Vittorio Favero Sinus floor elevation outcomes

Niklaus P. Lang
Luigi Canullo
following perforation of the
Joaquin Urbizo Velez Schneiderian membrane. An
Franco Bengazi
Daniele Botticelli
experimental study in sheep

Authors’ affiliations:
Vittorio Favero, Private Practice, Treviso (TV), Italy
Niklaus P. Lang, Center for Dental Medicine,
University of Zurich, Zurich, Switzerland
University of Bern, Bern, Switzerland
Luigi Canullo, Private Practice, Roma, Italy
Joaquin Urbizo Velez, Franco Bengazi, Daniele
Botticelli, Faculty of Dentistry, University of
Medical Science, La Habana, Cuba
Daniele Botticelli, ARDEC, Ariminum
Odontologica, Rimini, Italy
Corresponding author:
Dott. Daniele Botticelli
Avenida Salvador Allende
y G Vedado, La Habana, Cuba
Tel.: +53 7 879 3360
Fax: +53 7 870 3312
e-mail: daniele.botticelli@gmail.com
Key words: alloplast, animal study, bone, bone graft, bone healing, collagen membrane, his-
tology, morphometry, sinus floor elevation
Abstract
Objective: To assess the influence of a collagen membrane covering a perforation of the sinus
(Schneiderian) membrane on the outcome (bone fill) of a sinus floor elevation.
Materials and Methods: Eighteen Pelibuey sheep were used. The animals underwent sinus floor
elevation on both sides of the upper jaw. A perforation of 5 9 4 mm in dimension of the sinus
mucosa was performed on both sides and, at a randomly selected test site, a collagen membrane
was placed to cover the perforation. A graft of biphasic calcium phosphate (60% HA/40% beta-
TCP) was subsequently placed bilaterally, and the access window was closed with a membrane
made of polylactic acid and a citric acid ester acetyl. The sacrifices were performed after 2, 4, and
12 weeks of healing.
Results: After 2 weeks of healing, the augmented volume was filled with biomaterial surrounded
by connective tissue and minimal new bone was detected. After 4 weeks of healing, new bone was
found mainly in connection with the sinus bony walls with percentages of 18.0  12.9% at the test
and 12.3  7.9% at the control sites. After 12 weeks of healing, similar amounts of newly formed
bone were found compared to the previous healing period, namely 16.7  8.0% and 13.7  10.1%
at the test and control sites, respectively, with the highest amount detected in the bottom of the
sinus cavity. The newly formed bone was distributed more evenly within the sinus cavity also
including the central areas. The differences between test and control sites did not reach statistical
significance.
Conclusion: Even though there were trends for more bone formation when applying a collagen
membrane on a sinus mucosal perforation of relatively small dimensions, this study failed to
establish the absolute necessity of such a procedure to achieve bone fill in the sinus cavity.

Sinus floor elevation is a well-known procedure
to address atrophy of the posterior sectors of
the upper jaw in order to install oral implants.
This procedure may be complicated by a series
of pitfalls such as the perforation of the Schne-
iderian membrane. Such complications have
been reported to occur at a rate of 10–55% (Sch-
wartz-Arad et al. 2004; Nolan et al. 2014).
Perforations may happen because of iatrogenic,
anatomic, or pathophysiologic reasons.
It has recently been shown that the perfo-
Date:
ration of the sinus membrane may result in a
Accepted 1 February 2015 higher loss or dislodgment of grafting mate-
To cite this article: rial, a higher loss of implants, and a higher
Favero V, Lang NP, Canullo L, Urbizo Velez J, Bengazi F, incidence of complications such as sinusitis
Botticelli D. Sinus floor elevation outcomes following
perforation of the Schneiderian membrane. An experimental (Nolan et al. 2014).
study in sheep. Small perforations may close spontane-
Clin. Oral Impl. Res. 00, 2015, 1–8.
doi: 10.1111/clr.12576 ously and deliberate closure may not be
necessary (Fugazzotto & Vlassis 2003; Shlomi
et al. 2004). Alternatively, sutures (Khoury
1999; Vlassis & Fugazzotto 1999; Schwartz-
Arad et al. 2004) or fibrin glue may success-
fully be used (Khoury 1999; Schwartz-Arad
et al. 2004; Kim et al. 2008). For larger perfo-
rations, the positioning of a buccal fat pad
pedicled flap (Kim et al. 2014) may be used.
The placement of resorbable membranes to
cover such a perforation has also been advo-
cated (Pikos 1999; Proussaefs et al. 2003; Tes-
tori et al. 2008; Kim et al. 2014). These
authors suggested the use of a collagen mem-
brane that may lead to a higher bone fill of
the sinus cavity. However, no randomized
studies are available to substantiate such
claims. Hence, the aim of this study was to
assess the influence of a collagen membrane

