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Sinus oor elevation utilizing thetransalveolar approach

B J A R N I E. P J E T U R S S O N & N I K L A U S P. LA N G

As implant dentistry developed, it became more evi-

dent that the posterior maxillary region was often

limited for standard implant placement because the

residual vertical bone height was often substantially

reduced as a result of the presence and pneumatiza-

tion of the maxillary sinus. Several treatment options

have been used in the posterior maxilla to overcome

the problem of inadequate bone quantity. The most

conservative treatment option would be to place

short implants to avoid entering the sinus cavity.

However, for the placement of even short implants,

there is still a need for at least 6 mm of residual bone

height. Another way of avoiding grafting the maxillary

sinus would be to place tilted implants mesially or

distally to the sinus cavity if these areas have ade-

quate bone. Furthermore, extra-long zygomatic

implants may be placed in the lateral part of the zygo-

matic bone. However, elevation of the maxillary sinusoor is considered as the treatment for solving this

problem.

Elevation of the maxillary sinus oor was rst

reported by Boyne in the 1960s. In 1980, Boyne &

James (3) described elevation of the maxillary sinus

oor in patients with large, pneumatized sinus cavi-

ties as a preparation for the placement of blade

implants. The authors described a two-stage proce-

dure: in the rst stage, the maxillary sinus was grafted

using autogenous particulate iliac bone; and, in the

second stage (approximately 3 months later), blade

implants were placed and later used to support xedor removable reconstructions (3). Such a one- or a

two-stage sinus oor elevation with a lateral window

approach is, however, a relatively invasive treatment

option.

In patients with appropriate residual bone height,

augmentation of the sinus oor can also be accom-

plished via transalveolar approach using the osteo-

tome technique (11, 26, 30). The problem of

inadequate bone height can be overcome by elevating

the maxillary sinus oor using the closed technique

to provide sufcient quantity of bone for the place-

ment of dental implants.

A transalveolar approach for sinus oor elevation,

with subsequent placement of implants, was rst sug-

gested by Tatum, in 1986 (32). A socket former for

the selected implant size was used to prepare the

implant site. A greenstick fracture of the sinus oor

was accomplished by hand tapping the socket for-

mer in a vertical direction. After preparation of the

implant site, a root-formed implant was placed and

allowed to heal in a submerged manner.

Summers (30) later described a different transalve-

olar approach using a set of tapered osteotomes with

increasing diameters (Fig. 1). This concept was

intended to increase the density of soft (type III and

type IV) maxillary bone, resulting in better primary

stability of inserted dental implants. Bone was con-served by this osteotome technique because there

was no drilling. Adjacent bone was compressed by

pushing and tapping as the sinus membrane was ele-

vated. Then, autogenous, allogenic or xenogenic

grafts were added to increase the volume below the

elevated sinus membrane.

Currently, two main techniques of sinus oor ele-

vation for dental implant placement are in use. The

rst is a two-stage technique with a lateral window

approach, followed by implant placement after a

healing period, and a one-stage technique using

either a lateral or a transalveolar approach. The sec-ond is the transalveolar approach, also referred to as

osteotome sinus oor elevation, the Summers tech-

nique or the Crestal approach, which may be con-

sidered as more conservative and less invasive than

the conventional lateral approach. In this technique a

small osteotomy is performed through the alveolar

crest of the edentulous ridge at the inferior border of

the maxillary sinus. This intrusion osteotomy elevates

the sinus membrane, thus creating a tent and

59

Periodontology 2000, Vol. 66, 2014, 5971 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Printed in Singapore. All rights reserved PERIODONTOLOGY 2000


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providing space for graft placement and/or blood clot

formation. It should be noted that the grafts are

placed blind into the space below the sinus mem-

brane. Hence, the main disadvantage of this tech-

nique is the uncertainty of possible perforations of

the sinus oor (Schneiderian) membrane.

By mastering these different methods, the most

edentulous areas in the maxilla can be restored with

implant-supported reconstructions. The concept of a

shortened dental arch must also be borne in mind.

The work of Kayser (14) has shown that patients can

maintain adequate (5080%) chewing capacity with a

premolar occlusion.

Anatomy of the maxillary sinusThe maxillary sinus maintains its overall size while

the posterior teeth remain in function. It is, however,

well known that the sinus expands with age, and

especially when posterior teeth are lost. One or more

septa, termed Underwoods septa, may divide the

maxillary sinus into several recesses.

The overall prevalence of one or more sinus septa is

26.531% (15, 35) and these are most common in the

area between the second premolar and the rst molar.

Edentulous segments have a higher prevalence of sinus

septa compared with dentate maxillary segments.

The sinus is lined with respiratory epithelium

(pseudostratied ciliated columnar epithelium) that

covers a loose, highly vascular connective tissue.

Underneath the connective tissue, immediately next

to the bony walls of the sinus, is the periosteum.

These structures (epithelium, connective tissue and

periosteum) are collectively referred to as the Schne-

iderian membrane.

Indications and contraindications

The main indication for maxillary sinus oor eleva-

tion utilizing a transalveolar approach is reduced

residual bone height that does not allow standard

implant placement.

