J Clin Periodontol 2008; 35 (Suppl. 8): 216–240 doi: 10.1111/j.1600-051X.2008.01272.

A systematic review of the success Bjarni E. Pjetursson1,2, Wah Ching

Tan3, Marcel Zwahlen4 and
Niklaus P. Lang2,5

of sinus floor elevation and survival 1

Faculty of Odontology, University of Iceland,
Reykjavik, Iceland; 2School of Dental
Medicine, University of Berne, Berne,

of implants inserted in combination Switzerland; 3Department of Restorative

Dentistry, National Dental Center, Singapore;
4
Research Support Unit, Department of

with sinus floor elevation Social and Preventive Medicine, University of

Berne, Berne, Switzerland; 5University of
Hong Kong, Prince Philip Dental Hospital,
Hong Kong SAR
Part I: Lateral approach
Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of
sinus floor elevation and survival of implants inserted in combination with sinus floor
elevation. Part I: Lateral approach. J Clin Periodontol 2008; 35 (Suppl. 8): 216–240.
doi: 10.1111/j.1600-051X.2008.01272.x.

Abstract
Objectives: The objectives of this systematic review were to assess the survival rate
of grafts and implants placed with sinus floor elevation.
Material and Methods: An electronic search was conducted to identify studies on sinus
floor elevation, with a mean follow-up time of at least 1 year after functional loading.
Results: The search provided 839 titles. Full-text analysis was performed for 175 articles
resulting in 48 studies that met the inclusion criteria, reporting on 12,020 implants. Meta-
analysis indicated an estimated annual failure rate of 3.48% [95% confidence interval
(CI): 2.48%–4.88%] translating into a 3-year implant survival of 90.1% (95% CI: 86.4%–
92.8%). However, when failure rates was analyzed on the subject level, the estimated Key words: biological complications; bone
annual failure was 6.04% (95% CI: 3.87%–9.43%) translating into 16.6% (95% CI: augmentation; bone grafting; complications;
10.9%–24.6%) of the subjects experiencing implant loss over 3 years. dental implants; failures; lateral approach;
Conclusion: The insertion of dental implants in combination with maxillary sinus longitudinal; meta-analysis; peri-implantitis;
sinus augmentation; sinus floor elevation;
floor elevation is a predictable treatment method showing high implant survival rates sinus grafting; success; survival; systematic
and low incidences of surgical complications. review
The best results (98.3% implant survival after 3 years) were obtained using rough
surface implants with membrane coverage of the lateral window. Accepted for publication 20 May 2008

Conflict of interest and source of
funding statement
The authors declare that they do not have
any conflict of interests.
The study was self-funded by the authors
and their institutions and the Clinical
Research Foundation (CRF) for the Promo-
tion of Oral Health, University of Berne,
Switzerland. Dr. Wah Ching Tan was an ITI
Scholar for the year 2006/2007 (ITI Founda-
tion, Basel, Switzerland, Educational grant).
The 6th European Workshop on Perio-
dontology was supported by an unrestricted
educational grant from Straumann AG.
216
Elevation of the maxillary sinus floor
was first reported by Boyne in the
1960s. Fifteen years later, Boyne &
James (1980) reported on elevation of
the maxillary sinus floor in patients with
large, pneumatized sinus cavities in
preparation for the placement of blade
implants. The authors described a two-
stage procedure, where the maxillary
sinus was grafted using autogenous par-
ticulate iliac bone at the first stage of
surgery. After approximately 3 months,
a second stage surgery was performed in
which blade implants were placed and
Journal compilation r 2008 Blackwell Munksgaard
later used to support fixed or removable
reconstructions (Boyne & James 1980).
It is evident that the reduced vertical
bone height in the posterior maxillary
region often limited standard implant
placement. An elevation of the maxil-
lary sinus floor is an option in solving
this problem. Various surgical techni-
ques have been presented to enter the
sinus cavity elevating the sinus mem-
brane and placing bone grafts.
To date, two main techniques of sinus
floor elevation for dental implant place-
ment are in use: a two-stage technique
r 2008 The Authors

