Hong-Chang Lai Osteotome sinus floor elevation with or

Long-Fei Zhuang
Xiao-Fei Lv
without grafting: a preliminary
Zhi-Yong Zhang clinical trial
Yun-Xin Zhang
Zhi-Yuan Zhang

Authors’ affiliations:
Hong-Chang Lai, Long-Fei Zhuang, Xiao-Fei Lv,
Zhi-Yong Zhang, Yun-Xin Zhang, Department of
Oral & Maxillofacial Implantology, Shanghai Ninth
People’s Hospital, School of Medicine, Shanghai
Jiaotong University, Shanghai, China
Zhi-Yuan Zhang, Department of Oral &
Maxillofacial Surgery, Shanghai Ninth People’s
Hospital, School of Medicine, Shanghai Jiaotong
University, Shanghai, China
Corresponding author:
Prof. Hong-Chang Lai
Department of Oral & Maxillofacial Implantology
Shanghai Ninth People’s Hospital
School of Medicine Shanghai Jiaotong University
Shanghai 200011
China
Tel.: þ 86 21 232 71 699
Fax: þ 86 21 530 73 068
e-mail: lhc9@hotmail.com
Key words: cumulative survival rate, dental implant, endo-sinus bone gain, osteotome
sinus floor elevation, radiographic analysis
Abstract
Objectives: This clinical trial aimed (1) to evaluate the predictability of the osteotome sinus
floor elevation (OSFE) technique, (2) to study the influence of simultaneous grafting on the
clinical success of placing dental implants in the posterior maxilla using OSFE and (3) to
observe the bone changes in the elevated space with OSFE without grafting.
s
Material and methods: Two hundred and eighty Straumann implants were placed in the
posterior maxillae of 202 patients using OSFE. One hundred and ninety-one implants were
placed in 125 patients without grafting. The implants were allowed to heal for 3–4 months
for non-grafted implants and for 6–8 months for grafted cases. For radiographic analyses,
periapical and panoramic radiographs were taken of 30 implants at 3 and 9 months to
assess the bone changes for the elevated sites without grafting.
Results: Two hundred and sixty-eight of 280 implants fulfilling the survival criteria
represented a cumulative survival rate of 95.71%. The residual bone height (RBH) was
5.6  2.5 mm for the non-grafted group and 4.7  2.1 mm for the grafted group. The
perforation rate was 4.29%. No significant differences were found between the two groups
in RBH, survival rate or membrane perforation rate. The radiographic analyses
demonstrated that new bone formation in the elevated sinus was visible and the endo-sinus
bone gain was 2.26  0.92 mm and 2.66  0.87 mm at 3- and 9- month follow-up,
respectively. Crestal bone loss (CBL) was 0.89  0.5 and 1.2  0.48 mm at 3 and 9 months.
For the two test groups, RBH did not have a significant influence on the survival of the
implants. At the 9-month follow-up, the endo-sinus bone gain and CBL were not
significantly correlated to RBH. The implant protrusion length was significantly correlated
to the endo-sinus bone gain.
Conclusions: The findings of this study indicated that uneventful osseointegration may be
predictable on applying OSFE whether with or without grafting in atrophic posterior
maxilla. Spontaneous new bone formation seemed to be expected with implants placed
using OSFE without simultaneous grafting.

Date:
Accepted 4 November 2009
To cite this article:
Lai H-C, Zhuang L-F, Lv X-F, Zhang Z-Y, Zhang Y-X,
Zhang Z-Y. Osteotome sinus floor elevation with or
without grafting: a preliminary clinical trial.
Clin. Oral Impl. Res. 21, 2010; 520–526.
doi: 10.1111/j.1600-0501.2009.01889.x
Posterior maxillae commonly pose a chal-
lenge for successful dental implants due to
the poor bone quality and insufficient bone
quantity. Efforts have been made to allow
successful implant placement in the poster-
ior maxilla subject to limited bone height
under the sinus. Approaches available now
include the application of tilting implants,
short implants, the sinus floor elevation
technique, etc.
The osteotome sinus floor elevation
(OSFE) technique, first introduced by Ta-
tum (1986), has been proved to be a pre-
dictable procedure (Bruschi et al. 1998;