Contraindications for transalveolar sinus oor ele-

vation may be divided into two groups: medical; and

local.Medical contraindications include the following:

chemotherapy or radiotherapy of the head and neck

area at the time of transalveolar sinus oor elevation

or in the preceding 6 months, depending on the eld

of radiation; an immunocompromised status; medical

conditions affecting bone metabolism; uncontrolled

diabetes; drug or alcohol abuse; patient noncompli-

ance; and psychiatric conditions. Whether or not

smoking is an absolute contraindication for transalve-

olar sinus oor elevation remains controversial.

A recent systematic review (25) investigated the inu-

ence of smoking on the survival rate of implants

inserted in combination with sinus oor elevation uti-

lizing the lateral approach. Five of the included studies

investigated the inuence of smoking, on implant sur-

vival after sinusoor elevation. A group of nonsmokers

with 2159 implants and a group of smokers with 863

implants were compared. The group of smokers had a

higher annual failure rate of implants compared with

the group of nonsmokers (3.5% vs. 1.9%, respectively).

However, this difference did not reach statistical sig-

nicance in a Poisson regression analysis. In addition,

patients with a history of inner-ear complications andpositional vertigo are not suitable for the osteotome

technique.

Alteration of the nasalmaxillary complex that

interferes with normal ventilation, as well as mucocil-

iary clearance of the maxillary sinus, may be a contra-

indication for transalveolar sinus oor elevation.

However, such abnormal conditions may be clinically

asymptomatic or present only with mild clinical

symptoms. These conditions include viral, bacterial

and mycotic rhinosinusitis, allergic sinusitis, sinusitis

caused by intrasinus foreign bodies and odontogenic

sinusitis resulting from necrotic pulp tissue. All odon-

togenic, peri-apical and radicular cysts of the maxil-

lary sinus should be treated before sinus oor

elevation. Transalveolar sinus oor elevation under

any of the above conditions may disturb the ne

mucociliary balance, resulting in mucus stasis, sup-

rainfection or a subacute sinusitis.

Local contraindications are inadequate residual

bone height (< 45 mm) and crestal bone width not

Fig. 1. In 1994, Summers introduced a set of tapered os-

teotomes with different diameters to compress and push

the residual bone from the implant preparation into the

sinus cavity and to elevate the sinus membrane.

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allowing for sufcient primary stability of the implant.

In addition, an oblique sinus oor (> 45 inclination)

is not suitable for the osteotome technique (Fig. 2).

The reason for this is that the osteotomes rst enter

the sinus cavity at the lower level of an oblique sinus

oor, whilst still having bone resistance on the higher

level. In this situation, there is a high risk of perforat-

ing the sinus membrane with the sharp margin of the

osteotome. Absolute local contraindications for sinusoor elevation are: acute sinusitis; allergic rhinitis

and chronic recurrent sinusitis; scarred and hypo-

functional mucosae; local aggressive benign tumors;

and malignant tumors.

Surgical technique

After the presentation of the original Summers tech-

nique, only minor modications have been presented

(6, 12, 24, 26). The technique described here is a mod-

ication of the original technique (24). Presurgical patient preparation includes oral rin-

sing with 0.1% chlorhexidine for a period of 1 min.

Local anesthesia is administered into the buccal

and palatal regions of the surgical area.

A mid-crestal incision, with or without a releasing

incision, is made and a full-thickness mucoperio-

stealap is raised.

Using a surgical stent or a distance indicator, the

implant positions are marked on the alveolar crest

with a small round bur (#1). After locating the

implant positions exactly, the opening of the prep-

arations are widened with two sizes of round burs

(#2 and #3) to a diameter about half a millimeter

smaller than the implant diameter intended

(Fig. 3).

The distance from the crestal oor of the ridge tothe oor of the maxillary sinus, measured before

implant site preparation on the pre-operative

radiograph, may, in most cases, be conrmed at

the time of surgery by penetrating the opening of

the preparation with a blunt periodontal probe

through the soft trabecular bone (type III or type

IV bone) to the oor of the maxillary sinus.

After conrming the distance to the sinus oor,

small-diameter pilot drills (11.5 mm smaller than

the diameter of the intended implant) are used to

prepare the implant site to a distance of approxi-

mately 2 mm from the sinus oor (Fig. 4). In the

presence of soft type IV bone and a residual bone

height of 56 mm, there is usually no need to use

the pilot drills. It is sufcient to perforate the corti-

cal bone at the alveolar crest using the round

burs.

The rst osteotome used in the implant site is a

small-diameter tapered osteotome with a rounded

tip (Fig. 5). With light malleting, the osteotome is

pushed toward the compact bone of the sinus

oor (Fig. 6). After reaching the sinus oor, the os-

teotome is pushed about 1 mm further with lightmalleting in order to create a greenstick fracture

on the compact bone of the sinus oor. A tapered

osteotome with a small diameter is chosen to min-

Fig. 2. The oblique inferior border of the maxillary sinus

lies approximately 60to the inferior border of the alveolar

crest (the dotted lines represent the outlines of the residual

bone). In a clinical situation like this, it is difcult to ele-

vate the maxillary sinus oor using osteotomes. The os-

teotomes will rst enter the sinus cavity distally at the

lowest level of the oblique sinus oor whilst still having

bone resistance on the cranial level of the sinus oor.

