res. 00, 2011, 1–9
doi: 10.1111/j.1600-0501.2011.02278.x of events that ultimately leads to alveolar 2008; Tan et al. 2008). A number of alternatives

© 2011 John Wiley & Sons A/S 1

Galindo-Moreno et al
Implant migration into the maxillary sinus

to ridge augmentation procedures, such as Materials and methods proportions. Kendall Tau-b was used for
tilted implants, zygomatic implants, ptery- determining the significance of associations
goid implants, short implants (<10 mm), res- Study population between ordinal and scale variables, and Cra-
torations in cantilever or even graftless sinus Migrated implants from patients who mer V was used for pairs of nominal vari-
floor elevation have been described as suit- suffered dental implant displacement into ables. Secondly, we studied how patient
able methods to restore posterior occlusal the maxillary sinus were included in this factors (smoking habits, alveolar height) and
function with implant-supported prostheses retrospective study. Migrations took place at implant features (implant design, diameter,
(Thor et al. 2007). different stages of the treatment sequence length) affect implant migration into sinus
An increasing debate exists in the scien- and maintenance, between the years 2005 cavity. Finally, backward logistic regression
tific community regarding the treatment of and 2010. Patients were treated in a private (P out = 0.10, 20 interactions) was used to
choice to obtain satisfactory outcomes with practice setting (P.G.-M.). Institutional explore whether presence or absence of
minimal trauma and to shorten the total Review Board from the University of Michi- related complications can be postdicted. Pres-
treatment time. However, selection of an gan issued an exemption to this study ence/absence of complications served as the
inadequate treatment option may derive into because of the use of collected existing data dependent and age, gender, smoking habits,
serious complications, such as implant in such a manner that subjects cannot be alveolar height, implant diameter, implant
migration inside the sinus cavity. Since the identified, directly or through identifiers length, and biomaterial served as predictors.
first case was described (Regev et al. 1995), linked to the subjects (HUM0048824). All of Analyses were performed using SPSS for
other authors have depicted the occurrence of the patients were informed about their clini- Windows (PASW 18.0; SPSS Inc., Chicago, IL,
this adverse event into the maxillary and cal circumstances, and everyone who under- USA).
other paranasal sinuses. Most reports have went corrective surgery signed an informed
included a limited number of implants consent.
(Regev et al. 1995; Iida et al. 2000; Raghoebar Results
& Vissink 2003; Nakamura et al. 2004; Gal- Data collection
indo et al. 2005; Varol et al. 2006; Guler & Diagnosis of the migration was assessed Fourteen patients (6 women) presenting a
Delilbasi 2007; Kim et al. 2007; Kitamura based on imaging techniques, such as cone total of 15 migrated implants were enrolled
2007; Lubbe et al. 2008; Flanagan 2009; beam computerized tomography (CBCT) and in this study. One patient presented two
Borgonovo et al. 2010; Kluppel et al. 2010; panoramic radiography (PR). Radiographic migrations in the same maxillary sinus
Ramotar et al. 2010; Scarano et al. 2010; diagnosis was complemented with a clinical (Fig. 1), although just one of them was con-
Tsodoulos et al. 2010), with only a couple examination in all patients. sidered in the statistical analyses. Mean age
that include a slightly larger series of cases Standardized digital panoramic radiographs was 54.87 years (SD ± 8.75), ranging from 38
(Chiapasco et al. 2009; Ridaura-Ruiz et al. (Kodak ACR-2000; Eastman Kodak Com- to 65 years. A total of 66.7% of the subjects
2009). Various treatment modalities have pany, Rochester, NY, USA) were obtained at were smokers. Mean ABH was 5.2 mm
been employed to deal with this complica- the diagnosis appointment, prior to surgery (SD ± 2.98). ABH was below 6 mm in
tion, from a conservative approach (i.e. leave when it was realized. Specialized software 85.71% of the patients (n = 12). In the other
the migrated implant untreated under moni- (Dent-A-View v1.0; DigiDent, DIT, Nesher, two sites, corresponding to two different
toring) to endoscopic transnasal procedures or Israel) was used to make linear measure- patients, initial height was more than 6 mm.
a conventional Cadwell-Luc technique. ments. However, these patients had undergone previ-
Different theories have been proposed and Information recorded included patient’s age ous sinus augmentation for delayed implant
aimed at explaining the mechanism by which and gender, smoking habits (smoker/non- placement. Baseline remnant bone height
implant migrations occurs. Some of the smoker), initial implant location, implant (RBH) considered for these two sites was 10.4
proposed primary factors involved in this diameter and length, implant macro- and and 12.7 mm, respectively. The implant oste-
complication include changes in the intrasin- micro design features (i.e. implant design and otomy was prepared by means of a trephine
usal and nasal pressures (Galindo et al. 2005), type of surface), sinus augmentation status (3 mm internal/4 mm external diameter) in
autoimmune reaction to the implant or (presence or absence), grafting material used, both cases. Interestingly, although initial
incorrect distribution of occlusal forces available bone height at the time of implant ABH was below 6 mm in all cases, only three
(Regev et al. 1995). Nevertheless, it is impor- placement (ABH), type of prosthesis, pathol- patients underwent maxillary sinus augmen-
tant to consider that inadequate treatment to ogy derived from the migration and type of tation following a lateral window approach
rehabilitate edentulous segments of the pos- therapy indicated to resolve the complica- (Fig. 2a). Five sites (33.3%) were treated with
terior maxilla (e.g. absence of implant site tion. an osteotome technique (Fig. 2b), although
development) may be the underlying cause of only in one case a grafting material was used
implant migration in many instances (Chiap- Data analysis (Anorganic bovine bone; BioOss®, Geistlich
asco et al. 2009). Statistical data analysis was aimed firstly at Pharma AG, Wolhusen Switzerland), and
This retrospective study aimed at iden- describing the main features of the distribu- 46.7% of the sites did not receive any treat-
tifying the factors that may contribute to tion of the measures: central tendency and ment at all before implant insertion (Fig. 2c).
the occurrence of implant migration into data dispersion for scalar variables, and rela- This indicates that 73.3% of these sites did
the maxillary sinus cavity. In addition, we tive frequencies for categorical ones. Only 14 not receive any augmentation procedure to
evaluated the pathology derived from these implants were considered for the statistical increase the available bone height prior to
adverse events and proposed different thera- analyses, considering just one implant per implant placement. Implant-supported pros-
peutic approaches to resolve these complica- patient. Binomial and chi-square randomiza- theses included single-tooth restorations
tions. tion-based tests were used for the analysis of (26.7%), fixed partial denture (46.7%), over-