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 1
Favero et al
Perforation of the sinus mucosa

covering a perforation of the sinus (Schneide- membrane was performed with scissors Histological preparation
rian) membrane on the outcome (bone fill) of (Fig. 1d). At a randomly selected test site, a The biopsies were removed and maintained
a sinus floor elevation in an animal model. collagen membrane of porcine origin (Bio- in 4% formaldehyde solution. The histologi-
Gideâ; Geistlich Biomaterials, Wolhusen, cal procedures were performed in the Labora-
LU, Switzerland) was placed underneath the tory of Histology at the Faculty of
Material and methods Odontology of the University of La Habana,
sinus mucosa (Fig. 2a). No membrane was
interposed between the mucosal perforation Cuba. Block sections, each containing one
The research protocol was submitted to and
and the graft at the control sites. Following sinus, were obtained. The blocks were cut in
approved by the Ethical Committee of the
this, the underlying cavity was filled with a a bucco-lingual plane at the level of the land-
University of Medical Sciences, School of
biphasic calcium phosphate (60% HA/40% mark reference, using a diamond band saw
Dentistry, La Habana, Cuba.
beta-TCP) (easy-graftTM CRYSTAL; Sunstar fitted in a precision slicing machine (Exaktâ;
Eighteen Pelibuey sheep, with a mean
GUIDOR, Etoy, Switzerland) in both sides of Apparatebau, Norderstedt, Germany). One
body weight of about 36 kg and a mean age
the maxilla (Fig. 2b). hemi-block was dehydrated in a series of
of 3 years, were provided by CENPALAB
A steel wire landmark was positioned on graded ethanols and subsequently embedded
(Centro Nacional para la Producci
on de Ani-
top of the access window (Fig. 2c) that was in resin (Technovitâ 7200 VLC; Kulzer, Fried-
males de Laboratorio) of La Habana, Cuba.
subsequently covered with a polylactide acid richsdorf, Germany). One section was
The surgical sessions were performed at the
blended with a citric acid ester membrane selected and reduced to a thickness of about
Centro de Cirug
ıa Experimental (CENCEX)
(GUIDORâ matrix barrier; Sunstar Americas 60 lm using a cutting–grinding device (Ex-
Facultad de Medicina “Victoria de Gir
on”,
Inc., Chicago, IL, USA; Fig. 2d). Suturing in aktâ; Apparatebau). The histological slides
Universidad de Ciencias M
edicas de la Ha-
layers was then provided. were stained with Stevenel’s blue and aliza-
bana, Cuba. The animals were kept at the
Gentamicinâ (Gentamicin-5; Bela-Pharm rin red and examined under a standard light
facilities of CENPALAB during the experi-
GMBH, Vechta, Germany) 8 ml/100 kg every microscope for histometric analysis.
mental period.
12 h was administered during the first post-
The animals were randomly divided in
operative day and every 24 h during the fol- Histological evaluations
three groups of six animals each and fasted
lowing 3 days. The histological measurements were per-
for 24 h preoperatively, but allowed to drink
At sacrifice, the animals were first anesthe- formed in an Eclipse Ci microscope (Nikon
water ad libitum. Anesthesia was induced by
tized and then euthanized with an overdose Corporation, Tokyo, Japan), equipped with a
0.2 mg/kg of midazolam (Dormicumâ; Roche,
of pentobarbital sodium and subsequently digital video camera (Digital Sight DS-2Mv;
Basel, Switzerland) and 5 mg/kg of ketamine
perfused with 10% formalin. The maxilla Nikon Corporation, Tokyo, Japan) connected
(Ketamina-50; Liorad, La Habana, Cuba), fol-
was retrieved en bloc, trimmed, and to a computer, and using the software NIS-
lowed by orotracheal intubation. The anesthe-
immersed in formalin solution. Elements D 4.10 (Laboratory Imaging; Nikon
sia was maintained with a mixture of oxygen
The animals were sacrificed after 2 (Group Corporation).
and 3% isoflurane (Isofluorane-vet; Merial,
A), 4 (Group B), and 12 weeks (Group C), The following landmarks were identified
Toulouse, France) at a rate of 5 l/min. The
respectively. (Fig. 3): (INC) the top of the infraorbital nerve
general anesthesia was supplemented by local
administration of 2% mepivacaine HCI with
1 : 100,000 epinephrine. Prior to surgery, the (a) (b)
surgical sites were rinsed with 0.12% chlorh-
exidine digluconate (PeriogardTM; Colgate-
Palmolive Ltd, New York, NY, USA). All sur-
geries were performed under good clinical and
laboratory practices.