with a lateral window approach, fol-
lowed by implant placement after a
healing period, and a one-stage techni-
que using either a lateral or transalveolar
approach. The decision to apply the one-
or the two-stage techniques is based on
the amount of residual bone available
and the possibility of achieving primary
stability for the inserted implants.
In cases where bone grafts are favored,
autogenous bone grafts are considered the
gold standard due to their maintenance of
cellular viability and presumptive osteo-
genic capacity. The use of autogenous
grafts in sinus floor elevation was first
reported by Boyne & James (1980) and
Tatum (1986).
Grafts may be harvested intra-orally
or extra-orally. Common intra-oral
donor sites include the maxillary tuber-
osity, the zygomatico-maxillary but-
tress, the zygoma, the mandibular
symphysis as well as the body and
ramus of the mandible. The harvested
bone may be used as block sections or
particulate grafts.
The extra-oral donor sites include the
anterior or posterior iliac crest, the tibial
plateau, the rib and the calvaria.
Autologous bone grafts contain bone
morphogenic proteins (BMPs) capable
of attracting osteogenic cells from the
surrounding tissues. They also contain
other growth factors essential for the
process of graft incorporation.
Tricalcium phosphate was the first
bone substitute to be applied success-
fully for sinus floor elevation (Tatum
1986). Over the years, allografts, allo-
plasts and xenografts of various types
have been used alone or in combination
with autografts.
One indication for using bone sub-
stitutes is to reduce the volume of auto-
genous bone to be harvested. When a
large sinus cavity is grafted with auto-
genous bone alone, 5–6 ml of bone may
by necessary. The amount of autogenous
bone to be harvested is greatly reduced
when bone substitutes are applied alone
or in combination with autografts.
In a clinical study (Ellegaard et al.
2006), 131 implants were placed using
the lateral approach. The sinus mem-
brane was elevated, implants were
inserted and left to protrude into the
sinus cavity. The sinus membrane was
allowed to settle onto the apices of the
implants, thus creating a space to be
filled with blood coagulum. After a
mean follow-up time of 5 years, the
survival rate of these implants was
90%. It must be kept in mind, however,
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
that the residual bone height in this study
was at least 3 mm.
Of the 900 patient records that were
screened for the Sinus Consensus Con-
ference in 1996 (Jensen et al. 1998), only
100 had radiographs of adequate quality
for analysis of the residual bone height.
In total, only 145 grafted sinuses in 100
patients, with 349 implants were ana-
lyzed. 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 44 mm,
seven were placed in residual bone
with a height of 5–8 mm. None of the
implants placed in residual bone height
of more than 8 mm was lost. There was a
statistically significant difference in
implant loss when residual bone height
was 4 mm or less, as compared with
5 mm or greater (Geurs et al. 2001).
Several treatment options have been
utilized in posterior maxillae to over-
come the problem of inadequate bone
quantity. The most conservative treat-
ment is the insertion of short implants to
avoid the need for entering the sinus
cavity. However, for placement of short
implants, at least 6 mm of residual bone
height is still required. Another way of
avoiding grafting the maxillary sinus
would be the placement of tilted
implants in a position mesial or distal
to the sinus cavity if these areas yield
adequate bone quantity. However, in
patients with appropriate residual bone
height, minor augmentation of the sinus
floor may be accomplished via the
transalveolar technique using osteo-
tomes (Summers 1994, Rosen et al.
1999, Ferrigno et al. 2006).
Of the various options, the most inva-
sive treatment for sites with inadequate
residual bone height for implant place-
ment is the one- or two-staged sinus
floor elevation via lateral approach. By
mastering these different methods, most
edentulous areas in the maxilla may by
restored with implant-supported recon-
structions. The concept of a shortened
dental arch must also be considered. The
work of Käyser (1981) showed that
patients maintain adequate chewing
capacity of 50–80% with a premolar
occlusion (Fontijn-Tekamp et al. 2000).
A review prepared for the Consensus
Meeting of the European Association of
Osseointegration (EAO) (Renouard &
Nisand 2006) concluded on the basis
of 12 studies on machined surface
implants and 22 studies on rough tex-
tured implants that the survival and
success rates of short (410 mm)
217
implants were comparable to those
obtained with longer implants.
In 2003, Wallace and Froum pub-
lished a systematic review on the effect
of maxillary sinus floor elevations and
the survival of dental implants. The
criteria for review included human stu-
dies with a minimum of 20 interventions,
a follow-up time of one year of func-
tional loading and with an outcome vari-
able of implant survival being reported.
The main results indicated:
i. A survival rate of implants placed
in conjunction with sinus floor
elevation with the lateral approach
varied between 61.7% and 100%,
with an average of 91.8%.
ii. Implant survival rates compared