2 | Clin. Oral Impl. Res. 0, 2011 / 1–9 © 2011 John Wiley & Sons A/S
 Galindo-Moreno et al
Implant migration into the maxillary sinus

(a)

(b)

Fig. 1. Two migrations in the same maxillary sinus.

denture (6.7%), and full arch rehabilitation previous treatment appeared to be associated
(20.0%). to the biomaterial used (Cramer V = 0.874,
Complications associated with the migra- P = 0.002) and to age (Kendall Tau-B = 0.41,
tion were mobility of the fixed prosthetic reha- P = 0.073). Finally, we tried to determine if we
bilitation (46.7%), acute sinusitis (13.3%), could classify the patients according to
local gingival swelling (6.7%), and bacterial or whether they had related complications or
(c)
fungal infection (6.7%) (Fig. 3). Approximately not. Backward logistic regression (P
one-fourth of the patients (26.7%) did not out = 0.10) indicated that the best predictive
report previous symptoms and the diagnoses model included age, ABH, implant diameter,
were incidental, following routine radio- and biomaterial (χ2(4) = 17.39, P = 0.002,
graphic analysis. Many of our patients (46.7%) Snell-Cox pseudo-R2 = 0.70). All cases were
rejected to have the implant removed, given correctly classified as having or not having
the absence of clinical symptoms. All related complications. As a validation of logis-
implants removed (53.3%) were extracted tic regression, linear discriminant analysis
using a modified Caldwell Luc approach. including these predictors, correctly classified
Regarding the frequency distribution of fourteen of the fourteen related complications.
migration several significant results were Older patients typically require a more com-
observed. First, implant design (conical vs. plex prosthetic approach, given the higher
cylindrical) appears to be important for number of missing teeth, along with poorer Fig. 2. (a) Implant migration after maxillary sinus
augmentation following a lateral window approach. (b)
explaining migration of implants, since bone density, and less quantity of residual
Implant migration after maxillary sinus augmentation
migration proportion was higher for cylindri- bone, which may involve inferior biomechani- following osteotome technique with no grafting. (c)
cal than for conical implants (P = 0.013 by cal conditions in the posterior maxillary bone, Implant migration in a patient who did not receive any
the binomial test). The practical implications as suggested by Regev et al. (1995). The coexis- treatment at all before implant insertion.