Clinical procedures
Through an extraoral approach, an oblique
incision was made along the sagittal axis
between the facial tuberosity and the inferior
(c) (d)
orbital rim. The skin and periosteum were
elevated separately, and the bony facial sinus
wall was exposed in both sides of the maxilla
(Fig. 1a).
A 12 9 8 mm window was cut in this wall
using a Piezosurgery device (Mectron s.p.a,
Carasco, Genova, Italy) and removed (Fig. 1b).
The Schneiderian membrane was subse-
quently carefully elevated with sinus floor
elevators (Fig. 1c), and the created space was
packed with sterile cotton gauzes to stop Fig. 1. Clinical view. (a) The skin and periosteum were separately elevated and the bony facial sinus wall exposed.
bleeding. After removal of the gauzes, a (b) A 12 9 8 mm window was cut and removed. (c) The Schneiderian membrane was subsequently carefully ele-
5 9 4 mm perforation on the Schneiderian vated. (d) A 5 9 4 mm perforation on the Schneiderian membrane was performed.

2 | Clin. Oral Impl. Res. 0, 2015 / 1–8 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Favero et al
Perforation of the sinus mucosa

Table 1. Percentage of tissue components after 2 weeks of healing. Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
Total 0.2 (0.4) 56.6 (10.7) 13.5 (2.9) 29.7 (9.9)
0.0 (0.0; 0.0) 57.8 (50.8; 63.7) 14.4 (11.1; 15.7) 26.6* (22.4; 37.5)
Zone A 0.0 (0.0) 57.8 (13.3) 11.7 (3.0) 30.5 (10.9)
0.0 (0.0; 0.0) 60.9 (49.9; 64.9) 11.9 (9.5; 13.7) 29.0 (22.8; 37.4)
Zone B 0.5 (1.2) 54.4 (12.6) 15.2 (5.3) 29.8 (13.5)
0.0 (0.0; 0.0) 54.9 (44.7; 64.3) 15.5 (10.9; 18.3) 24.3 (21.4; 40.0)
Zone C 0.0 (0.0) 57.8 (9.8) 13.6 (2.4) 28.6 (8.4)
0.0 (0.0; 0.0) 59.4* (50.5; 65.4) 13.0 (12.1; 15.2) 26.0* (22.8; 35.5)
Control
Total 0.0 (0.0) 43.5 (8.0) 16.5 (5.1) 40.0 (7.9)
0.0 (0.0; 0.0) 41.3 (39.1; 45.0) 14.5 (12.7; 19.4) 42.7* (34.8; 45.2)
Zone A 0.0 (0.0) 47.5 (10.0) 15.6 (6.3) 36.8 (8.6)
0.0 (0.0; 0.0) 46.5 (39.7; 52.9) 13.9 (12.5; 14.9) 34.9 (33.3; 42.7)
Zone B 0.0 (0.0) 40.8 (8.6) 16.7 (5.4) 42.5 (8.9)
0.0 (0.0; 0.0) 44.2 (34.5; 45.4) 16.8 (12.9; 18.7) 43.7 (35.2; 47.9)
Zone C 0.0 (0.0) 42.3 (13.3) 17.2 (6.2) 40.5 (10.7)
0.0 (0.0; 0.0) 42.5* (33.4; 49.7) 14.3 (13.9; 19.5) 41.0* (32.7; 47.5)

*P < 0.05 between test and control.