520 c 2010 John Wiley & Sons A/S



Fugazzotto & Vlassis 1998; Komarnyckyj &
London 1998; Rosen et al. 1999). For OSFE,
access to the sinus membrane is achieved
through a crestal approach. Therefore, com-
pared with the window technique, OSFE is
considered to be less invasive and less trau-
matic while having a limitation with regard
to the residual bone height (RBH) under the
sinus. According to the consensus conference
in 1996, the OSFE technique should be
limited to RBH ranging from 7 to 9 mm
(Jensen et al. 1998). However, with the im-
provement of implant design and surgical
technique, the high predictability of implant
therapy has encouraged re-evaluation of this
limitation. Favorable results have been re-
ported with more compromised sites even
with RBH of around 4 mm (Winter et al.
2002; Nedir et al. 2006). Moreover, there is
controversy regarding the necessity of a graft-
ing material in order to maintain the space for
new bone formation (Bruschi et al. 1998;
Haas et al. 1998; Winter et al. 2002; Lundg-
ren et al. 2004; Leblebicioglu et al. 2005;
Nedir et al. 2006; Tan et al. 2008). In a
previous pilot study (Lai et al. 2008), 42
implants were placed in posterior maxillae
with OSFE without bone grafting materials.
The RBH ranged from 4to 8 mm (average
6.36 mm). The 5-month result also demon-
strated predictable results. But, to date, there
are still insufficient data regarding the clinical
results of the implants in posterior maxilla
with the OSFE technique without grafting
and the necessity of grafting with OSFE still
remains to be elucidated.
In this context, therefore, the authors at-
tempted to assess the clinical success of
dental implants placed in posterior maxillae
using OSFE with or without grafting and to
observe the endo-sinus bone changes when
no grafting materials are applied. The current
clinical trial was aimed at testing the hypoth-
esis that the application of grafting materials
may not significantly improve the clinical
success of the dental implants placed using
OSFE with an RBH range between 2 and
8 mm and that spontaneous new bone forma-
tion may be observed with implants placed
using OSFE without simultaneous grafting.
Material and methods
Patient data and pre-operative treatment
s Number of
Two hundred and eighty Straumann
implants (Straumann AG, Waldenburg,
c 2010 John Wiley & Sons A/S
 521 |
Lai et al  Osteotome sinus floor elevation with or without grafting
Switzerland) were placed in 202 patients
(92 men and 110 women) between January
2003 and January 2008. Patient age ranged
from 20 to 68 years (mean 47  3.6 years).
Table 1 shows the distribution of the im-
plant position.
A complete pre-treatment examination
was conducted for each patient. Panoramic
radiographs were taken of all patients. The
residual alveolar height was measured on
the panoramic radiographs by one exami-
ner, and each height was measured twice to
obtain an average. Computer tomography
(CT) scans were performed when it was
difficult to define the sinus floor on the
panoramic radiograph.
The inclusion criteria were (1) edentu-
lous in the posterior maxillary region; (2)
RBH ranging from 2 to 8 mm; (3) no
rhinitis or sinusitis; and (4) bone width
sufficient to maintain the primary stabi-
lity. The patients were excluded if they
were (1) heavy smokers (  10 cigarettes
per day); (2) systemically contra-indicated
for implant placement (e.g. uncontrolled