of this result will depend on the a priori tence of this set of factors may facilitate the
probability of each design. Second, it seems migration and, subsequently, the prosthetic
that the smaller the implant diameter, the mobility, which was the most commonly tori et al. 2008), and zygomatic or pterygoid
greater the probability of prosthesis mobility related complication to implant migration implants (Malevez et al. 2004). These surgi-
(P = 0.01, chi-square-based randomization (46.7%). All the descriptive information cal techniques require advanced training and
test, http://udel.edu/~mcdonald/statrand.xls). recorded with the corresponding statistical experience to ensure clinical safety. For
Third, there seems to be a significant linear values is presented in Table 1. example, placement of zygomatic and ptery-
increase of the frequency of mobility as the goid implants requires a learning curve to
implant length increases (Kendall Tau-B = avoid adverse events, such as ocular lesions,
0.536, P = 0.042). This trend is clearly Discussion hemorrhage of the pterygoid plexus, oculo-
observed when lengths are grouped in inter- facial paraesthesia, or deep fascia infection
vals of 2 mm (Kendall Tau-B = 1). Fourth, Many options are available to rehabilitate (Balshi et al. 1999; Penarrocha et al. 2009).
when ABH was grouped in 2 mm intervals, a atrophic maxillae with implant-supported Similarly, the success of tilted implants is
curvilinear impact on mobility was observed prostheses. These may include maxillary based on proper case analysis, adequate clini-
(R2 = 0.80), being the interval 5–6.9 mm sinus augmentation, alveolar ridge splitting, cal performance, and the delivery of a well-
worse than the remaining ones. Next, we horizontal ridge augmentation by means of designed prosthetic restoration that mini-
explored the relationships between variables block grafting or guided bone regeneration mizes lateral occlusal loading (Testori et al.
that may have a clinical impact. In this sense, (Chiapasco et al. 2006), tilted implants (Tes- 2008). Sinus augmentation is the most

© 2011 John Wiley & Sons A/S 3 | Clin. Oral Impl. Res. 0, 2011 / 1–9
Galindo-Moreno et al
Implant migration into the maxillary sinus