Table 2. Percentage of tissue components after 4 weeks of healing. Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
Total 18.0 (12.9) 40.3 (15.1) 8.4 (4.4) 33.3 (9.0)
15.1 (12.9; 25.4) 34.5 (28.6; 52.6) 9.9 (5.8; 11.8) 30.7 (28.1; 34.1)
Zone A 20.0 (14.2) 38.3 (17.5) 8.0 (4.7) 33.6 (10.6)
18.4 (12.4; 32.2) 34.4 (25.5; 52.7;) 10.0 (4.5; 11.4) 32.6 (28.5; 37.0)
Zone B 16.4 (11.8) 39.8 (15.2) 9.1 (5.0) 34.7 (8.9)
15.4 (9.7; 26.3) 36.1 (29.7; 48.4) 9.7 (4.9; 13.4) 35.0 (32.6; 39.4)
Zone C 17.7 (14.8) 42.6 (16.4) 8.1 (4.0) 31.6 (11.4)
14.4 (12.6; 19.0) 43.2 (29.0; 55.9) 9.4 (7.9; 10.7) 27.5 (27.1; 28.7)
Control
Total 12.3 (7.9) 48.6 (18.5) 7.6 (4.8) 31.5 (14.4)
12.7 (5.7; 17.5) 43.8 (38.7; 45.7) 6.3 (4.9; 11.6) 37.8 (25.7; 40.8)
Zone A 8.8 (6.7) 53.9 (25.4) 6.5 (5.8) 30.7 (18.8)
10.3 (3.4; 14.3) 44.2 (37.4; 61.3) 6.4 (2.8; 7.9) 40.3 (20.6; 43.4)
Zone B 15.0 (11.8) 46.6 (24.6) 7.8 (6.7) 30.7 (17.5)
16.1 (4.3; 23.8) 37.8; (33.4; 42.8) 5.9 (3.0; 10.6) 32.9 (26.8; 40.0)
Zone C 13.0 (7.3) 45.2 (10.7) 8.7 (5.0) 33.2 (9.0)
9.8 (8.3; 18.2) 47.1 (39.8; 50.2) 9.1 (6.2; 12.3) 34.5 (29.2; 36.0)

Table 3. Percentage of tissue components after 12 weeks of healing. Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
Total 16.7 (8.0) 40.3 (8.2) 6.9 (1.8) 36.1 (9.2)
16.4 (11.3; 17.5) 37.0 (35.9; 41.0) 7.4* (6.7; 7.9) 37.3 (29.6: 40.0)
Zone A 8.4 (7.8) 53.6 (18.9) 5.7 (2.9) 32.3 (17.6)
7.6; (5.1; 7.9) 48.0 (45.0; 52.8) 5.5 (3.5; 8.2) 40.7 (25.0; 43.1)
Zone B 15.5 (10.6) 35.5 (7.1) 7.2 (3.2) 41.8 (11.4)
16.8 (9.3, 19.2) 35.0 (30.9; 39.6) 7.5 (5.3; 8.4) 40.9 (35.6; 46.7)
Zone C 26.4 (8.4) 31.6 (5.5) 8.0 (2.4) 34.0 (7.3)
25.5 (19.5; 30.7) 31.2* (29.9; 36.0) 7.4* (5.9; 9.9) 34.6 (28.3; 39.8)
Control
Total 13.7 (10.1) 51.9 (23.8) 4.2 (2.7) 30.2 (15.6)
13.1 (10.3; 15.0) 44.5 (37.8; 52.5) 4.8* (2.5; 6.1) 34.8 (26.5; 41.5)
Zone A 14.6 (13.2) 45.6 (24.5) 3.7 (3.1) 36.1 (17.2)
11.0 (5.7; 23.3) 38.5 (35.3; 41.2) 3.3 (2.5; 4.1) 41.7 (30.1; 48.3)
Zone B 11.6 (10.6) 49.0 (26.2) 5.4 (4.2) 34.0 (17.1)
9.6 (6.4; 12.9) 43.3 (38.1; 46.0) 5.9 (1.9; 8.8) 38.6 (37.3; 40.9)
Zone C 14.9 (12.3) 61.6 (28.8) 3.3 (2.6) 20.2 (16.4)
16.6 (4.5; 25.0) 50.0* (42.5; 85.2) 3.4* (1.4; 4.7) 25.7 (5.6; 31.6)

*P < 0.05 between test and control.