favorably with reported survival
rates for implants placed in the
non-grafted maxillae.
iii. Rough surfaced implants yielded
higher survival rates than did
machined surface implants when
placed in grafted sinuses.
iv. Implants placed into sinuses ele-
vated with particulate autografts
showed higher survival rates than
those placed in sinuses that had
been augmented with block grafts.
v. Implant survival rates were high-
er when barrier membranes were
placed over the lateral window.
vi. The utilization of grafts consist-
ing of 100% autogenous bone or
the inclusion of autogenous bone
as a component of composite
grafts did not affect implant
survival.
Unfortunately, the factor of the resi-
dual height affecting the survival rate of
implants in sinus-grafted sites was not
examined in the review. Hence, it is of
great interest to review the survival of
implants placed in grafted sinus sites
with residual bone height of 6 mm
or less.
The objectives of this systematic
review were to assess the survival rates
of grafts and implants placed in sites
with sinus augmentation via the lateral
approach, with a mean residual bone
height of 6 mm or less, and to evaluate
the incidence of surgical complications.
218 Pjetursson et al.
Material and Methods
Search strategy and study selection
A MEDLINE (PubMed) search from
1965 up to November 2007 was con-
ducted for articles published in the
dental literature, and limited to human
trials, using the search terms ‘‘sinus
lift’’, ‘‘sinus augmentation’’, ‘‘sinus
grafting’’, ‘‘sinus floor elevation’’.
Manual searches of the bibliographies
of all full text articles and related
reviews selected from the electronic
search were also performed.
Inclusion criteria
Because of the absence of appropriate
RCTs, this systematic review included
prospective and retrospective cohort stu-
dies. The additional inclusion criteria
for study selection were:
 publications in the dental literature,
based on human subjects, without
language restriction,
 studies with a mean follow-up time
of at least 1 year or more after
functional loading,
 mean residual bone height at the site
of implant placement of up to 6 mm,
 studies reporting on implant survival
rates,
 case series with a minimum of 10
patients,
 studies without multiple interven-
tions (like simultaneous ridge aug-
mentations), and
 studies with clearly defined survival
or success criteria.
Studies on sinus augmentation via the
transalveolar approach were excluded in
this review and will be separately ana-
lyzed (Tan et al. 2008).
Selection of studies
Titles and abstracts of the searches were
initially screened by two independent
reviewers (B. E. P. & W. C. T.) for
possible inclusion in the review. The
full text of all studies of possible
relevance was then obtained for inde-
pendent assessment by the reviewers.
Any disagreement was resolved by dis-
cussion. The k values were 0.76 and
0.53 at the title and abstract levels,
respectively.
Figure 1 describes the process of
identifying the 48 studies selected from
an initial yield of 839 titles. Data were
extracted independently by the two
First electronic search:
839 titles
Independently selected by 2 reviewers:
160 titles
Abstracts obtained
Discussion
Agreed on 143 abstracts
Full text obtained
Hand search added:
32 titles
Total full text articles.
175
Exclusions:
2: not reporting on sinus floor elevation
29: reporting on the transalveolar technique.
26: no survival data or no distinction of survival data between
implants inserted in sites with various grafting techniques
10: mean follow-up < 1 year in function or no loading time
8: mean residual bone height > 6 mm or majority of implants
inserted in sites with residual bone height > 6 mm
24: no information on residual bone height
7: combination of grafting techniques
10: sample size of less than 10 patients
11: multiple publications on the same patient cohorts
Final number of studies included:
48
Fig. 1. Search strategy.
reviewers using a data extraction form. placed in sites with residual bone
Disagreement regarding data extraction height 46 mm,
was resolved in consensus.  combination of grafting techniques,
 sample size of o10 patients,
 multiple publications on the same
patient cohorts, and
Excluded studies  studies applying the transalveolar
technique
Of the 175 full-text articles examined,
127 were excluded from the final ana-
lysis (see reference list).
The main reasons for exclusion were Data extraction
(Fig. 1):
The data was analyzed separately for
sinus floor elevation with the lateral or
 not reporting on sinus floor eleva- the transalveolar techniques.
tion, Of the 48 studies included, informa-
 no survival data or no distinction of tion on the survival of the sinus grafts
survival data between implants and implants were retrieved. Survival
placed in sites with various grafting was defined as implants remaining in
techniques, situ at the follow-up, irrespective of
 mean follow-upo1 year in function their conditions. Failure was defined as
or no loading time, implants that were lost, before or after
 no information on residual bone functional loading.
height or mean residual bone height Complications included Schneiderian
46 mm or majority of implants membrane perforation, infection and
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard

total graft loss, resulting in inability of
implant installation.
Statistical analysis
Failure rates were calculated by dividing
the number of events (failures or com-
plications) in the numerator by the total
exposure time (implant-time) in the
denominator.
The numerator was usually extracted
directly from the publication. The total
exposure time was calculated by taking
the sum of
(1) The exposure time of implants that
could be followed for the whole
observation time.
(2) The exposure time up to a failure of
implants that were lost during the
observation time.
(3) The exposure time up to the end of
observation time for implants that
did not complete the observation
period due to reasons such as death,
change of address, refusal to parti-
cipate in the follow-up, chronic ill-
nesses, missed appointments and
work commitments.
For each study, event rates for
implants were calculated by dividing
the total number of events by the total
implant exposure time in years. For
further analysis, the total number of
events was considered to be Poisson
distributed for a given sum of implant
exposure years and Poisson regression
with a logarithmic link-function and
total exposure time per study as an
offset variable were used (Kirkwood &
Sterne 2003a).
Robust standard errors were calcu-
lated to obtain 95% confidence intervals
(CIs) of the summary estimates of the
event rates. The Spearman goodness-of-
fit statistics and associated p-values
were calculated to assess heterogeneity
of the study specific event rates. If the
goodness-of-fit p-value was below 0.05,
indicating heterogeneity, random-
effects Poisson regression (with Gam-
ma-distributed random-effects) was
used to obtain a summary estimate of
the event rates. One-year survival pro-
portions were calculated via the rela-
tionship between event rates and
survival function S, S(T) 5 exp( T 
event rate), by assuming constant event
rates (Kirkwood & Sterne 2003b). The
95% CI for the survival proportions
were calculated by using the 95% con-
fidence limits of the event rates.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
Multivariable Poisson regression was
used to investigate formally whether
event rates varied by grafting material,
surgical approach, implant surfaces,
membrane coverage of the lateral win-
dow, smoking status, bone availability
and study design.
All analyses were performed using
Statas, version 8.2 (Stata Corp., Col-
lege Station, TX, USA).
Results
Included studies
A total of 48 studies on implants
inserted in combination with sinus floor
elevation utilizing the lateral approach
were included in the analysis. The char-
acteristics of the selected studies are
shown in Table 1.
The first study was published in 1996.
The median year of publication was
2002. Twenty-six of the studies were
prospective and the remaining 22 were
retrospective studies (Table 1).
The 48 studies included around 4,000
patients between 15 and 86 years of age.
Information on patient drop-out was
retrieved from 17 of the 48 studies and
ranged from 0% to 20% (Table 1). The
studies were mainly conducted in an
institutional environment such as
universities or in specialist’s clinics
(Table 1).
Surgical approach
Two different surgical techniques to
access the sinus cavity were utilized in
the 48 studies. The most frequently used
technique (28 studies) was the ‘‘trap-
door technique’’ or in-fracturing of the
cortical bony plate like a trap-door and
using it as the superior border of the
sinus compartment leaving it attached to
the underlying Schneiderian membrane.
The second surgical technique reported
was the preparation of an access hole by
removing the entire buccal bone plate
before the elevation of the sinus mem-
brane. This method was used in 12 of
the studies. The remainder of the studies
did not report any details on the surgical
techniques used (Table 1).
Fourteen studies reported on sinus
floor elevations where the implants
were placed simultaneously (one-stage)
and 16 studies reported on sinus floor
elevation with delayed (two-stage) implant
installation at 3 to 12 months after sinus
grafting. Seventeen of the studies
reported on both one- or two-stage tech-
219
niques (Table 1). One study even ran-
domized the patients into two groups
utilizing one- or two-stage techniques
(Wannfors et al. 2000). This RCT, how-
ever, included only 20 patients per treat-
ment group and yielded insufficient
statistical power to make any definitive
conclusion regarding the result of the
surgical approach.
The decision to use the one- or the
two-stage technique was mainly based
on the amount of residual bone available
and the possibility of achieving primary
stability for the inserted implants.
Grafting material
Autogenous bone grafts which are con-
sidered the gold standard of grafting due
to their maintenance of cellular viability
and presumptive osteogenic capacity
were used in 23 out of the 48 studies.
In the older studies, published between
1996 and 2001, autogenous block grafts,
harvested from the iliac crest or intra-
orally were frequently used. Since 2001
no studies reported on sinus floor eleva-
tion using solely this grafting material.
In nine studies, particulate autogenous
bone harvested extra-orally from the
iliac crest and the calvaria (1 study) or
intra-orally were used as grafting mate-
rials. In 19 studies, a combination of
particulate autogenous bone and various
bone substitutes were used as grafting
material to reduce the volume of bone
that must be harvested. In these combi-
nation grafts, the ratio of autogenous
bone ranged between 20% and 70%. In
12 studies, various bone substitutes were
used alone without using additional
autogenous bone as grafting material.
Three out of the 48 studies did not re-
port on the grafting materials utilized
(Table 1).
After inserting the grafting material, a
resorbable or non-resorbable membrane
was always used to cover the lateral
window in 11 out of the 48 studies. In
18 studies, no membrane coverage of
the lateral window was performed. Four
studies included both patients with and
without membrane coverage (Table 1).
A vast majority of the authors pre-
scribed antibiotic prophylaxis in combi-
nation with sinus floor elevation
procedures. Twenty-five authors pre-
scribed both pre- and post- surgical use
of antibiotics. In 2 studies, only pre-
surgical antibiotics were prescribed and
in another nine studies, only post-surgi-
cal intake was prescribed. Moreover, in
two studies (Zitzmann & Schärer 1998,
 Table 1. Study and patient characteristics of the reviewed studies for implants in sinus graft (lateral approach)
220