diabetes, hypertension, carotid diseases);
(3) subject to uncontrolled periodontal dis-
eases; (4) subject to bruxism.
The patients who fulfilled the inclusion
criteria were allocated to either of the two
test groups, i.e. (1) OSFE without grafting
and (2) OSFE with simultaneous grafting.
No specific randomization was applied. All
the patients, whether included in this
study or not, were to be given an eight-
digit registration number by the hospital at
the first visit when registering at the recep-
tion. The patient was allocated to the
grafting group if the patient registration
number that was given at registration was
odd or was allocated to the non-grafting
group if the number was even. One hun-
dred and ninety-one implants were placed
in 125 patients with no grafting and 89
implants were placed in 77 cases with
simultaneous grafting.
Informed consents were signed after a
comprehensive consultation. All patients
Table 1. Distribution of implant position in
the maxilla
Right Left
maxillae maxillae
Edentulous 17 1615 1424 2526 27
position
32 7523 8 6 2179 36
implants
received oral hygiene instructions before
entering the study.
Surgical procedure
For all the cases, local infiltration anesthe-
sia was used. Following a midcrestal inci-
sion, with mesial and distal releasing
incisions extending well up into the buccal
fold, a full-thickness mucoperiosteal flap
was reflected. A round bur was first used to
mark the implant positions. Then, a mini-
mal pilot drilling (+2.2 mm) was per-
formed to a depth approximately 1 mm
away from the sinus floor boundary accord-
ing to the depth taken from the panoramic
radiograph or the CT scan. The cortical part
of the implant bed was further widened to
either +3.5 mm for +4.1 mm implants
or +4.2 mm for +4.8 mm implants. At
this stage, the integrity of the sinus mem-
brane was examined using the Valsava
maneuver. Then the elevation of the
maxillary sinus was achieved using a
+2.8 mm osteotome by light malleting
to achieve the initial sinus up-fracture
and was developed with osteotomes of
increasing diameters gradually till the final
depth. For the group of simultaneous graft-
ing, the autogenous bone chips harvested
during the drilling procedure were mixed
with an alloplastic bone-replacing material,
s
b-tricalcium phosphate Cerasorb (Cura-
san AG, Kleiostheim, Germany), and the
mixture was placed into the ‘‘socket’’ by
osteotomes when elevating the sinus mem-
brane until the final depth. No profile drill
was used for any of the cases. The implants
were placed in the prepared osteotomy site
using a hand ratchet without tapping. All
implants were placed in sites using a non-
submerged technique and in a one-stage
procedure. A panoramic and a periapical
radiograph were immediately taken of all
the cases (baseline).
Postoperative treatment
Anti-inflammatory cefradine (Xinya Co.,
Shanghai, China, 500 mg, four times a day
for 7 days) and metronidazole (Xinyiwan-
xiang, Shanghai, China, 400 mg, three
times a day for 7 days) were used
after the surgery. Non-steroidal anti-
inflammatory agents were prescribed for
postsurgical analgesia. A 0.12% chlorhex-
idine oral rinse was prescribed for 60 s five
to six times a day for 14 days. Sutures were
removed after 1 week. Patients were not
Clin. Oral Impl. Res. 21, 2010 / 520–526
Lai et al  Osteotome sinus floor elevation with or without grafting