4 | Clin. Oral Impl. Res. 0, 2015 / 1–8 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Favero et al
Perforation of the sinus mucosa

Table 1. Percentage of tissue components after 2 weeks of healing. Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
Total 0.2 (0.4) 56.6 (10.7) 13.5 (2.9) 29.7 (9.9)
0.0 (0.0; 0.0) 57.8 (50.8; 63.7) 14.4 (11.1; 15.7) 26.6* (22.4; 37.5)
Zone A 0.0 (0.0) 57.8 (13.3) 11.7 (3.0) 30.5 (10.9)
0.0 (0.0; 0.0) 60.9 (49.9; 64.9) 11.9 (9.5; 13.7) 29.0 (22.8; 37.4)
Zone B 0.5 (1.2) 54.4 (12.6) 15.2 (5.3) 29.8 (13.5)
0.0 (0.0; 0.0) 54.9 (44.7; 64.3) 15.5 (10.9; 18.3) 24.3 (21.4; 40.0)
Zone C 0.0 (0.0) 57.8 (9.8) 13.6 (2.4) 28.6 (8.4)
0.0 (0.0; 0.0) 59.4* (50.5; 65.4) 13.0 (12.1; 15.2) 26.0* (22.8; 35.5)
Control
Total 0.0 (0.0) 43.5 (8.0) 16.5 (5.1) 40.0 (7.9)
0.0 (0.0; 0.0) 41.3 (39.1; 45.0) 14.5 (12.7; 19.4) 42.7* (34.8; 45.2)
Zone A 0.0 (0.0) 47.5 (10.0) 15.6 (6.3) 36.8 (8.6)
0.0 (0.0; 0.0) 46.5 (39.7; 52.9) 13.9 (12.5; 14.9) 34.9 (33.3; 42.7)
Zone B 0.0 (0.0) 40.8 (8.6) 16.7 (5.4) 42.5 (8.9)
0.0 (0.0; 0.0) 44.2 (34.5; 45.4) 16.8 (12.9; 18.7) 43.7 (35.2; 47.9)
Zone C 0.0 (0.0) 42.3 (13.3) 17.2 (6.2) 40.5 (10.7)
0.0 (0.0; 0.0) 42.5* (33.4; 49.7) 14.3 (13.9; 19.5) 41.0* (32.7; 47.5)

*P < 0.05 between test and control.

Table 2. Percentage of tissue components after 4 weeks of healing. Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
Total 18.0 (12.9) 40.3 (15.1) 8.4 (4.4) 33.3 (9.0)
15.1 (12.9; 25.4) 34.5 (28.6; 52.6) 9.9 (5.8; 11.8) 30.7 (28.1; 34.1)
Zone A 20.0 (14.2) 38.3 (17.5) 8.0 (4.7) 33.6 (10.6)
18.4 (12.4; 32.2) 34.4 (25.5; 52.7;) 10.0 (4.5; 11.4) 32.6 (28.5; 37.0)
Zone B 16.4 (11.8) 39.8 (15.2) 9.1 (5.0) 34.7 (8.9)
15.4 (9.7; 26.3) 36.1 (29.7; 48.4) 9.7 (4.9; 13.4) 35.0 (32.6; 39.4)
Zone C 17.7 (14.8) 42.6 (16.4) 8.1 (4.0) 31.6 (11.4)
14.4 (12.6; 19.0) 43.2 (29.0; 55.9) 9.4 (7.9; 10.7) 27.5 (27.1; 28.7)
Control
Total 12.3 (7.9) 48.6 (18.5) 7.6 (4.8) 31.5 (14.4)
12.7 (5.7; 17.5) 43.8 (38.7; 45.7) 6.3 (4.9; 11.6) 37.8 (25.7; 40.8)
Zone A 8.8 (6.7) 53.9 (25.4) 6.5 (5.8) 30.7 (18.8)
10.3 (3.4; 14.3) 44.2 (37.4; 61.3) 6.4 (2.8; 7.9) 40.3 (20.6; 43.4)
Zone B 15.0 (11.8) 46.6 (24.6) 7.8 (6.7) 30.7 (17.5)
16.1 (4.3; 23.8) 37.8; (33.4; 42.8) 5.9 (3.0; 10.6) 32.9 (26.8; 40.0)
Zone C 13.0 (7.3) 45.2 (10.7) 8.7 (5.0) 33.2 (9.0)
9.8 (8.3; 18.2) 47.1 (39.8; 50.2) 9.1 (6.2; 12.3) 34.5 (29.2; 36.0)