Study Year of Study Setting No. of Age Mean Residual Surgical procedure Drop-
publi- design patients range age bone out (in
cation height 1 or 2 antibiotic surgical membrane graft materials implant percent)
(mm) stage prophyl- approach coverage types
axis

Bornstein 2008 Prosp. Institution 56 19–74 53.9 o4 2 stage Pre Trap door Yes ABG1DBBM ITI 10.7
et al. or -TCP
Pjetursson et al.

(7.8 months) Access hole Resorbable

Galindo- 2007 Prosp. Institution 70 NR NR X5 1 stage Pre, post Access hole Yes ABG1DBBM1 Astra Tech NR
Moreno et al. PRP
o5 2 stage Resorbable Microdent
(6–8 months)
Krennmair 2007 Retrosp. Institution 12 42–66 53.8 3.5 2 stage NR Access hole Yes ABG1DBBM Frialit-2 NR
et al. Resorbable Camlog
Marchetti 2007 Prosp. Institution 30 23–67 48.8 5.3 1 stage Pre, post Trap door No 70% ABG130% Frialit NR
et al. DBBM
2.5 2 stage Brånemark
(5 months)
Karabuda 2006 Prosp. Institution 91 29–74 46 X5 1 stage Pre, post Trap door Yes DBBM1fully Camlog 7.7
et al. synthetic Xive
ceramic graft MIS
o5 2 stage Resorbable
Lindenmüller 2006 Retrosp. Institution 80 18–82 57 4.5 1 stage Post NR NR ABG ITI NR
& Lambrecht Ceros 82 Frialit
Algipore
2.4 2 stage
(6–12
months)
Peleg et al. 2006a Retrosp. Institution 731 42–81 53 1–7 1 stage Pre, post Trap door Yes 50% ABG150% Zimmer 1.8
Private Resorbable DBBM/DFDBA/
bone cement
Baccar et al. 2005 Retrosp. Private 44 24–68 43 3 2 stage Pre, post Access hole No ABG1DBBM Spline Sulzer NR
(4–12 ABG Dental
months)
Ewers 2005 Retrosp. Institution 118 NR NR 3.6 2 stage NR Access hole Yes 90% AlgiPore/C NR NR
(6 months) Resorbable Graft/AlgOss
Non- AlgOss110%
resorbable ABG1Blood or
PRP
Papa et al. 2005 Prosp. Institution 50 35–60 48 4–6 2 stage Post Trap door NR ABG NR 0
(6 months) DBBM
Coral HA
Weingart 2005 Retrosp. Institution 57 20–69 55 4 2 stage Pre, post Trap door Yes ABG particulate ITI NR
et al. (6 months) Resorbable
Hallman & 2004 Retrosp. Institution 50 23–82 61 o5 2 stage Pre, post NR NR DBBM1fibrin ITI 0
Nordin (8 months) glue
Hallman & 2004 Prosp. Institution 20 48–69 62 o5 2 stage Pre Trap door No 80% DBBM: 20% Brånemark 20
Zetterqvist Private (6 months) ABG 1fibrin glue

r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard
 Hatano et al. 2004 Prosp. Institution 191 26–76 55.5 4–6 1 stage NR Access hole No 66% ABG: 33% Brånemark NR
DBBM
Iturriaga & 2004 Prosp. Institution 58 NR NR o5 2 stage NR NR NR ABG (calvarium) Astra NR
Ruiz Private (3–11 months) 3i Osseotite
Calcitek
Corevent
Semados

r 2008 The Authors

Mazor et al. 2004 Retrosp Private 105 25–69 51 o5 1 stage Pre, post Access hole Yes ABG1DBBM1 Zimmer NR
Resorbable PRP
Peleg et al. 2004 Prosp. Institution NR NR NR o5 1 stage NR NR NR ABG alone Zimmer NR
Private 50% DBBM: 50%
ABG
Velich et al. 2004 Retrosp. Institution 624 NR 50 2–6 1 stage NR NR NR Various Brånemark NR
2 stage combinations SIS
(6.5 months) ITI Protetim
Mangano 2003 Prosp. Private 12 42–67 54 4.5 1 stage Post Trap door No HA Mac system 16.7
et al.
McCarthy 2003 Retrosp. Institution 18 18–75 43.7 X4 1 stage NR Trap door Yes ABG block/ Brånemark NR