Hence, the risk of the sharp margin perforating the sinus

membrane is high.

Fig. 3. The exact position of the implant site is rst marked

with a small round bur (#1) and then extended with

two sizes of round burs (#2 and #3) to a diameter about

0.51 mm smaller than that of the implant to be installed.

Transalveolar sinusoor elevation

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imize the force needed to fracture the compact

bone.

The second tapered osteotome, also with a

rounded tip and with a diameter slightly larger

than that of the rst, is used to increase the frac-

ture area of the sinus oor (Fig. 7). The second os-

teotome is applied to the same length as the rst. The third osteotome used is a straight osteotome

with a diameter about 11.5 mm smaller than the

implant to be placed (Fig. 8). Instead of using the

osteotomes to fracture the sinus oor, piezoelec-

tric surgery may be used (Fig. 9). The advantage of

this technique is that perforation of the sinus oor

may be achieved in a more controlled way than

with osteotomes and thus the risk of membrane

perforation may be reduced (28). Moreover, this

Fig. 4. The implant site is prepared to a distance approxi-

mately 2 mm below the sinus oor using a small-diameter

pilot drill.

Fig. 5. The rst osteotome used in the implant site is a

small-diameter tapered osteotome. Such an osteotome is

chosen to minimize the force needed to fracture the com-

pact bone.

Fig. 6. After reaching the sinus oor, the osteotome is

pushed approximately 1 mm further with light malletingin order to create a greenstick fracture on the compact

bone of the sinusoor.

Fig. 7. A second osteotome, which is also tapered, but with

a diameter slightly larger than the rst, is used to increase

the fractured area of the sinusoor.

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could reduce the risk of benign paroxysmal posi-

tional vertigo. The main disadvantage of this tech-

nique is that it is more time consuming than

malleting, especially when the cortical bone at the

sinusoor is relatively thick.

From this point onwards, the technique utilized in

the surgical procedure depends on whether or not

grafts will be placed.

Implant placement withoutgrafting material

Without applying grafting material, the straight

osteotome, with a diameter about 11.5 mm smal-

ler than that of the implant, will be pushed further

until it penetrates the sinus oor.

The last osteotome to be used should have a form

and diameter suitable for the implant to be

placed. For example, for a cylindrical implant with

a diameter of 4.1 mm, the last osteotome should

be a straight osteotome with a diameter about

0.5 mm smaller than the implant diameter. It is

important that the last osteotome only enters the

preparation site once. If several attempts have to

be made in sites with soft bone (type III or type

IV), there is a risk of increasing the diameter of the

preparation, which may jeopardize good primary

stability. On the other hand, if the diameter of the

last osteotome is too small compared with the

implant diameter, too much force must be used to

insert the implant. By squeezing the bone, morebone trauma, and hence greater bone resorption,

will occur, delaying the osseointegration process

(1). Therefore, it is important, especially when

placing implants in sites with reduced bone vol-

ume, that a ne balance between good primary

stability and trauma to the bone is achieved.

During the entire preparation, it is crucial to

maintain precise control of the penetration length.

Regular osteotomes have sharp cutting edges and

thus entry into the sinus cavity increases the risk

of membrane perforation. The nal step before

placing the implant is to check that the prepara-

tion is patent to the planned insertion depth. An

osteotome with a rounded tip, or a depth gauge

with a relevant diameter, is pushed to the appro-

priate length (Fig. 10).

Implant placement with graftingmaterials

When performing the osteotome technique with

grafting materials, the osteotomes are not sup-posed to enter the sinus cavity per se. Repositioned

bone particles, grafting materials and trapped uid

will create a hydraulic effect, moving the fractured

sinusoor and the sinus membrane upwards. The

sinus membrane is less likely to tear under this

kind of pressure that has auid consistency.

After pushing the third osteotome up to the sinus

oor and before placing any grafting material, the

sinus membrane must be tested for any perfora-

tions. This is performed using the Valsalva maneuver

Fig. 8. The last osteotome to be used must have a form

and diameter suitable for the implant to be placed. For

example, for a cylindrical implant with a diameter of

4.1 mm, the last osteotome should be straight with a diam-

eter approximately 0.5 mm smaller than that of the

implant. It is important that the last osteotome is allowed

to enter the preparation site only once.

Fig. 9. A kit of diamante-coated

insertion tips for piezosurgery that

can be used to prepare the implant

site and to trim down or perforate

the cortical bone at the lower border

of the maxillary sinus.


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(nose blowing). The nostrils of the patient are

compressed (Fig. 11) and the patient blows their

nose against the resistance. If air leaks out of the

implant site, the sinus membrane is perforated

and therefore no grafting material should beplaced in the sinus cavity.

