Sinus perforation is a serious complication of the mucous membrane of the nasal cavity that is related to dental procedures and non-dental causes.

The human skull contains 4 sinuses filled with air; the most relevant one to dentists is the maxillary sinus cavity, which extends over the maxillary jaw and teeth and below the cheekbones on either side of the nose and is connected to the nasal cavity.

What Is Sinus Perforation? 

Sinus perforation is an unintended hole in the sinus membrane in the maxillary sinus during dental treatment by accident, trauma, or infection.

The sinus membrane, a thin and delicate tissue lining, separates the sinus cavity from the oral cavity. When this barrier is breached, communication is established between the mouth and the sinus.

Is Sinus perforation an emergency?

Yes, once a patient is confirmed to have sinus perforation, this hole causes serious complications.

This abnormal opening between the maxillary sinus and the oral cavity permits the saliva and bacteria to escape to the nasal cavity, which may lead to infection, bleeding, and pain.

The complication of inappropriate management of sinus perforation 

If the opening is left untreated for 48-72 hours, it develops into Oroantral Fistula (OAF), which is the initial stage of permanent pathological communication that will resist spontaneous closure of the opening through the extraction socket.

What Causes Sinus Perforation?

There are several causes that can occur during the dental procedure: 

• During the extraction of the upper back teeth, 
  The dental Tooth extraction of maxillary “upper” molars and premolars can end up with sinus perforation.
  The long or tilted roots of maxillary back teeth are sometimes close to or extend into the sinus membrane.
  As the tip of the tooth’s root is pulled out of the tooth’s socket during extraction, it punctures the maxillary sinus membrane.

• During dental implant placement 
  Pushing an implant too deep into the maxillary jawbone risks perforating the sinus membrane. 
  The selection of the Implant post may be too long or too thick, which risks the maxillary bone fracture.
  The maxillary bone at the back area of premolars and molars is very thin and more likely to fracture. The risk is also elevated with improper surgical techniques or the use of incorrect implant sizes and placement strategies.

• Due to an infection related to the upper back teeth
  Periapical lesions, such as severe abscesses or cysts. Especially associated with the maxillary molars, it can lead to bone resorption, weakening the bony septa, and leading to sinus perforation.

• During Sinus Lift Surgeries
  Although the main purpose is to increase the height of the thin posterior maxillary bone via bone graft and membrane, any inappropriate surgical intervention can lead to perforating the delicate lining of the sinus, which causes sinus perforation and failure of the surgery.
• Orthognathic Surgery, such as Le Fort I osteotomy 
• Bone Tumors in the maxillofacial region, such as sarcomas and osteomas.

What Are The Symptoms Of Sinus Perforation?

There are common clinical manifestations in sinus perforation that happen immediately on the chairside and after dental procedures.

Immediate post-operative signs and symptoms of Sinus Perforation 

Patients experience these symptoms of sinus perforation after dental extraction or surgery, on the chairside, or 24 hours after the surgery.

1. Hissing or whistling during breathing or speech.
2. Airflow or obvious bubbling on the extraction site.
3. Change in voice resonance.
4. Clear or bloody nasal discharge.
5. Nasal congestion and difficulty breathing through the nose
6. An unusual and unpleasant taste or odor in the mouth or nose may be present.
7. Saliva, fluids, or sometimes food passing from the mouth to the nose.
8. Bleeding in the dental implant site is a symptom of sinus perforation after dental implant placement.

If a patient experiences any of these symptoms, they should contact their dentist immediately.

Delayed signs and symptoms of Sinus Perforation

Several symptoms may manifest or persist in the days and weeks following a dental procedure complicated by sinus perforation.

• Persistent pain, discomfort, and tenderness in the upper jaw.
• Pain radiates to the cheek, nose, and eye on the affected side.
• Headache localized around the nasal and sinus region.
• Persistent Swelling around the dental implant site or in the cheek can worsen over time.
• If the patient has a fever, this may indicate a secondary infection.
• Some patients may experience loss of smell or taste.
• In rare cases, patients might feel ear pain or a severe toothache.

These severe signs and symptoms can’t be ignored or managed by OTC medications, the patient should head to a professional surgeon or dentist who can manage the case appropriately for the patient’s health. 

Why can’t you be worried at Suave Clinic?