Journal compilation r 2008 Blackwell Munksgaard

et al. particulate 50%
ABG150%DBBM
o4 2 stage Resorbable
(6 months) Non-
resorbable
No
Rodriguez 2003 Prosp. Institution 15 NR NR o5 1 stage Post & Trap door No DBBM1PRP NR 0
et al. in graft
Stricker et al. 2003 Prosp. Institution 41 38–73 55 Min 5 1 stage No Trap door No ABG (iliac) ITI 0
2 stage
(4.9 months)
Valentini & 2003 Retrosp. Institution 59 NR NR X5 1 stage Pre, post Trap door No 50% DFDBA: IMZ 1.7
Abensur 50% DBBM Brånemark
DBBM
o5 2 stage
(6 months)
Engelke et al. 2002 Prosp. Institution 83 27–86 55.6 5.8 1 stage Post Access hole NR ABG1-TCP Various NR
2 stage
(6 months)
Hallman et al. 2002 Prosp. Institution 21 19–80 54 o5 2 stage Pre, post NR Yes 80% DBBM: Brånemark 0
(6–9 months) Resorbable 20% ABG or
No DBBM or ABG
Kan et al. 2002 Retrosp. Institution 60 41–84 64.6 44 1 stage NR Trap door NR ABG1DFDBA HA surface NR
DBBM1DFDBA Ti surface
44 2 stage
Cordioli et al. 2001 Prosp. Institution 12 35–63 48 3–5 1 stage Post Trap door Yes 20–30% ABG 3i 0
Private Resorbable particulate1
70–80% Biogran
Geurs et al. 2001 Retrosp. Institution 100 NR NR 5 NR NR NR NR Various NR NR
Systematic review of sinus floor elevation

Hising et al. 2001 Retrosp. Institution 30 24–84 60 o4 2 stage Pre, post Access hole No ABG (i/o)1DBBM Various NR
(11.9 months)
Kahnberg 2001 Prosp. Institution 26 40–72 56 2.5 1 stage Pre, post Trap door No ABG block (iliac) Brånemark 11.5
et al. Access hole
221
 Table 1. (Contd.)
222

Study Year of Study Setting No. of Age Mean Residual Surgical procedure Drop-
publi- design patients range age bone out (in
cation height 1 or 2 antibiotic surgical membrane graft materials implant percent)
(mm) stage prophyl- approach coverage types
axis

Raghoebar 2001 Prosp. Institution 99 17–73 48 X5 1 stage Post Trap door No ABG (iliac or i/o) Brånemark NR
et al. o5 (3) 2 stage
Tawil & 2001 Prosp. Institution 29 38–75 56 5.7 1 stage Pre, post Trap door Yes DBBM Brånemark NR
Pjetursson et al.