(a) reno et al. 2007). Both the lateral access and floor, by the maxillary sinus anatomy, and by
the transcrestal osteotome-based approach the force applied during the surgical tech-
have demonstrated high predictability, nique (Berengo et al. 2004). During transcres-
regardless of the grafting material employed, tal sinus floor elevation the force required for
as long as they are applied following an evi- membrane detachment increases as the area
dence-based approach (Wallace & Froum to elevate does (Pommer & Watzek 2009).
2003; Pjetursson et al. 2008, 2009). Consequently, in cases of narrow internal
In 80% of the cases in the here reported sinus anatomy where the circumference of
study was either performed a sinus augmen- the elevated area is smaller, the elevation
tation via osteotome approach (33.3%) or no height would be higher than in wide sinuses,
augmentation (46.7%) at all. Despite the as long as the same force is applied (Pommer
(b)
development and predictability of the lateral et al. 2009). The area of force transmission
approach, some clinicians avoid the use of applied during sinus elevation by means of
this technique since it may be more trau- osteotomes equals the surface area of the
matic and difficult to perform. Interestingly, proximal end of the osteotome. Therefore,
for some clinicians this idea could be rein- higher forces are applied using osteotomes of
forced, because some authors even have high- a larger diameter, due to an increased load
lighted of placing implants inside the sinus transfer. Considering that the diameter of the
cavity without grafting with similar success final osteotome used must be similar to the
rates (Lundgren et al. 2004; Thor et al. 2007). one of the implant, chances of having a
This concept is based on an early study membrane perforation may be higher in clini-
(c) reporting that significant bone gain (>5 mm) cal scenarios in which forces applied are not
can be achieved even in presence of perfo- properly controlled by an experienced clini-
rated sinus membrane (Boyne 1993), with no cian. The average height of sinus elevation
clinical consequences. Conversely, osteotom- has been reported to range between 2.5 and
e-based sinus augmentation is considered a 8.6 mm for transcrestal techniques (Engelke
less traumatic and safer approach for implant et al. 2003; Toffler 2004; Vitkov et al. 2005;
site development in the posterior maxilla. Nedir et al. 2006). This would imply that
However, some considerations can be made this procedure might be limited to a residual
in this respect. Schneiderian′s membrane bone height unless over 8 mm, allowing
integrity contributes to adequate graft heal- clinicians to conduct a one-stage surgery
ing, probably due to its high reparative poten- protocol (Misch 1990a; Katranji et al. 2008).
(d)
tial (Srouji et al. 2009, 2010). This element Overdrilling, use of trephines, or inade-
is essential to maintain the sinus cavity quate performance of an osteotome technique
isolated from the graft and implant/s. Schne- at the time of implant placement in the pos-
iderian′s membrane perforation increases the terior maxilla could lead to lack of primary
possibility of complications, such as postop- implant stability. Insufficient primary stabil-
erative maxillary sinusitis due to retrograde ity may induce micromovements in early
bacterial contamination or graft migration healing stages, particularly in soft bone.
into the sinus (Pikos 1999), compromising Micromotion is considered an etiologic factor
the success of the technique (Cho et al. for implant failure. It has been associated
2001), and eventually implant survival (Her- with the formation of fibers at the host-
Fig. 3. (a) Lateral approach for migrated implant retrie-
nandez-Alfaro et al. 2008). In transcrestal implant interface, as an adaptation to
val. (b) Detail of the implant removed surrounded by
unknown material submitted to histopathological anal- approaches, perforation rates range between mechanical forces (Akagawa et al. 1986).
ysis. (c) Moderate chronic inflammatory reaction in 2% and 25% (Berengo et al. 2004; Ferrigno Continuous micromotion superior to 150 lm
contact with Periodic Acid Schiff positivity substance et al. 2006). However, perforation of the has been shown to compromise implant heal-
(*) (PAS 9100). (d) Demonstration of mycotic ingrowth
Schneiderian′s membrane cannot be identi- ing, while micromotions of 30–50 lm are
with numerous hyphae (black color) in the material
isolate around dental implant (Grocott’s Methenamine
fied unless a simultaneous intraoperative considered acceptable (Pilliar 1991). Davies
Silver Stain 9400). antroscopy is performed (Engelke & Deckwer suggested that micromotion can interfere
1997). Nkenke and coworkers concluded that with formation of the fibrin clot on the
a mean elevation of 3.0 ± 0.8 mm could be implant surface during early wound-healing
accepted technical approach to compensate attained by an endoscopically controlled (Davies 1998). According to Brunski, micro-
for the limited available bone typically pres- osteotome technique alone before concomi- motion can also damage early vascular struc-
ent in these locations after tooth loss. Multi- tant spontaneous perforation of the sinus tures and prevent the chemotaxis of cells
ple modifications of the original sinus membrane in the periphery of the elevated needed for bone regeneration, which may
augmentation technique (Boyne & James area, occurred (Nkenke et al. 2002). Maxi- result in scar tissue formation instead of
1980) have been proposed, comprising a vari- mum elevation allowed with no perforation bone formation (Brunski 1999). For this
ety of biomaterials, (Galindo-Moreno et al. is determined by the elastic properties and reason, early or immediate implant loading
2008) and techniques (e.g. lateral, transcrestal thickness of the Schneiderian′s membrane, has been traditionally avoided during wound-
or balloon) (Vitkov et al. 2005; Galindo-Mo- by the strength of its attachment to the sinus healing period as a prerequisite for osseointe-