If no air leaks out, the sinus membrane is intact

and the preparation is lled with grafting material

(Fig. 12). The grafting material is slowly pushed

into the sinus cavity with the same straight third

osteotome (Fig. 13). This procedure is repeated

four to ve times until about 0.20.3 g of grafting

material has been pushed into the sinus cavity

below the sinus membrane (Fig. 14). At the fourth

and fth times of applying grafting material, the

tip of the osteotome may enter about 1 mm into

the maxillary sinus cavity to test if there is resis-tance in the preparation site.

Finally, before implant placement (Fig. 15), the

preparation is checked for patency, as mentioned

before, and the Valsalva maneuver is repeated.

To achieve good primary stability in the soft trabec-

ular bone on the posterior maxilla, implants with a

slightly tapered conguration, or implants with a

tulip-shaped neck, are recommended. However, it

must always be borne in mind that applying too

much force to the bone will result in greater bone

resorption, delaying the osseointegration process (1).

Postsurgical care

The postsurgical care required after implant place-

ment using the osteotome technique is similar to the

postsurgical care required after standard implantplacement. To minimize postoperative discomfort,

the surgical intervention should be carried out as

atraumatically as possible. Precautions must be taken

to avoid perforation of the ap and the sinus mem-

brane. The bone should be kept moist during surgery,

and tension-free closure of the primaryap is essen-

tial.

In addition to the standard oral care at home, rins-

ing twice daily, for the rst 3 weeks after surgery, with

Fig. 10. The nal step before placing the implant is to

check that the preparation is patent to the planned inser-

tion depth. An osteotome with a rounded tip or a depth

gauge appropriate for the diameter of the implant is

pushed to the decided length.

Fig. 11. To test the sinus membrane for perforations, the

nostrils of the patients are compressed and the patient is

asked to blow his nose. If air leaks out of the implant site,

the sinus membrane is perforated, and no grafting mate-

rial should be placed in the sinus cavity.

Fig. 12. If the sinus membrane is intact, the preparation

site is lled four to ve times with grafting material.

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0.10.2% chlorhexidine is recommended. Although

there are no studies comparing postsurgical care with

and without the use of prophylactic antibiotics, anti-

biotic prophylaxis (e.g. 750 mg of amoxicillin, three

times daily for a period of 1 week) has been recom-

mended for patients in whom bone substitutes were

used.

Complications

When performing transalveolar sinus oor elevation,

the risk of complications must be considered and the

appropriate treatment foreseen. During transalveolar

sinus oor elevation the intrusion osteotomy proce-

dure elevates the sinus membrane, thus creating a

tent. This provides space for the blood clot and/or

grafting material. An endoscopic study has shownthat the sinus oor can be elevated up to 5 mm with-

out perforating the membrane (10). It should be

noted that the bone grafts are placed blind into the

space below the sinus membrane. Hence, the main

disadvantage of this technique is the uncertainty of

possible perforation of the sinus membrane. This

constitutes the most common intra-operative compli-

cation. The presence of maxillary sinus septa and root

apices penetrating into the sinus may increase the

risk of membrane perforation. In a recent systematic

review on transalveolar sinus oor elevation (31),

eight studies with 1621 implants, out of the 19 studiesincluded in the review, presented data on the inci-

dence of perforation of the Schneiderian membrane,

which varied between 0 and 21.4%, with a mean of

3.8%.

Smaller perforations may be closed through the

transalveolar preparation by using tissue brin glue.

For larger perforations, access must be accomplished

through a lateral window, and barrier membranes,

lamellar bone plates or suture should be used, alone

Fig. 14. Grafting material is slowly pushed into the sinus

cavity using a straight osteotome. The tip of the osteotome

is only supposed to enter the sinus cavity after some graft-

ing material has been pushed through the preparation site

to elevate the sinus membrane.

Fig. 15. A rough-textured implant was installed after pre-

paring the implant site using the osteotome technique. To

achieve good primary stability, implants with a slightly

tapered conguration or implants with a tulip-shaped

neck are recommended.

Fig. 13. The grafting material is then slowly pushed into

the sinus cavity using a straight osteotome with a diameter

about 11.5 mm smaller than that of the intended implant

size.


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or in combination with tissue brin glue, to close the

membrane perforation. If the perforation occurs

before any grafting material is inserted, the procedure

should be aborted and a second attempt to achieve a

transalveolar sinus oor elevation may be performed

69 months later (33, 36).

Postoperative infection after transalveolar sinus

oor elevation is a rare complication. Six studies, with

884 implants, included in the systematic review ofTan et al. (31), reported on postoperative infection.

The incidence ranged from 0% to 2.5% with a mean

of 0.8%. Other complications reported were postoper-

ative hemorrhage, nasal bleeding, blocked nose,

hematomas and loosening of cover screws, resulting

in suppuration and benign paroxysmal positional ver-

tigo (37). The benign paroxysmal positional vertigo

may cause substantial stress in the patient if not cor-

rectly identied and properly managed (26). No air

embolism was reported in the study using hydraulic

sinus condensing (6).

Grafting materials

In the original publication (32), the author did not

use any grafting material to increase and maintain

the volume of the elevated area. Later on, Summer

(30) described the bone-added osteotome sinus oor

elevation technique, frequently referred to as the

Summers technique. Tapered osteotomes with

increasing diameters were used to compress the bone

and push and tap it in a vertical direction as the sinusmembrane was elevated. Autogenous, allogenic or xe-

nogenic grafting material was added to maintain the

volume below the elevated sinus membrane.