Table 3. Percentage of tissue components after 12 weeks of healing. Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
Total 16.7 (8.0) 40.3 (8.2) 6.9 (1.8) 36.1 (9.2)
16.4 (11.3; 17.5) 37.0 (35.9; 41.0) 7.4* (6.7; 7.9) 37.3 (29.6: 40.0)
Zone A 8.4 (7.8) 53.6 (18.9) 5.7 (2.9) 32.3 (17.6)
7.6; (5.1; 7.9) 48.0 (45.0; 52.8) 5.5 (3.5; 8.2) 40.7 (25.0; 43.1)
Zone B 15.5 (10.6) 35.5 (7.1) 7.2 (3.2) 41.8 (11.4)
16.8 (9.3, 19.2) 35.0 (30.9; 39.6) 7.5 (5.3; 8.4) 40.9 (35.6; 46.7)
Zone C 26.4 (8.4) 31.6 (5.5) 8.0 (2.4) 34.0 (7.3)
25.5 (19.5; 30.7) 31.2* (29.9; 36.0) 7.4* (5.9; 9.9) 34.6 (28.3; 39.8)
Control
Total 13.7 (10.1) 51.9 (23.8) 4.2 (2.7) 30.2 (15.6)
13.1 (10.3; 15.0) 44.5 (37.8; 52.5) 4.8* (2.5; 6.1) 34.8 (26.5; 41.5)
Zone A 14.6 (13.2) 45.6 (24.5) 3.7 (3.1) 36.1 (17.2)
11.0 (5.7; 23.3) 38.5 (35.3; 41.2) 3.3 (2.5; 4.1) 41.7 (30.1; 48.3)
Zone B 11.6 (10.6) 49.0 (26.2) 5.4 (4.2) 34.0 (17.1)
9.6 (6.4; 12.9) 43.3 (38.1; 46.0) 5.9 (1.9; 8.8) 38.6 (37.3; 40.9)
Zone C 14.9 (12.3) 61.6 (28.8) 3.3 (2.6) 20.2 (16.4)
16.6 (4.5; 25.0) 50.0* (42.5; 85.2) 3.4* (1.4; 4.7) 25.7 (5.6; 31.6)

*P < 0.05 between test and control.

4 | Clin. Oral Impl. Res. 0, 2015 / 1–8 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Favero et al
Perforation of the sinus mucosa

Table 4. Percentage of tissue components in the submucosal layer (Zone SM). Mean values (standard deviations) and medians (25th–75th percentiles)
New bone Connective tissue Provisional matrix/bone marrow Biomaterial
Test
2 weeks 0.0 (0.0) 52.2 (8.0) 0.0 (0.0) 47.8 (8.0)
0.0; (0.0; 0.0) 53.3 (49.8; 58.1) 0.0 (0.0; 0.0) 46.7 (41.9; 50.2)
4 weeks 3.0 (3.3) 56.2 (5.7) 0.7 (1.2) 40.1 (7.8)
2.0* (1.2; 3.5) 55.7 (52.0; 59.4) 0.0 (0.0; 1.2) 41.2 (35.7; 44.4)
12 weeks 6.7 (3.9) 63.6 (12.1) 0.1 (0.2) 29.6 (12.7)
7.3* (3.9; 10.0) 60.4 (54.4; 67.1) 0.0 (0.0; 0.0) 33.1 (27.1; 35.2)
Control
2 weeks 0.3 (0.6) 56.7 (11.0) 0.9 (1.4) 42.2 (10.0)
0.0 (0.0; 0.0) 55.7 (51.7; 60.1) 0.0 (0.0; 1.5) 44.3 (38.5; 48.3)
4 weeks 0.0 (0.0) 58.2 (8.8) 0.0 (0.0) 41.8 (8.8)
0.0* (0.0; 0.0) 55.6 (53.3; 60.3) 0.0 (0.0; 0.0) 44.4 (39.7; 46.7)
12 weeks 2.0* (2.2) 67.6 (19.0) 0.0 (0.0) 30.4 (17.7)
1.4 (0.2; 4.0) 64.4 (58.5; 77.1) 0.0 (0.0; 0.0) 33.0 (22.8; 36.8)

*P < 0.05 between test and control.

(a) (b)

(c) (d)

Fig. 5. Ground section illustrating the healing after

2 weeks. The cavity originated from elevation of the
Schneiderian membrane was mainly filled with connec-
tive tissue that was surrounding the biomaterial. Image
originally grabbed at 920 magnification. Stevenel’s blue
and alizarin red stain.

beyond the borders of the windows outside

the sinus.