allowed to use any removable prostheses
during the healing period.
Prosthetic procedure
The implants were allowed to heal for 3–4
months for non-grafted implants and for
6–8 months for grafted cases. A panoramic
and a periapical radiograph were taken to
examine whether there was continued radi-
olucency around the implant body. When
implants were stable, solid abutments were
tightened with a 35 N cm torque, the
impressions were taken and porcelain-
fused-to-gold prostheses were cemented to
the solid abutment after 7–10 days.
Follow-up and radiographic analyses
Patients were recalled for a radiographic
and clinical examination 1 (n ¼ 268),
2 (n ¼ 229), 3 (n ¼ 147), 4 (n ¼ 83) and
5 (n ¼ 29) years after prostheses attach-
ment. At each visit, a panoramic radio-
graph was taken to evaluate the bone
level and peri-implant radiolucency. Clin-
ical examination included the assessment
of implant mobility, the prostheses and
patients’ satisfaction. The patients were
asked orally about the comfort, appearance,
ability to chew and general satisfaction and
were asked to grade these as excellent,
good, fair or poor. The survival of implants
was evaluated using the criteria proposed
by Buser et al. (1997).
Thirty implants placed in 25 patients (11
males, 14 females) using OSFE without
grafting between June 2007 and June
2008 were enrolled for radiographic ana-
lyses. The patient age ranged from 18 to 62
(mean 43  2.9). Periapical and panoramic
radiographs were taken on the day of sur-
gery (baseline), at 3 and 9 months after
surgery. The following parameters were
measured using the software SIDEXIS
(SIDEXIS 1.12, Sirona Dental System
GmbH, Bensheim, Germany): (1) endo-
sinus bone gain change; (2) crestal bone
loss (CBL). For these parameters, both
mesial and distal aspects of the implants,
i.e. 60 sides, were measured.
Statistical analyses
SPSS Software (SPSS 16.0, SPSS Inc., Chi-
cago, IL, USA) was applied to conduct the
statistical analyses. Descriptive statistics,
mean and standard deviation were used to
assess the radiographic parameters of the
two test groups including RBH, implant
protrusion length and endo-sinus bone
gain. An unpaired t-test was applied to
compare the RBH of the two test groups.
The survival rates and the membrane per-
foration rates were calculated of the two
test groups and of the different test groups
classified according to RBH, implant
length and implant diameter. To bypass
the problem of dependencies between mul-
tiple implants within one patient, the pa-
tient-based survival rates and membrane
perforation rates were calculated with one
implant per patient randomly chosen. A w2-
test was applied to compare the survival
rates and the membrane perforation rates of
the two groups and to compare these rates
of the three groups classified according to
RBH, implant length and implant dia-
meter. Partial correlation coefficient was
used to assess the correlation between RBH
and endo-sinus bone gain and CBL and
between implant protrusion length and
endo-sinus bone gain and CBL. The signif-
icance level was set at 0.05.
Results
Two hundred and sixty-eight of 280 im-
plants fulfilling the survival criteria repre-
sented a cumulative survival rate of
95.71%. Two implants failed during the
first week after surgery showing signs of
infection. Eight implants failed before load-
ing. The other two failed at 3 and 12
months after loading, respectively. The
perforation of the sinus membrane was
found for 12 procedures. The perforation
rate was 4.29%. Three patients showed
minor signs of nose bleeding during the
first 3 days after surgery. No other post-
operative complications were observed.
The RBH was 5.6  2.5 mm for the
non-grafted group and 4.7  2.1 mm for
the grafted group (P ¼ 0.082). The survival
rates and the membrane perforation rates
for the two groups are described in Table 2.
No significant differences were found be-
tween the two groups in the survival rate or
the membrane perforation rate. Table 3
demonstrates the survival rates of implants
placed in sites with different RBH. For the
two test groups, RBH did not have a sig-
nificant influence on the survival of the
implants. A Significant difference was only
found between the two test groups for
RBH ¼ 6–8 mm. But it should be noted
that the sample size is only 23 for the
grafting sites and 91 for non-grafting. Im-
plant diameter and length had no signifi-
cant effect on the survival rates (Table 4).
For the 30 implants included in the radio-
graphic analyses, the pre-treatment RBH
was 4.97  1.47 mm (mesial 5.2  1.53
mm and distal 4.73  1.38 mm). The pro-
trusion length of the implants measured at
baseline was 3.94  1.14 mm (mesial
3.62  1.12 mm, distal 4.26  1.08 mm).
The survival during the observation period
was 100%. Only one implant was subject to
membrane perforation.
The endo-sinus bone gain and CBL com-
pared with baseline at 3 and 9 months are
shown in Table 5. At the 3-month follow-
up, de novo endo-sinus bone formation