Grafting material is added incrementally to the os-

teotomy site and condensed until the desired graft

height is reached. Pressure from the osteotomes on

the graft material and trapped uids exerts hydraulic

pressure on the sinus membrane, resulting in eleva-

tion over a larger area (6). A recent study (16) that

compared the use of the bone-added osteotome sinus

oor elevation technique with sinus oor elevation

utilizing the lateral approach, concluded minimalbone resorption for both methods. The bone resorp-

tion reported was 1.35 mm for the bone-added osteo-

tome sinus oor elevation technique and 1.36 mm

for the lateral approach over a period of 2 years after

the procedure was performed.

From the 19 studies included in the systematic

review of Tan et al. (31), 15 used grafting material. De-

proteinized bovine bone mineral was used in ve

studies, autogenous bone graft in two studies and col-

lagen in another two studies. Five studies used combi-

nations of grafts consisting of autogenous bone graft

and Bioglass; autogenous bone graft and deprotei-

nized bovine bone mineral; autogenous bone graft

and collagen; autogenous bone graft, demineralized

freeze-dried bone allograft and tricalcium phosphate;

and autogenous bone graft, deminerialized freeze-

dried bone allograft and antibiotics in the graft. Vari-

ous types of graft were used in two studies. Threestudies performed the procedure without graft place-

ment and one study did not report on the graft used.

It is still controversial whether or not it is necessary

to apply grafting material to maintain the space for

new bone formation after elevating the sinus mem-

brane utilizing the transalveolar osteotome technique.

Studies in monkeys (2) showed, that implants pro-

truding into the maxillary sinus following elevation of

the sinus membrane without grafting material, exhib-

ited spontaneous bone formation over more than half

of the height of the implant. Hence, protrusion of an

implant into the maxillary sinus does not appear to be

an indication for bone grafting. In the same study,

it was also seen that the design of the implant

inuenced the amount of spontaneous bone forma-

tion. Implants with open apices or deep-threaded

congurations did not reveal substantial amounts of

new-bone formation. On the other hand, implants

with rounded apices tended to show spontaneous

bone formation extending all around the implants if

they only penetrated 23 mm into the maxillary sinus.

However, when the same implants penetrated 5 mm

into the maxillary sinus, only partial (50%) growth ofnew bone was seen toward the apex of the implant.

A recent clinical study (22) reported similar clinical

results. The authors reported on 25, 10-mm dental

implants inserted using the transalveolar approach

without grafting material. The implants protruded, on

average, 4.9 1.9 mm into the sinus cavity after sur-

gery. After a follow-up period of 5 years, the implant

protrusion was reduced to 1.5 0.9 mm. Hence,

3.4 mm (or 70%) of the penetrating part of the

implants showed spontaneous bone formation.

In a clinical study (12), implants were installed into

the sinuses of 40 patients using the transalveolartechnique with no graft or cushion material. The

authors reported a mean gain of alveolar bone height,

determined from scanned panoramic radiographs, of

3.9 1.9 mm.

In a retrospective study that assessed, radiographi-

cally, sinus oor remodeling after implant insertion

using a modied transalveolar technique without

grafting material (27), 24 patients were available for

follow up. The implant survival rate was 100%. Bone

Pjetursson & Lang

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lling around the implants was measured and com-

pared with baseline digital radiographs. The mean

height of the newly formed bone was 2.2 1.7 mm

mesially and 2.5 1.5 mm distally, or 86.3 22.1%

and 89.7 13.3% of new-bone formation, respec-

tively.

In a prospective study (23), 252 implants were

inserted using the transalveolar sinus oor elevation

technique, with or without grafting material. For 35%of these implants, deproteinized bovine bone mineral

of particle size 0.251 mm was used as the grafting

material, but for the remaining 164 implants, no

grafting material was utilized. Peri-apical radiographs

were made using a paralleling technique and digi-

tized. Two investigators, blind to whether or not graft-

ing material was used, subsequently evaluated the

pattern of tissue remodeling. The mean radiographic

bone gain using the trans-alveolar technique with

grafting material was signicantly more or 4.1 mm

(SD 2.4 mm) compared with a mean bone gain of

1.7 mm (SD 2.0 mm) when no grafting material was

used (Fig. 16A,B).

Success and implant survival

A recent systematic review (31) analyzed the survival

and complication rates of implants inserted in combi-

nation with transalveolar sinus oor elevation. An

electronic search was conducted to identify prospec-

tive and retrospective cohort studies on transalveolar

sinus

oor elevation, with a mean follow-up time ofat least 1 year after functional loading. The search

provided 849 titles. Full-text analysis was performed

for 176 articles, resulting in 19 studies that met the

inclusion criteria. Meta-analysis of these studies indi-

cated an estimated annual failure rate of 2.5% (95%

condence interval: 1.44.5%), translating to an esti-

mated survival rate of 92.8% (95% condence interval:

87.496.0%) after 3 years in function for implants

placed in transalveolarly augmented sinuses

(Table 1). Furthermore, subject-based analysis

revealed an estimated annual failure of 3.71% (95%

condence interval: 1.21

11.38%), which translated to10.5% (95% condence interval: 3.628.9%) of sub-

jects experiencing implant loss over 3 years.