Fig. 4. (a) Graphic illustrating the percentages of new bone (NB) and biomaterial (BM) found at the various periods
of observation at the Test (T-) and Control (C-) sites. (b–d) Percentages of new bone after 2, 4, and 12 weeks of heal- Twelve weeks of healing
ing, respectively, at the various zones evaluated (Fig. 3).

After 12 weeks of healing, within the zones

test and control sites, with total percent-
ages of 18.0  12.9% and 12.3  7.9%,
respectively. The difference, however, was
not statistically significant. No differences
in new bone formation were found between
test and control sites in the different zones
evaluated. In both groups, the newly formed
bone was mainly located in continuity with
the bony walls of the sinus (Fig. 9) while,
in the center of all zones, a lower amount
of new bone could be observed. In some
specimens, the biomaterial was found
mainly surrounded by connective tissue
while, in other specimens, it was sur-
rounded by newly formed bone.
In the submucosal zone, only little bone
was found at the test sites (3.0  3.3%),
mainly located nearby the rim of the antros-
tomy. No bone formation was found at the
control site so that the difference between
test and control resulted to be statistically
significant. The biomaterial was well-con-
tained below the sinus mucosa at most of
the control sites while, at the test sites, five
of six specimens showed a loss of continuity
of the sinus mucosa with a concomitant pen-
etration of the graft through the mucosa. The
sinus mucosa at the elevated areas was found
to be of similar dimensions to that attached
to the parent bone.
Connective tissue was still penetrating the
access window that presented very little new
bone at the edges. Alike the previous period
of healing, the biomaterial was often seen
A–C, similar amounts of newly formed
bone were found compared to the previous
period of healing with percentages of
16.7  8.0% and 13.7  10.1% at the test
and control sites, respectively. The differ-
ence, however, was not statistically signifi-
cant. Moreover, when bone formation was
compared between test and control sites for
the various zones, the differences did not
reach statistical significance. Compared to
the previous period of healing, the newly
formed bone was more evenly distributed
within the sinus cavity also including the
central areas of the sinus in all zones eval-
uated (Fig. 10).
In the submucosal zone, new bone was
found at a percentage of 6.7  3.9% at the