Table 2. Implant 5-year cumulative survival rate and membrane perforation rate for the two test groups
Group Number of implants Implant failures Survival rate (%) Membrane perforation rate (%)
(A) Impant-based survival rate and membrane perforation rate
Grafting (G) 89 7 92.13 7.87
No grafting (NG) 191 5 97.38 2.62
P value – – 0.089 0.089
Group Number of patients Patients with failures Survival rate (%) Membrane perforation rate (%)
(B) Patient-based survival rate and membrane perforation rate
Grafting (G) 77 5 93.51 2.6
No grafting (NG) 125 2 98.4 2.4
P value – – 0.147 0.705

522 | Clin. Oral Impl. Res. 21, 2010 / 520–526 c 2010 John Wiley & Sons A/S

 Lai et al  Osteotome sinus floor elevation with or without grafting

Table 3. Five-year cumulative survival rates for the two test groups according to residual et al. 2009). Engelke and Deckwer (1997)
bone height also revealed in an endoscopic study that
RBH (mm) P value
the sinus oor might be elevated up to 5 mm
2–4 4–6 6–8 without perforating the membrane.
Grafting 89.47% (n ¼ 19) 93.33% (n ¼ 45) 91.3% (n ¼ 23) 0.866 When placing implants in posterior max-
No grafting (NG) 90% (n ¼ 20) 97.56% (n ¼ 82) 98.9% (n ¼ 91) 0.076 illae, the guideline now available is given to
P value 0.957 0.241 0.042 –
the RBH. Tan et al. (2008) concluded in
RBH, residual bone height. their systemic review that the failure rate
of the implants placed with transalveolar
sinus floor augmentation increased and
correlated with reduced RBH. Rosen et al.
Table 4. Five-year cumulative survival rate according to the implant length and diameter (1999) reported a significantly lower survi-
Implant length (mm) Implant diameter (mm) val rate for implants placed with RBH,
 8 mm (short implant)  10 mm 4.1 RN 4.8 WN which was o4 mm. Pjetursson et al.
(2008) also reported similar results. In the
6 mm 8 mm 10 12
present study, however, implants placed in
Number 12 121 139 8 165 115
sites with RBH o4 mm were not related to
Number of failures 1 5 6 0 8 4
Survival rate (%) 95.49 95.92 95.15 96.52 a significantly lower survival rate. This
P value 0.859 0.578 finding may be explained by the implant
stability. In the previous study (Lai et al.
2008), the stability of implants placed in
posterior maxillae with an RBH of 4–8 mm
Table 5. Radiographic results calculated at 3 and 9 months according to the baseline by OSFE without bone grafting was stu-
Endo-sinus bone gain (mm) Crestal bone loss (mm) died. The ISQ values demonstrated that all
Mesial Distal Total Mesial Distal Total the implants achieved good primary stabi-
lity and reached a comparably high stability
3 months 2.11  0.94 2.42  0.88 2.26  0.92 0.85  0.48 0.92  0.51 0.89  0.5
9 months 2.47  0.85 2.85  0.87 2.66  0.87 1.14  0.47 1.25  0.52 1.2  0.48 at 16 weeks postoperation with a dip be-
tween 2 and 6 weeks in the stability curve.
The pre-treatment vertical bone height did
was observed for 42 sides of the implants. placed with the window technique or those not have a statistically significant influ-
The new bone demonstrated a lower den- placed in non-elevated sites. In the present ence on the mean ISQ and its changing
sity. The original sinus floor outline was trial, the 5-year cumulative survival rate of pattern. Gabbert et al. (2009) also reported
still recognized. At 9 months, a new sinus implants placed with OSFE was 95.71%. that an RBH of 3–8 mm did not result in
floor outline was observed for 48 sides (Figs The result was in accordance with the significantly lower survival than 8 mm
1 and 2). survival rates reported by other clinicians bone height. Still, it should be noted that
At the 9-month follow-up, the endo- and researchers (Ferrigno et al. 2006; Nedir studies of higher evidence level may be
sinus bone gain and CBL were not signifi- et al. 2006, 2009; Pjetursson et al. 2008, needed to further confirm the result.
cantly correlated to RBH (Table 6). The 2009a; Schmidlin et al. 2008; Gabbert Moreover, the question regarding the
protrusion length of the implants signifi- et al. 2009). Tan et al. (2008) reported, in necessity of simultaneous grafting remains
cantly correlated to the endo-sinus bone a recent systemic review, that the 3-year open. Simultaneous application of grafting
gain (Table 7). survival rate of implants placed in transal- materials has been reported to result in
veolar sinus floor augmentation sites was improved outcomes with a transalveolar
92.8%, which was comparable with those sinus floor elevation procedure (Pjetursson
Discussion in non-elevated sites, and the correspond- et al. 2009b). In the present trial, however,
ing survival rate of implants placed through the application of OSFE in combination
OSFE has expanded the prosthetic option the lateral approach reported by the same with grafting materials did not demonstrate
by enabling the placement of an additional group in a systemic review was 90.1% a significantly higher survival rate com-
implant support in maxillary segments (Po0.05) (Pjetursson et al. 2008). pared with the non-grafting sites. Gabbert
with atrophic ridges and pneumatized si- because of the indirect overview of the et al. (2009) and Nedir et al. (2009) also
nuses. OSFE is thought to be less invasive, elevated sinus floor, the OSFE procedure reported high survival rates for implants
to have no need for re-entry and to reduce had once been thought to increase the risk placed using OSFE without grafting. So
the healing time and cost. On the other of membrane perforation. In the present far, although only a limited number of
hand, however, the sinus floor is elevated study, however, the perforation rate was studies have been available, the OSFE
‘‘blindly’’ with OSFE (Diserens et al. only 4.29%. This result was confirmed by technique seemed to be predictable when
2005), and therefore it has been questioned the perforation rates reported by many no grafting materials were used.
whether implants placed with OSFE could other researches (Diserens et al. 2005; Grafting the sites is thought to improve
have a survival rate comparable with those Becker et al. 2008; Tan et al. 2008; Gabbert the primary stability by providing more

c 2010 John Wiley & Sons A/S

 523 | Clin. Oral Impl. Res. 21, 2010 / 520–526
Lai et al  Osteotome sinus floor elevation with or without grafting