Residual bone height

Of the 900 patient records screened for the Consensus

Conference in 1996, only 100 had radiographs of

adequate quality for analysis of the residual bone

height. In total, residual bone height was analyzed for

only 145 sinus grafts in 100 patients with 349

implants. After a mean follow-up period of 3.2 years,20 implants were lost. Of the implants lost, 13 were

initially placed in residual bone with a height of

4 mm and seven were placed in residual bone with a

height of 58 mm. None of the implants placed in

residual bone with a height of> 8 mm was lost. There

was a statistically signicant difference in implant

loss when residual bone height was 4 mm com-

pared with 5 mm (13). Hence, for implants placed

in combination with sinus oor elevation using the

A

B

Fig. 16. (A) A radiograph, taken at the 5-year follow-up

visit, of an implant placed in the rst quadrant, utilizing

the osteotome technique without grafting material. A new

cortical bony plate at the inferior border of the maxillary

sinus is clearly visible, but no bony structure can be

detected apical to the implant. (B) A radiograph (the same

patient as shown in panel (A) of an implant placed in the

second quadrant utilizing the osteotome technique with

xenograft grafting material, taken after 5 years in function

A dome-shaped structure is clearly visible, documenting a

denite increase in bone volume compared with the initial

situation The dome is surrounded with a new cortical

bony plate.


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Table1.

Annualfailureratesandsurvivalofimplantsplacedusing

thetransalveolarsinusoorelevatio

ntechnique

Study

Yearof

publication

Totalno.of

implants

Mean

follow-up

time(yea

rs)

No.of

failures

Before

loading

After

loading

Totalimplant

exp

osuretime

Estimatedfailure

rate(per100implantyears)

Estimatedsurvival

after3years(%)

Pjeturssonetal.(24)

2008

252

3.2

6

3

3

697

0.8

6

97.5

Krennmairetal.(18)

2007

14

3.7

0

0

0

52

0

100.0

Stavropoulosetal.(29)

2007

35

1

6

4

2

32

18.8

57.0

Levineetal.(20)

2007

45

1.7

5

5

0

77

6.4

9

82.3

Zhaoetal.(39)

2007

126

3.5

0

0

0

441

0

100.0

Ferrignoetal.(11)

2006

588

5

9

1

8

2641

0.1

1

99.0

Nediretal.(21)

2006

25

1

0

0

0

25

0

100.0

Chen&Cha(6)

2005

1557

3.2

8

8

0

4957

0.1

6

99.5

Deporteretal.(9)

2005

104

3.1

2

1

1

323

0.6

2

98.2

Leblebiciogluetal.(19)

2005

75

2

2

2

0

152

1.3

2

96.1

Toferetal.(34)

2004

276

2

14

10

4

558

1.7

9

94.8

Winteretal.(38)

2002

58

1.5

5

4

1

86

5.8

1

84.0

Cavicchiaetal.(5)

2001

97

2.9

8

5

3

268

2.9

9

91.4

Cosci&Luccioli(8)

2000

265

2.4

8

NR

NR

626

1.2

8

96.2

Rosenetal.(26)

1999

174

1.7

8

3

5

288

2.7

8

92.0

Bruschietal.(4)

1998

499

4.3

12

NR

NR

2158

0.5

6

98.3

Komarnyckyj&London(17)

1998

16

1

1

1

0

18

5.5

6

84.6

Zitzmann&Scharer(40)

1998

59

1.3

3

3

0

77

3.9

0

89.0

Coatoam&Krieger(7)

1997

123

1.9

6

5

1

169

3.5

5

89.9

Total

4388

103

55

28

13645

Summaryestimate(95%CI)*

2.4

8(1.3

74.4

9)

92.8

(87.496.0

)

NR,notreported.

*Basedonrandom-effectsPoissonregression,

testforheterogeneityP 5 mm. Moreover, for short 6-mm implants, the sur-

vival rate was only 48%. This clearly demonstrates

that the transalveolar sinus oor elevation technique

was most predictable with a residual alveolar bone

height of 5 mm and with implants of 8 mm.

Patient-centered outcomes

In the study of Pjetursson et al. (24), 163 patients

were examined at their follow-up visit and asked to

give their opinion on nine statements related to the

treatment. The rst two statements dealt with general

satisfaction with the treatment. The patients were

asked if they would undergo a similar treatmentagain, if needed, and the results were recorded on a

visual analog scale. The mean visual analog scale

score was 91 17 and the median (range) was 98 (0

100). The patients were also asked if they would rec-

ommend this treatment to a friend or a relative, if

indicated. The mean visual analog scale score was

90 17 and the median (range) was 97 (0100). For

both statements, only ve (3%) patients stated that

they would not be willing to undergo such a treat-

ment again.