4 | Clin. Oral Impl. Res. 0, 2011 / 1–9 © 2011 John Wiley & Sons A/S
 Table 1. Demographic and implant-related information
Referring Previous Implant Implant Implant Manufacturer: Time of Related Migration
doctor Age Sex Habits ABH treatment Biomaterial location diameter length surface Prosthesis detection complications treatment
1 50 M S 2.2 O ABB 26 4.5 13 Astra Tech: ST Post-loading No Cadwell-
Osseospeed Luc
2 60 M No 3.7 No No 25 4 10 3i: Osseotite PFD Healing Infection Cadwell-
Luc
3 58 M S 5.3 No No 25 4 12 Calcitek: PFD Post-loading Prosthesis No
HA Coating Movement
4 62 M S 5.8 No No 26 4.2 16 Microdent: PFD Post-loading Prosthesis Cadwell-

© 2011 John Wiley & Sons A/S

Sandblasted- Movement Luc
etched
5 65 F No 1.3 No No 15 4 13 3i: Osseotite OD Post-loading Prosthesis No
Movement
5 38 F No 5.8 No No 15 4 15 3i: Osseotite ST Post-loading No No
5 45 M S 4.7 O No 25 4 15 3i: Osseotite PFD Post-loading No No
6 55 M No 5.2 LA ABB 26 4 11 Astra Tech: PFD Healing No Cadwell-
Osseospeed Luc
7 60 M S 2.7 O No 26 4.1 13 Zimmer: MTX PFD Healing Swelling Cadwell-
Luc
8 45 M S 12.7 LA+T ABB+ACB 16 4.2 14 Microdent: PFD Post-loading Prosthesis No
Sandblasted- Movement
etched
8 50 F S 10.4 LA+T ABB+ACB 26 4.2 12 Microdent: FA Post-loading Prosthesis Cadwell-
Sandblasted- Movement Luc
etched
9 65 F S 5.2 No No 15 4 15 3i: Osseotite FA Healing Acute No
Sinusitis
9 65 F S 5.2 No No 17 4 11.5 3i: Osseotite FA Healing Acute No
Sinusitis
10 45 F No 2.9 O No 16 4.5 15 Astra Tech: ST Post-loading Prosthesis Cadwell-
Osseospeed Movement Luc
11 60 F S 4.9 O No 17 4.2 16 Microdent: ST Post-loading Prosthesis Cadwell-
Sandblasted- Movement Luc
etched

Total/ 54.87 ± M = 53.3% S = 66.7% 5.20 ± No = 46.7% No = 73.3% 26 = 33.3% 4.13 ± 13.43 ± 3i: Osseotite = PFD = Post-loading Prosthesis Cadwell-
Means ± 8.75 F = 46.7 No = 33.3 2.98 O = 33.3% ABB = 13.3% 25 = 20% 0.18 1.88 40% 46.7% = 66.7% Movement Luc =
SD (95) LA+T = 13.3% ABB+ACB = 15 = 20% Microdent: ST = Healing = 46.7% 53.3%
LA = 6.7 13.3 16 = 13.3% Sandblasted- 26.7% = 33.3% No = 26.7% None =
17 = 13.3 etched = 26.7% FA = Intrasurgery Acute 46.7
Astra Tech: 20% =0 sinusitis
Osseospeed = OD = = 13.3%
20% 6.7 Swelling
Calcitek: = 6.7%
Infection

5 |
HA Coating =
6.7% = 6.7
Zimmer:
MTX = 6.7

Gender: M = male, F = female; Habits: S = smoking; ABH: =available bone height at the time of implant placement; previous treatment: O = osteotome, LA = lateral approach, LA+T = lateral approach
+ trephine; biomaterial: ABB = anorganic bovine bone, ACB = autogenous cortical bone; prosthesis: ST = single tooth, PFD = partial fixed Denture, OD = overdenture, FA = full arch rehabilitation.