the implants could be placed beneath the

level of cortical bone, thus providing the
cortical anchorage, which may contribute
to the primary implant stability even in
sites with RBH o4 mm.
Moreover, the application of grafting
material is thought to create and maintain
Fig. 1. (a) Panoramic radiograph taken immediately after implant placement demonstrating an elevated sinus
the space for new bone formation. Many
membrane. (b) Panoramic radiograph taken 3 months after implant placement demonstrating the apparent researchers have attempted to investigate
increased endo-sinus bone (arrow). (c) Panoramic radiograph taken 9 months after implant placement the bone remodeling and bone formation
demonstrating the apparent increased endo-sinus bone (arrow). under the elevated sinus with simulta-
neous grafting (Brägger et al. 2004; Dise-
rens et al. 2005; Artzi et al. 2008; Kirmeier
et al. 2008; Pjetursson et al. 2008; Kim
et al. 2009). Pjetursson et al. (2008) de-
scribed a cloudy dome structure with a hazy
demarcation observed for grafting sites,
which showed signs of shrinkage during
the follow-up to the level of the implant
apex. The other researchers reported similar
observations. Their results were in favor of
grafting from the point of view of bone gain
measured from panoramic and intra-oral
radiographs, but it should also be noted
Fig. 2. (a) Radiograph taken immediately after implant placement demonstrating an elevated sinus membrane that it is difficult to judge from a panoramic
and the elevated sinus floor on the top of the implant apex (arrow). (b) Radiograph taken 9 months after implant
or an intra-oral radiograph whether the
placement demonstrating the increased endo-sinus bone and new bone formation around the implant (arrow).
grafting material has transformed into
bone (Diserens et al. 2005).
The present study focused on the endo-
Table 6. Radiographic analyses according to RBH at 9-month follow-up
sinus bone gain of implants placed without
RBH (mm)
grafting. New bone formation in the
2–4 4–6 6–8 elevated sinus was visible and the endo-
Mean (mm) 3.1  0.61 5  0.54 6.6  0.49 sinus bone gain was 2.26  0.92 and
Number of implant sides 17 24 19 2.66  0.87 mm at the 3- and 9-month
Endo-sinus bone gain (mm) 2.77  1.13 2.79  0.55 2.37  0.73
CBL (mm) 1.17  0.43 1.23  0.53 1.2  0.48 follow-up, respectively. These findings
were in accordance with other studies
Partial correlation coefficient was  0.158 between RBH and endo-sinus bone gain (P40.05). Partial
(Leblebicioglu et al. 2005; Gabbert et al.
correlation coefficient was  0.248 between RBH and CBL (P40.05).
2009; Nedir et al. 2009). Gabbert et al.
CBL, crestal bone loss; RBH, residual bone height.
(2009) reported that apical bone gain could
be observed in 30% implants with internal
sinus lift without grafting. Nedir et al.
Table 7. Radiographic analyses according to implant protrusion length at 9 months (2009) demonstrated that all the implants
Implant protrusion length (mm) gained endo-sinus bone without grafting
2–4 4–6 and the mean gained bone was
2.5  1.2 mm, which increased signifi-
Mean 3.1  0.64 4.97  0.64
Number of implant sides 33 27 cantly to 3.1  1.5 mm during the first 3
Endo-sinus bone gain (mm) 2.34  0.98 3.06  0.64 years. The findings regarding the CBL
Crestal bone loss (CBL) (mm) 1.19  0.51 1.23  0.45 change of the current study were also in
Partial correlation coefficient was 0.518 between implant protrusion length and endo-sinus bone accordance with those of Nedir et al. (2009)
gain (Po0.001). Partial correlation coefficient was 0.106 between implant protrusion length and CBL and the reason for CBL change remains
(P40.05). unclear. That the ‘‘machined’’ surface of
the implant neck was not expected to
integrate with bone may contribute to the
bony anchorage of implants. But the result achieve good primary stability. Profile CBL reduction. RBH and implant protru-
of the previous study (Lai et al. 2008) drills were not used for preparing any of sion length are thought to be the influen-
demonstrated that the implants placed the implant sites in our study, and there- cing factor of endo-sinus bone changes. In
with OSFE without grafting could also fore the conical ‘‘machined’’ neck part of the present study, there was no significant