These mishandling situations are rare at  Suave Clinic, as evidenced by the reviews and testimonials of our patients.
Our skilled professional dentists follow certain work guidelines that limit dental surgery complications.
The precautions followed at Suave Clinic are a result of the thorough comprehensive oral diagnosis, periapical x-ray before tooth extraction, and good assessment of the radiographs required before dental implants such as CT, or CBCTs which helps evaluate the bone height and density, whether patients need bone grafts, and the perfect place for dental implant placement.
All that lowers the chance of sinus perforation during dental procedures.

Diagnosis Methods of Sinus Perforation

At Suave Clinic, we receive patients with clinical manifestations of a perforated sinus. Here is how we deal with it properly: 

• Complete medical and clinical history of the patient.
• Evaluation of all the symptoms that the patient complains about.
• ِA thorough oral diagnosis and visualization of the area of pain.
• The presence of an Oro-antral fistula is a clear sign of sinus perforation.
• In the case of no Oro-antral Fistula, the Valsalva maneuver is used, which is a common diagnostic test, where the patient is asked to pinch his nostrils, close his mouth, and try to exhale, the air bubbles in the affected site confirmed sign of Sinus Perforation.
  • However, if this test is done forcefully, the small sinus perforation becomes larger.
• Panoramic radiographs can visualize the communication between the posterior maxillary jaw and the maxillary sinus, although CT and CBCT are more confirmatory and provide detailed three-dimensional assessments of the extent and location of the perforation.

What Is Sinus Perforation Treatment?

There are treatment options for Sinus Perforation depending on the size of the perforation.

Conservative management for small perforations 

Small perforations are less than 4-5mm, they are asymptomatic to the patient, only the dentist will notice bubbly blood after maxillary posterior molar extraction or after dental placement.

These small perforations may heal spontaneously by maintaining a stable blood clot in the extraction site and following post-operative instructions and pharmacological interventions.

Pharmacological intervention that promotes healing The medication needed after a small sinus perforation is left to heal spontaneously 

• Antibiotics: to limit the risk of secondary infection and treat the existing sinus inflammation 
• Nasal decongestion orally or locally by nasal sprays for only 3 days, like Afrin or Sudafed, to alleviate nasal congestion and promote drainage from the sinus cavity.
• Saline nasal rinses are performed gently with small pumps to promote healing and maintain a healthy sinus lining.
• Pain killers as Ibuprofen, to manage discomfort 

Surgical repair of larger sinus perforations 

Painful and symptomatic sinus perforation means that the perforation is larger than 5mm, which indicates surgical interventions.

1. Primary Closure by Gum Suture
   If a relatively small perforation is detected immediately on the chairside, primary closure is directly achieved by suturing the gum tissue of the extraction site or around the dental implant by a figure-eight suture that is often called an air-water-tight suture that prevents any escape of saliva or air into or out of the sinus.

2. Flap procedure
   Used for larger perforations where gum suturing isn’t applicable, or in case of the presence of an oro-antral fistula, which the surgeon will remove, creating a large damaged area.
   The flap is done by taking gum tissue out of its place and using it to cover the defect, then suturing the incision site. There are several types of flaps 
   • Buccal advancement flap 
   • Palatal flap 
   • Buccal fat pad graft for larger oro-antral communications 

3. Membranes and Bone Grafting 
   A resorbable membrane can be placed over the perforation site, and if the maxillary sinus is large and the maxillary jaw is thin, bone grafting may be necessary to provide support and facilitate healing by a Sinus Lift Procedure.

4. In complex cases, collaboration with an ENT specialist may be necessary.
5.  Platelet-rich fibrin as a growth factor may aid in the healing process.

The selection of the most appropriate treatment approach is highly dependent on the perforation size, the patient’s symptoms, and their general health.

The faster the diagnosis of sinus perforation, the better the prognosis.

What Are The Guidelines After Sinus Perforation Surgery?

As long as the sinus doesn’t have infection or inflammation, it will heal spontaneously, although there are some aftercare instructions you should follow to promote healing with minimal side effects:

• Don’t panic if you find some blood in your nose, as it may be some blood from the maxillary sinus.
• Avoid any disturbance of the blood clot in the extraction socket, so :
• Don’t suck, don’t gargle, don’t spit, and don’t blow your nose to keep the blood clot stable.
• Avoid anything that causes you to sneeze or cough.
• Avoid smoking.
• Take the medications as prescribed and don’t skip follow-up sessions.

Sinus Perforation FAQs