Clin. Oral Impl. Res. 0, 2011 / 1–9

Galindo-Moreno et al
Implant migration into the maxillary sinus
Galindo-Moreno et al
Implant migration into the maxillary sinus

gration (Szmukler-Moncler et al. 1998). This considered as the minimal residual bone ous cases previously reported in the litera-
concept is of capital importance in areas of height necessary to conduct a one-stage sinus ture, just only one patient from the 62 had
low-density bone, where reasonable doubts augmentation surgery, because primary sta- been treated to properly prepared sites for
regarding implant stability exists. On the bility can be achieved (Peleg et al. 1999; Rios implant placement, before the migration
other hand, lateral approaches allow us to et al. 2009; Zinner & Small 1996). Several (Table 2).
visualize the new increased ridge where the classifications discuss the indications for Interestingly, Olson and coworkers
implant could be stabilized. both techniques contemplating a wide array reported higher survival rates for implants
Our results showed that the incidence of of factors (Misch 1990b; Wang & Katranji placed in grafted sinus areas than for those
implant migration into the sinus cavity is 2008). These concepts may be confusing for placed in maxillary pristine bone (Olson
higher for cylindrical implants as compared non-adequately trained clinicians, which may et al. 2000). In this sense, it has been
to conical ones, for narrower implants, and move them to perform theoretically less suggested that areas that received maxillary
when implants were placed in smokers. A invasive procedures or even none. sinus augmentation achieve equal or superior
singular finding in this study was that the It is crucial to realize that this emerging bone volume and density as compared to
longer the implant, the stronger the associa- complication could be primarily derived from maxillary pristine bone (Trisi & Rao 1999;
tion with migration. This could be looked as lack of adequate information or knowledge to Ulm et al. 1999; Handschel et al. 2009). Our
an illogical result, but we should not disre- make a proper clinical judgment and surgical group showed that both cellular activity and
gard that 73.3% of the sites did not receive performance. Clinical complications are vital bone content are higher in areas grafted
any biomaterial and the mean length of the reported regularly in most journals of the with a mixture of anorganic bovine bone plus
implants in this series was 13.43 ± 1.88 mm, field. From single case reports, to a growing cortical autogenous bone as compared to
independently of the mean ABH (5.20 ± number of larger series, dental implants maxillary pristine bone (Galindo-Moreno
2.98 mm). Interestingly, mean implant length migrated to paranasal sinuses have been et al. 2010). In light of this information, it is
without bone contact inside the sinus cavity reported over the last 15 years. However, it is reasonable to think that successful maxillary
was 8.23 mm. In light of this information, it a major concern that, in the last few years, sinus augmentation may prevent implant
can be stated that the concordance between several reports including a total of 62 migration.
the technique conducted by the professionals implants migrated to paranasal sinuses have Implant placement in atrophic sites
and the chosen implant for each clinical case been described (Table 2). In our series, treat- commonly requires site development and,
was not correct, which could greatly explain ment was incorrectly planned for 80% of the therefore, advanced surgical skill and experi-
the occurrence of this complication for most sites. Furthermore, 46.7% of them did not ence to reduce the risk of developing a com-
cases. Another remarkable finding was the receive any previous treatment where RBH plication (Wheeler & Bollinger 2009). In the
statistically significant relationship between was less than 5 mm, ignoring all general rec- majority of the cases reported in this study
ABH of 5–7 mm and the increase of migra- ommendations and established protocols. It implant placements were performed by
tion. According to the literature, this can be is important to highlight that of the numer- general dentists, where proper protocol was