524 | Clin. Oral Impl. Res. 21, 2010 / 520–526 c 2010 John Wiley & Sons A/S


correlation between RBH and endo-sinus
bone gain. This finding was different from
the result of Nedir et al. (2006). The
difference may be explained by the different
statistical methods. The implant protru-
sion length was significantly correlated to
endo-sinus bone gain. This result may be
explained by increasing the space under the
elevated sinus. Still, due to the limited
documentation and the low level of evi-
dence available, randomized-controlled
clinical trials of OSFE with or without
bone grafting are needed to further confirm
the radiographic result.
It is also one of the main purposes of
grafting to allow for longer implants. Pje-
tursson et al. (2008) reported a survival rate
of only 47.6% for 6 mm implants placed
with the transalveolar osteotome techni-
que, which was significantly lower than
References
Artzi, Z., Weinreb, M., Carmeli, G., Lev-Dor, R.,
Dard, M. & Nemcovsky, C.E. (2008) Histomor-
phometric assessment of bone formation in sinus
augmentation utilizing a combination of autoge-
nous and hydroxyapatite/biphasic tricalcium
phosphate graft materials: at 6 and 9 months in
humans. Clinical Oral Implants Research 19:
686–692.
Becker, S.T., Terheyden, H., Steinriede, A., Beh-
rens, E., Springer, I. & Wiltfang, J. (2008) Pro-
spective observation of 41 perforations of the
Schneiderian membrane during sinus floor eleva-
tion. Clinical Oral Implants Research 19:
1285–1289.
Brägger, U., Gerber, C., Joss, A., Haenni, S., Meier,
A., Hashorva, E. & Lang, N.P. (2004) Patterns of
tissue remodeling after placement of ITI dental
implants using an osteotome technique: a long-
itudinal radiographic case cohort study. Clinical
Oral Implants Research 15: 158–166.
Bruschi, G.B., Scipioni, A., Calesini, G. & Bruschi,
E. (1998) Localized management of sinus floor
with simultaneous implant placement: a clinical
report. The International Journal of Oral & Max-
illofacial Implants 13: 219–226.
Buser, D., Mericske-Stern, R., Bernard, J.P., Beh-
neke, A., Behneke, N., Hirt, H.P., Belser, U.C. &
Lang, L.P. (1997) Long-term evaluation of non-
submerged ITI implants. Part 1: 8-year life table
analysis of a prospective multi-center study with
2359 implants. Clinical Oral Implants Research
8: 161–172.
Diserens, V., Mericske, E. & Mericske-Stern, R.
(2005) Radiographic analysis of the transcrestal
sinus floor elevation: short-term observations.
Clinical Implant Dentistry & Related Research
7: 70–78.
Engelke, W. & Deckwer, I. (1997) Endoscopically
controlled sinus oor augmentation. A preliminary
report. Clinical Oral Implants Research 8: 527–531.
c 2010 John Wiley & Sons A/S
 525 |
Lai et al  Osteotome sinus floor elevation with or without grafting
longer implants. In our study, no signifi-
cant difference was found between long
(10 mm or more in length) and short im-
plants (6 or 8 mm in length). The authors
(Lai et al. 2008) reported that implant
length did not have a statistically signifi-
cant influence on the implant stability. But
the results should be interpreted with cau-
tion due to the limited sample size. Only
seven 6 mm implants were involved in the
study of Pjetursson et al. (2009a) and the
corresponding number in our study was
only 12. Long-term results with more short
implants involved will be needed to provide
more evidence.
In conclusion, placing implants in
atrophic posterior maxillae applying
OSFE, whether with or without simulta-
neous grafting, may be predictable. No
significant differences in survival or mem-
Ferrigno, N., Laureti, M. & Fanali, S. (2006) Dental
implants placement in conjunction with osteotome
sinus floor elevation: a 12-year life-table analysis
from a prospective study on 588 ITI implants.
Clinical Oral Implants Research 17: 194–205.
Fugazzotto, P.A. & Vlassis, J. (1998) Long-term
success of sinus augmentation using various sur-
gical approaches and grafting materials. The Inter-
national Journal of Oral & Maxillofacial
Implants 13: 52–58.
Gabbert, O., Koob, A., Schmitter, M. & Rammels-
berg, P. (2009) Implants placed in combination
with an internal sinus lift without graft material:
an analysis of short-term failure. Journal of Clin-
ical Periodontology 36: 177–183.
Haas, R., Donath, K., Födinger, M. & Watzek, G.
(1998) Bovine hydroxyapatite for maxillary sinus
grafting: comparative histomorphometric findings
in sheep. Clinical Oral Implants Research 9:
107–116.
Jensen, O.T., Shulman, L.B., Block, M.S. & Iacone,
V.J. (1998) Report of the sinus consensus confer-
ence of 1996. The International Journal of Oral &
Maxillofacial Implants 19: 199–207.
Kim, Y.K., Yun, P.Y., Kim, S.G., Kim, B.S. & Ong,