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd 5 | Clin. Oral Impl. Res. 0, 2015 / 1–8
Favero et al
Perforation of the sinus mucosa
Fig. 6. Ground section illustrating the healing after
2 weeks. Particles of biomaterial that have passed
through the sinus mucosa, most likely at the level of
the perforation. Image originally grabbed at 920 magni-
fication. Stevenel’s blue and alizarin red stain.
Fig. 7. Ground section illustrating the healing after
2 weeks. Very little new bone was observed at the edges
of the antrostomy. Image originally grabbed at 920
magnification. Stevenel’s blue and alizarin red stain.
Fig. 8. Ground section illustrating the healing after
2 weeks. Biomaterial particles were detected beyond the
border of the access window. Image originally grabbed
at 920 magnification. Stevenel’s blue and alizarin red
stain.
test and of 2.0  2.2% at the control sites,
the difference being statistically significant.
Again, the new bone was mainly located
close to the rim of the antrostomy. Just one
single perforation was still observed, located
in a control site. All the other sites did not
6 | Clin. Oral Impl. Res. 0, 2015 / 1–8
Fig. 9. Ground section illustrating the healing after
4 weeks. The newly formed bone was mainly located in
continuity with the bony walls of the sinus. Image orig-
inally grabbed at 920 magnification. Stevenel’s blue
and alizarin red stain.
Fig. 10. Ground section illustrating the healing after
12 weeks. The newly formed bone was more evenly dis-
tributed within the sinus cavity also including the cen-
tral areas of the sinus in all zones evaluated. Image
originally grabbed at 920 magnification. Stevenel’s blue
and alizarin red stain.
show penetration of biomaterial through the
sinus mucosa.
Although new bone could be documented
on the edges of the access windows, connec-
tive tissue and biomaterial were occupying
the center of the windows so that, in none of
specimens, a complete obliteration with bone
developed. However, grafting material was
rarely observed outside the lateral wall of the
sinus.
The total percentage of biomaterial found
within zones A–C was 30–40% during the
various periods of healing.
Discussion
The aim of the present study was to assess
the influence of a collagen membrane applied
following a perforation of the sinus mucosa
on the outcome (bone fill) after sinus floor
elevation. The data emerging from the pres-
ent experiment showed that the use of a
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
collagen membrane for coverage of a perfora-
tion was associated with a tendency toward a
greater percentage of newly formed bone
within the sinus cavity delimitated by bony
walls (zones A–C), although the difference
was not statistically significant at any of the
periods of healing examined. New bone for-
mation was negligible after 2 weeks, and it
was evident after 4 weeks of healing. The
amount of new bone did not change notably
between 4 and 12 weeks. Moreover, very lit-
tle bone was found in the submucosal layer
(zone SM), even though the difference
between test and control sites was statisti-
cally significant. The bone was found to form
from the resident bone, especially that at the
edge of the antrostomy.
After 2 weeks of healing, the perforation of
the Schneiderian membrane did not appear to
favor any penetration of the graft through the
mucosa both at the test and control sites.
After 4 weeks, however, a higher penetration
of biomaterial through the sinus mucosa was
observed compared to the previous healing
period. This penetration occurred more fre-
quently at the test sites compared to the con-
trol sites. Hence, it may be speculated that
the collagen membrane jeopardized the heal-
ing of the sinus mucosal rupture, although it
apparently tended to enhance new bone for-
mation. Nevertheless, after 12 weeks of heal-
ing, almost all specimens exhibited a
complete sinus mucosa without any disconti-
nuity. The use of collagen membranes to
repair perforations of the sinus mucosa has
been proposed by several authors (Pikos 1999;
Proussaefs et al. 2003; Testori et al. 2008;
Kim et al. 2014). These clinical studies
reported satisfactory results. However, none
of these studies were randomized controlled
clinical trials. Yet, the results of the present
study did not support nor discourage the use
of such devices in clinical practice.
Bone formation clearly started and pro-
gressed from the parent bone of the sinus
walls toward the center of the sinus cavity.
In fact, after 4 weeks of healing, new bone
was mainly detectable close to the sinus
bony walls, whereas, after 12 weeks of heal-
ing, bone was also found in the center
aspects of the sinus cavity. Bone formation
originating from the Schneiderian membrane
was never observed in the present study
(zone SM). This is in agreement with a previ-
ous experimental study in monkeys (Scala
et al. 2010, 2012). In that experiment, the
sequential early healing at elevated sinus
mucosae with concomitant implant installa-
tion was evaluated. The findings showed that
bone formation initiated from the bony floor

and septa of the sinus rather than from the
Schneiderian membrane.
The percentage of residual biomaterial was
generally in the order of magnitude of 30–
40% for all periods of observation. While the
biomaterial showed good osteoconductivity
and being identified often in close contact
with newly formed bone, a low resorptive
activity on the graft was noted. The impor-
tance of the use of a low resorbable material
in sinus lifting has been propagated in several
studies. In an experimental study in monkeys
(Scala et al. 2012), no bone filler was used
and the blood clot only was left to fill the
sinus cavity after elevation of the floor. A
collapse of the cavity after sinus floor eleva-
tion was documented already after 30 days of
healing. In another experimental study (Asai
et al. 2002), a sinus augmentation procedure
was performed in rabbits. After the proce-
dure, the nasal ostium was occluded with a
gelatin sponge at the test sites, while in the
control sites, the ostium was left open. No
bone fillers were used. It was shown that,
after 6 weeks of healing, the occluded sites
showed bone formation in the elevated areas
and maintenance of the obtained volume
while, at the control sites, the elevated vol-
ume of the sinus had almost completely re-
pneumatized. This was explained by the role
of the airway flow pressure on re-pneumati-
zation. In another experimental study in rab-
bits (Xu et al. 2004), the elevated region of
the sinus was filled with deproteinized
bovine bone matrix (DBBM) at the test sites,
while the control sites were filled with the
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Acknowledgements: This study has
been funded in part by Degradable Solutions
AG, a Sunstar Group Company, CH-8952
Schlieren ZH, Switzerland, Ariminum
Odontologica s.r.l., Rimini, Italy, and the
Clinical Research Foundation (CRF) for the
Promotion of Oral Health, CH- 3855 Brienz,
Switzerland. The authors gratefully
acknowledge the company Mectron s.p.a,
Carasco, Genova, Italy, for having provided
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