Approximately 23% of the patients found the surgi-

cal experience unpleasant. When asked about othersurgical complications, 5% of the patients felt that

their head was tilted too far back during the surgery

and 5% of the patients experienced vertigo, nausea

and felt disoriented after the surgical procedure, but

no patient had any problem with unusual eye move-

ments. A small group ofve patients had psychologi-

cal problems after the treatment and had to seek

medical assistance (24). The authors concluded that

even though 23% of the patients reported the surgical

procedure as unpleasant, more than 90% of the

patients were willing to undergo implant therapy

again, if necessary and dentally indicated.

Conclusions and clinicalsuggestions

Randomized controlled clinical trials with sufcientstatistical power, comparing transalveolar sinus oor

elevations with sinus oor elevation utilizing a lateral

approach on one side, and with short implants on the

other side are needed for evidence-based decision

making. Moreover, randomized controlled clinical tri-

als comparing transalveolar sinus oor elevation with

and without grafting materials would be of great

value.

In the posterior maxilla with residual bone height

58 mm and a relativelyat sinus oor, elevation of

the maxillary sinus oor using the transalveolar tech-

nique, with or without grafting material, is indicated

(Fig. 17). Implants with morphometry designed to

achieve high initial stability and with moderately

rough surface geometry giving a high percentage of

bone-to-implant contact during the initial healing

phase (1), should be preferred. Implants with slightly

conical morphometry, or implants with a wider

implant neck, tend to give better primary stability in

the event of reduced residual bone height and soft

bone geometry.

Fig. 17. The ideal indication for transalveolar sinus oor

elevation is a site with a residual bone height of 57 mm

and relatively at sinus oor anatomy. The radiograph,

taken after implant placement, shows a dome-shape con-

guration of the graft. In this instance, 0.25 g of grafting

material (xenograft) was used to elevate the sinus mem-

brane (the dotted lines represent the outlines of the resid-

ual bone).


69


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References

1. Abrahamsson I, Berglundh T, Linder E, Lang NP, Lindhe J.

Early bone formation adjacent to rough and turned endos-

seous implant surfaces. An experimental study in the dog.

Clin Oral Implants Res2004:15: 381392.

2. Boyne PJ. Analysis of performance of root-form endosseous

implants placed in the maxillary sinus.J Long-Term Eff Med

Implants1993:3: 143159.

3. Boyne PJ, James R. Grafting of the maxillary sinusoor withautogenous marrow and bone. J Oral Surg 1980: 38: 613

618.

4. Bruschi GB, Scipioni A, Calesini G, Bruschi E. Localized

management of sinus oor with simultaneous implant

placement: a clinical report. Int J Oral Maxillofac Implants

1998:3: 219226.

5. Cavicchia F, Bravi F, Petrelli G. Localized augmentation of

the maxillary sinus oor through a coronal approach for

the placement of implants. Int J Periodontics Restorative

Dent2001:21: 475485.

6. Chen L, Cha J. An 8-year retrospective study: 1,100 patients

receiving 1,557 implants using the minimally invasive

hydraulic sinus condensing technique. J Periodontol2005:

76: 482

491.7. Coatoam GW, Krieger JT. A four-year study examining the

results of indirect sinus augmentation procedures. J Oral

Implantol1997:23: 117127.

8. Cosci F, Luccioli M. A new sinus lift technique in conjunc-

tion with placement of 265 implants: a 6-year retrospective

study.Implant Dent2000:9: 363368.

9. Deporter DA, Caudry S, Kermalli J, Adegbembo A. Further

data on the predictability of the indirect sinus elevation

procedure used with short, sintered, porous-surfaced den-

tal implants. Int J Periodontics Restorative Dent 2005: 25:

585593.

10. Engelke W, Deckwer I. Endoscopically controlled sinus oor

augmentation. A preliminary report. Clin Oral Implants Res

1997:8: 527531.

11. Ferrigno N, Laureti M, Fanali S. Dental implant placement

in conjunction with osteotome sinus oor elevation:

12-year life-table analysis from a prospective study on 588

ITI implants.Clin Oral Implants Res2006:17: 194205.

12. Fugazzotto PA. The modied trephine/osteotome sinus

augmentation technique: technical considerations and dis-

cussion of indications.Implant Dent2001:10: 259264.

13. Jensen OT, Shulman LB, Block MS, Iavono VJ. Report of the

sinus consensus conference of 1996. Int J Oral Maxillofac

Implants1996:13(Suppl.): 1145.

14. Kayser AF. Shortened dental arches and oral function. J

Oral Rehabil1981:8: 457462.

15. Kim MJ, Jung UW, Kim CS, Kim KD, Choi SH, Kim CK, ChoKS. Maxillary sinus septa: prevalence, height, location, and

morphology. A reformatted computed tomography scan

analysis.J Periodontol2006:77: 903908.

16. Kim SM, Park JW, Suh JY, Sohn DS, Lee JM. Bone-added os-

teotome technique versus lateral approach for sinus oor

elevation: a comparative radiographic study. Implant Dent

2011:20: 465470.

17. Komarnyckyj OG, London RM. Osteotome single-stage den-

tal implant placement with and without sinus elevation: a

clinical report.Int J Oral Maxillofac Implants1998:13: 799

804.