J.L. (2009) Evaluation of sinus bone resorption and
marginal bone loss after sinus bone grafting and
implant placement. Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology, and Endodon-
tics 107: e21–e28.
Kirmeier, R., Payer, M., Wehrschuetz, M., Jakse,
N., Platzer, S. & Lorenzoni, M. (2008) Evaluation
of three-dimensional changes after sinus floor
augmentation with different grafting materials.
Clinical Oral Implants Research 19: 366–372.
Komarnyckyj, O.G. & London, R.M. (1998) Osteo-
tome single-stage dental implant placement with
and without sinus elevation: a clinical report. The
International Journal of Oral & Maxillofacial
Implants 13: 799–804.
brane perforation rates between the two
test groups were observed. Implant length
and RBH seemed to have no significant
influence on the survival rate. Spontaneous
new bone formation under the elevated
sinus floor seemed to be expected with
implants placed using OSFE without si-
multaneous grafting. Because of the limita-
tions of the current study, long-term
results of studies with randomization de-
sign may be required to confirm the result.
Acknowledgement: This study has
been supported by the Shanghai
Municipal Education Commission
(08zz57) and by Science and
Technology Commission of Shanghai
Municipality (09411955000).
Lai, H.C., Zhang, Z.Y., Wang, F., Zhuang, L.F. &
Liu, X. (2008) Resonance frequency analysis of
stability on ITI implants with osteotome sinus
floor elevation technique without grafting: a 5-
month prospective study. Clinical Oral Implants
Research 19: 469–475.
Leblebicioglu, B., Ersanli, S., Karabuda, C., Tosun,
T. & Gokdeniz, H. (2005) Radiographic evalua-
tion of dental implants placed using an osteotome
technique. Journal of Periodontology 76:
385–390.
Lundgren, S., Andersson, S., Gualini, F. & Sennerby,
L. (2004) Bone reformation with sinus membrane
elevation: a new surgical technique for maxillary
sinus floor augmentation. Clinical Implant Dentis-
try & Related Research 6: 165–173.
Nedir, R., Bischof, M., Vazquez, L., Nurdin, N.,
Szmukler-Moncler, S. & Bernard, J.P. (2009)
Osteotome sinus floor elevation technique with-
out grafting material: 3-year results of a prospec-
tive pilot study. Clinical Oral Implants Research
20: 701–707.
Nedir, R., Bischof, M., Vazquez, L., Szmukler-Mon-
cler, S. & Bernard, J.P. (2006) Osteotome sinus
floor elevation without grafting material: a 1-year
prospective pilot study with ITI implants. Clin-
ical Oral Implants Research 17: 679–686.
Pjetursson, B.E., Ignjatovic, D., Matuliene, G.,
Brägger, U., Schmidlin, K. & Lang, N.P. (2009a)
Transalveolar maxillary sinus floor elevation
using osteotomes with or without grafting mate-
rial. Part II: radiographic tissue remodeling. Clin-
ical Oral Implants Research 20: 677–683.
Pjetursson, B.E., Rast, C., Brägger, U., Schmidlin,
K., Zwahlen, M. & Lang, N.P. (2009b) Maxillary
sinus floor elevation using the (transalveolar)
osteotome technique with or without grafting
material. Part I: implant survival and patients’
perception. Clinical Oral Implants Research 20:
667–676.
Clin. Oral Impl. Res. 21, 2010 / 520–526
Lai et al  Osteotome sinus floor elevation with or without grafting
Pjetursson, B.E., Tan, W.C., Zwahlen, M. & Lang,
N.P. (2008) A systematic review of the success of
sinus floor elevation and survival of implants
inserted in combination with sinus floor eleva-
tion. Journal of Clinical Periodontology 35
(Suppl.): 216–240.
Rosen, P.S., Summers, R., Mellado, J.R., Salkin,
L.M., Shanaman, R.H., Marks, M.H. & Fugaz-
zotto, P.A. (1999) The bone-added osteotome
sinus floor elevation technique: multicenter retro-
spective report of consecutively treated patients.
526 | Clin. Oral Impl. Res. 21, 2010 / 520–526
The International Journal of Oral & Maxillofa-
cial Implants 14: 853–858.
Schmidlin, P.R., Müller, J., Bindl, A. & Imfeld, H.
(2008) Sinus floor elevation using an osteotome
technique without grafting materials or mem-
branes. The International Journal of Periodontics
and Restorative Dentistry 28: 401–409.
Tan, W.C., Lang, N.P., Zwahlen, M. & Pjetursson,
B.E. (2008) A systematic review of the success of
sinus floor elevation and survival of implants
inserted in combination with sinus floor eleva-
tion. Part II: transalveolar technique. Journal of
Clinical Periodontology 35 (Suppl.): 241–254.
Tatum, H. Jr (1986) Maxillary and sinus implant
reconstruction. Dental Clinics of North America
30: 207–229.
Winter, A.A., Pollack, A.S. & Odrich, R.B. (2002)
Placement of implants in the severely atrophic
posterior maxilla using localized management of
the sinus floor: a preliminary study. The Interna-
tional Journal of Oral & Maxillofacial Implants
17: 687–695.
c 2010 John Wiley & Sons A/S