Mawla 2 stage Resorbable

(6–9 months) No
Van den 2000 Prosp. Institution 24 32–65 50 4–8 2 stage Pre, post Trap door No DFDBA ITI 0
Bergh et al. (6 months)
Wannfors 2000 Prosp. Institution 20 31–72 54 2–7 1 stage Pre, post NR NR ABG block (iliac) Brånemark 0
et al. ABG particulate
(iliac)
20 39–78 57 2 stage
(6 months)
Johansson 1999 Prosp. Institution 39 40–77 56 o5 1 stage Pre, post Access hole No ABG block Brånemark NR
et al. (iliac or i/o)
Keller et al. 1999 Retrosp. Institution 37 18–73 56 2–4 1 stage NR Access hole No ABG block Brånemark NR
2 stage (iliac or i/o)
Khoury 1999 Retrosp. Institution 216 22–69 NR 1–5 1 stage Pre, post Trap door Yes Non- ABG blocks1/ IMZ NR
resorbable various fillers Brånemark
No Frialit-2
Kaptein et al. 1998 Retrosp. Institution 77 36–76 51 o5 2 stage Pre, post Trap door No ABG block IMZ NR
Private (4 months) (iliac)1ABG
particulate1HA
Van den 1998 Prosp. Institution 42 22–64 44 o4 2 stage Pre, post Trap door No ABG particulate ITI 0
Bergh et al. (4 months) (iliac)
Watzek et al. 1998 Retrosp. Institution 20 43–76 53.2 2.1 2 stage Pre, post Trap door No ABG (iliac) IMZ NR
(3–8 months) ABG (iliac)1HA Frialen
or DBBM
HA ABG (i/o)
1DBBM
Zitzmann & 1998 Prosp. Institution 10 36–75 58 4–6 1 stage Pre, post & Trap door Yes DBBM block Brånemark 0
Schärer in graft
44 2 stage Resorbable
Daelemans 1997 Retrosp. Institution 33 27–75 51.8 o5 1 stage Post NR NR ABG block Brånemark NR
et al.
Lundgren 1997 Prosp. Institution 20 46–70 57 o5 2 stage Pre, post Trap door NR ABG (iliac) Brånemark NR
et al.
Raghoebar 1997 Prosp. Institution 43 18–65 44 4.4 1 stage Post Trap door No ABG block Brånemark NR
et al. 2 stage (iliac or i/o)
Schliephake 1997 Retrosp. Institution NR 15–78 51.4 o5 2 stage Pre, post NR NR ABG block Brånemark NR
et al. (3–4 months) (iliac)
Blomqvist 1996 Retrosp. Institution 49 NR 55 2–4 1 stage Pre, post Trap door NR ABG block1 Brånemark NR
et al. particulate (iliac)

r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard
 Systematic review of sinus floor elevation 223

Hydroxyapatite; -TCP, beta-tri-calcium phosphate; PRP, platelet-rich plasma; PTFE, poly-tetra-fluoro-ethylene; SLA, sandblasted, large-grit, acid-etched; Ti, Titanium; TPS, Titanium plasma-sprayed surface;
ABG, autogenous bone graft; BG, Bioglass; CS, collagen sponge; DBBM, deproteinized bovine bone mineral; DFDBA, demineralized freeze-dried bone allograft; FDBA, freeze-dried bone allograft; HA,
Rodriguez et al. 2003) antibiotic powder tion into the sinus cavity were also
NR

NR was also added to the grafting material. reported occasionally.

In conclusion, only one author did not
prescribe prophylactic antibiotics after
3i Brånemark

DFDBA1coral HA coated TRS

sinus grafting. The information on the Survival of implants

use of antibiotics was not available in 11
of the studies (Table 1). Survival was defined as the implant
IMZ

HA

remaining in situ during the entire

observation period.
Survival of grafts For implants inserted in combination
with sinus floor elevation, 48 studies
Eighteen of the 48 studies reported on
provided data on the survival of a total
graft failure, defined as excessive graft
Various

of 12,020 implants after a mean follow-

ABG1

loss resulting in inability of implant

up time of 2.8 years (Table 3). 679
insertion at second stage surgery 3–12
implants were reported to be lost. In
months after sinus grafting. The inci-
meta-analysis, the estimated annual fail-
dence of graft failure ranged from 0% to
Resorbable

ure rate was 3.48% (95% CI: 2.48%–

17.9%. From the original 2140 sinuses
4.88%) translating into a 3-year implant
i/o, intra-oral; Min, minimum; NG, no graft; NR, not reported; Pre, pre-operative; Post, post-operative; Prosp., Prospective; Retrosp., Retrospective.

that were grafted, 41 had total graft

survival of 90.1% (95% CI: 86.4%–
Yes
NR

failure, translating into a mean graft

92.8%) (Table 3). Furthermore, 2.6%
failure of 1.9% (Table 2).
of the implants that were investigated
in these studies were lost during the
Trap door

Trap door

Surgical complications
When performing sinus floor elevation,
the risk of complications must be con-
sidered and the appropriate treatment
Pre, post
healing phase or before the implants
had been functionally loaded (Table 3).
None of the included studies had a
follow-up time of more than 10 years.
The longest mean observation period

foreseen. The most common intra- (6.1 years) was reported by Valentini
operative complication was the perfora- & Abensur (2003).
NR

tion of the sinus membrane. This was However, when failure rate was ana-
reported in 20 studies and ranged from lyzed based on subject level, the esti-
0–58.3%. The mean prevalence of mem- mated annual failure was 6.04% (95%
brane perforation was 19.5% (Table 2). CI: 3.87%–9.43%) translating into
1 stage
2 stage
1 stage