18. Krennmair G, Krainhofner M, Schmid-Schwap M, Pieh-

slinger E. Maxillary sinus lift for single implant-supported

restorations: a clinical study.Int J Oral Maxillofac Implants

2007:22: 351358.

19. Leblebicioglu B, Ersanli S, Karabuda C, Tosun T, Gokdeniz

H. Radiographic evaluation of dental implants placed using

an osteotome technique.J Periodontol2005:76: 385390.

20. Levine RA, Ganeles J, Jafn RA, Donald SC, Beagle JR, Keller

GW. Multicenter retrospective analysis of wide-neck dental

implants for single molar replacement. Int J Oral Maxillofac

Implants2007:22: 736

742.

21. Nedir R, Bischof M, Vazquez L, Szmukler-Moncler S, Ber-

nard JP. Osteotome sinus oor elevation without grafting

material: a 1-year prospective pilot study with ITI implants.

Clin Oral Implants Res2006:17: 679686.

22. Nedir R, Nurdin N, Vazquez L, Szmukler-Moncler S, Bischof

M, Bernard JP. Osteotome sinus oor elevation technique

without grafting: a 5-year prospective study. J Clin Period-

ontol2010:37: 10231028.

23. Pjetursson BE, Ignjatovic D, Matuliene G, Bragger U,

Schmidlin K, Lang NP. Maxillary sinus oor elevation using

the osteome technique with or without grafting material.

Part IIRadiographic tissue remodeling.Clin Oral Implants

Res2009:20: 677

683.24. Pjetursson BE, Rast C, Bragger U, Zwahlen M, Lang NP.

Maxillary sinus oor elevation using the osteome technique

with or without grafting material. Part I Implant survival

and patients perception. Clin Oral Implants Res2009: 20:

667676.

25. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic

review of the success of sinus oor elevation and survival of

implants inserted in combination with sinusoor elevation.

J Clin Periodontol2008:35(Suppl.): 216240.

26. Rosen PD, Summers R, Mellado JR, Salkin LM, Shanaman

RH, Marks MH, Fugazzotto PA. The bone-added osteotome

sinus oor elevation technique: multicenter retrospective

report of consecutively treated patients. Int J Oral Maxillo-

fac Implants1999:14: 853

858.27. Schmidlin PR, Muller J, Bindl A, Imfeld H. Sinus oor eleva-

tion using an osteotome technique without grafting materi-

als or membranes. Int J Periodontics Restorative Dent2008:

28: 401409.

28. Sohn DS, Lee JS, An KM, Choi BJ. Piezoelectric internal

sinus elevation (PISE) technique: a new method for internal

sinus elevation.Implant Dent2009:18: 458463.

29. Stavropoulos A, Karring T, Kostopoulos L. Fully vs. partially

rough implants in maxillary sinus oor augmentation: a

randomized-controlled clinical trial.Clin Oral Implants Res

2007:18: 95102.

30. Summers RB. A new concept in maxillary implant

surgery: the osteotome technique. Compendium 1994: 15:

152

162.31. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic

review of the success of sinus oor elevation and survival of

implants inserted in combination with sinusoor elevation.

Part II: transalveolar technique. J Clin Periodontol2008: 35

(Suppl.): 241254.

32. Tatum H. Maxillary and sinus implant reconstructions.

Dent Clin North Am1986:30: 207229.

33. Tatum OH, Lebowitz MS, Tatum CA, Borgner RA. Sinus

augmentation: rationale, development, long-term results. N

Y State Dent J1993:59: 4348.

Pjetursson & Lang

70


13/13

34. Tofer M. Osteotome-mediated sinus oor elevation: a

clinical report.Int J Oral Maxillofac Implants2004:19: 266

273.

35. Ulm CW, Solar P, Gsellmann B, Matejka M, Watzek G. The

edentulous maxillary alveolar process in the region of the

maxillary sinus a study of physical dimension. Int J Oral

Maxillofac Surg1995:24: 279282.

36. Van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing

DB. Anatomical aspects of sinus oor elevations. Clin Oral

Implants Res2000:11: 256265.

37. Vernamonte S, Mauro V, Vernamonte S, Messina AM. An

unusual complication of osteotome sinus oor elevation:

benign paroxysmal positional vertigo. Int J Oral Maxillofac

Surg2011:40: 216218.

38. Winter AA, Pollack AS, Odrich RB. Placement of implants in

the severely atrophic posterior maxilla using localized man-

agement of the sinus oor: a preliminary study. Int J Oral

Maxillofac Implants2002:17: 687695.

39. Zhao BD, Wang YH, Xu JS, Zheng J, Gong DL, Yu Y. Clinical

study of maxillary sinus oor elevation with simultaneous

placement of implants from the top of alveoli. Shanghai

Kou Qiang Yi Xue2007:16: 480483.

40. Zitzmann NU, Scharer P. Sinus elevation procedures in the

resorbed posterior maxilla. Comparison of the crestal and

lateral approaches. Oral Surg Oral Med Oral Path Oral

Radiol Endod1998:85: 817.


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sinus floor elevation utilizing the.pdf

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