Table 2. Reported cases of migrated dental implants into the maxillary sinus
No. of Concomitant/
No. of implants Previous Time of retrieval/detection
Author patients migrated Implant type treatment Implant retrieval after implant insertion
Borgonovo et al. (2010) 3 3 Unavailable None Cadwell-Luc/One spontaneously Unavailable
explanted
Chiapasco et al. (2009) 27 27 Straight None Cadwell-Luc 1–24 months
Flanagan Flanagan (2009) 1 1 Tapered None Cadwell-Luc During insertion
Galindo et al. (2005) 2 2 Straight None Cadwell-Luc/Follow-up 4 years/6 months
Guler & Delilbasi (2007) 2 2 Unavailable None Cadwell-Luc One during insertion;
One 8 years later
Iida et al. (2000) 1 1 Straight None Cadwell-Luc 15 years
Kim et al. (2007) 1 1 Straight None Middle meatal antrostomy 18 months
Kitamura (2007) 1 1 Straight None Transnasal endoscope 3 years
Kitamura & Zeredo (2010) Same patient that the previous report
Kluppel et al. (2010) 2 2 Tapered None Cadwell-Luc/Follow-up 6 months
Lubbe et al. (2008) 1 1 Straight None Transnasal endoscope 3 weeks
Nakamura et al. (2004) 1 1 Tapered None Endoscopy Within days
Raghoebar & Vissink (2003) 1 1 Straight None Cadwell-Luc 5 months
Ramotar et al. (2010) 2 2 Tapered None Endoscopy Within days
Regev et al. (1995) 3 3 Straight None Cadwell-Luc Months to years
Ridaura-Ruiz et al. (2009) 9 9 Straight None/1 Cadwell-Luc/2 Follow-up/ 4–10 months
sinus lift 1 crestal approach
Scarano et al. (2010) 1 1 Straight None Cadwell-Luc 7 years
Tsodoulos et al. (2010) 1 1 Straight None Cadwell-Luc 8 years
Varol et al. (2006) 3 3 Tapered None Endoscopy Within days

TOTAL 62 62 48 Straight 1 Sinus lifts 47 Cadwell-Luc Within days to years

9 Tapered 61 non- 8 encoscopy
5 Unavailable previously 1 crestal approach
treated 4 followed-up
1 spontaneously expelled
1 middle meatal antrostomy

6 | Clin. Oral Impl. Res. 0, 2011 / 1–9 © 2011 John Wiley & Sons A/S
 Galindo-Moreno et al
Implant migration into the maxillary sinus

not followed since majority of these doctors taught off the academic environment of the several of these factors are modifiable while
did not have the advanced training that is dental schools would be discontinued (Ogun- others are not, it is our responsibility to iden-
required to conduct these sophistical proce- salu et al. 2009). In summary, to prevent tify them to minimize the risk of developing
dures. This can be a problem because articles implant migration into the sinus, not only do this undesirable complication.
and course promotional brochures emphasize we need to educate our general dentists part-
the simplicity of placing implants by using ners of the risks associated with implant
novel systems, protocols or devices. One placement especially in the maxillary poster- Acknowledgments: The authors
clear example is a recent article titled “Tech- ior area where the bone is typically atrophic would like to thank Miguel Velasco-Torres,
nology helps an ‘amateur’ place implants” and soft in nature, but also to recommend DDS, Dental Radiologist at Centro de
(Whitehouse 2008). This type of advertise- advanced training, cooperation, and to Diagnóstico Granada, for his collaboration in
ment encourages an increasing number of encourage referral and team work (Pikos the development of this study, Andres
dentists, with limited or no surgical training, 2009). These should be the ways to prevent Catena for his statistical advices, and
to perform implant surgical procedures in complications, so that we can all benefit Francisco O′Valle for the histopathological
their practices. Another important factor to from professional interexchange and under- support. This study was partially supported
consider is that many of the courses on surgi- standing. by Junta de Andalucia Funding Program for
cal implant placement are sponsored by research groups in Spain (Projects #CTS-138
implant companies, or providers, and are and #CTS-583). MPM was also supported by
Conclusions
primarily oriented at selling surgical kits and the Talentia Scholarship Program from the
implants. Many of these programs are abbre- Regional Ministry for Innovation, Science
Implant migration to the maxillary sinus cav-
viated in length, 1–3 days, or less than a and Enterprise – Junta de Andalucia (Spain).
ity is an increasingly serious complication
week. If minimal educational guidelines Authors do not have any financial interests,
influenced by multiple factors that involves
could be established and accepted by the either directly or indirectly, in the products
three main fronts: 1) Implant, 2) Patient and,
implant industry as a whole, most of the listed in the study.
3) Surgeon related factors. Understanding that
abbreviated training courses presently being

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© 2011 John Wiley & Sons A/S 9 | Clin. Oral Impl. Res. 0, 2011 / 1–9