There is still a controversy whether this 16.6% (95% CI: 10.9%–24.6%) of the
complication influenced the survival subjects experiencing implant loss over
rate of the implants. Some authors 3 years (Table 4).
o6

o5

(Khoury 1999) reported a correlation In a separate analysis, a group of 18

between membrane perforation and studies with a total of 2307 machined
implant failure while other studies surface implants and a group of 25
NR

reported no correlation. studies with a total of 6399 rough sur-

57

Smaller perforations (o5 mm) were face implants were analyzed. For the
usually closed by using tissue fibrin former, the annual failure rate was
18–74

30–71

glue, suturing or by covering them 6.86%, translating into a survival of

with a resorbable barrier membrane. In only 81.4% after 3 years (Table 5) and
conditions of larger perforations, larger for the latter group the annual failure
24

50

barrier membranes, lamellar bone plates rate was 1.19%, translating into a survi-
or suturing was used either alone or in val of 96.5% after 3 years (Table 6).
combination with tissue fibrin glue to Moreover, 8.1% of the machined surface
Institution

provide a superior border for the graft- implants were lost already during the
Private

ing material. healing phase compared with only 1.1%

Infection of the grafted sinuses was a of the rough surface implants (Tables 5
rare complication. This was reported in and 6). Investigating the difference in
24 studies and the mean incidence was events rates in a Poisson regression ana-
Retrosp.

Prosp.

2.9%, ranging from 0–7.4% (Table 2). lysis showed that the difference was
The risk for infection seemed to increase highly significant (po0.0001) (Table 15).
with membrane perforation. Infection of The relative failure rates of different
1996

1996

the grafted sinuses was usually seen 3 to types of grafting materials were ana-
7 days post-surgically. lyzed with multivariable random-effect
Other complications like excessive Poisson regression using bone substi-
Wheeler et al.

bleeding from the bony window or the tutes alone as the reference, and includ-
Zinner &

sinus membrane, haematoma, wound ing all implants (Table 7). The
Small

dehiscences, injury of the infraorbital combination of autogenous bone and

neurovascular bundle, implant migra- bone substitutes showed significantly
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
224 Pjetursson et al.

Table 2. Incidence of surgical complications with sinus floor elevation

Study Year of Total no. Membrane Post operative Total graft
publication of grafts perforation infection failure

no. % no. % no. %

Bornstein et al. 2008 59 18 30.5 1 1.7 1 1.7

Marchetti et al. 2007 48 0 0 1 2.1 0 0
Galindo-Moreno et al. 2007 98 0 0 0 0 0 0
Krennmair et al. 2007 12 7 58.3 NR NR NR NR
Lindenmüller & Lambrecht 2006 98 11 11.2 3 3.1 0 0
Weingart et al. 2005 114 NR NR NR NR 3 2.6
Ewers 2005 209 43 20.6 25 12.0 1 0.5
Papa et al. 2005 76 8 10.5 2 2.6 3 3.9
Baccar et al. 2005 45 6 13.3 1 2.2 NR NR
Iturriaga & Ruiz 2004 79 NR NR 2 2.5 2 2.5
Peleg et al. 2004 194 NR NR 0 0 0 0
Hallman & Zetterqvist 2004 30 9 30 2 6.7 NR NR
Mazor et al. 2004 105 NR NR 3 2.9 NR NR
Hallman & Nordin 2004 71 10 14.1 2 2.8 NR NR
Velich et al. 2004 810 NR NR NR NR 22 2.7
McCarthy et al. 2003 27 NR NR 2 7.4 1 3.7
Stricker et al. 2003 66 25 37.9 NR NR NR NR
Engelke et al. 2003 118 28 23.7 1 0.8 1 0.8
Rodriguez et al. 2003 24 NR NR 0 0 0 0
Mangano et al. 2003 12 NR NR 0 0 0 0
Valentini & Abensur 2003 78 NR NR 1 1.3 NR NR
Raghoebar et al. 2001 182 47 25.8 7 3.8 NR NR
Kahnberg et al. 2001 39 NR NR NR NR 7 17.9
Tawil & Mawla 2001 30 5 16.7 0 0 NR NR
Van den Bergh et al. 2000 30 6 20 2 6.7 NR NR
Khoury 1999 216 52 24.1 NR NR NR NR
Van den Bergh et al. 1998 62 3 4.8 2 3.2 NR NR
Kaptein et al. 1998 88 14 15.9 2 2.3 NR NR
Zitzmann & Schärer 1998 10 NR NR NR NR 0 0
Watzek et al. 1998 40 4 10 NR NR NR NR
Daelemans et al. 1997 44 NR NR NR NR 0 0
Raghoebar et al. 1997 81 28 34.6 2 2.5 0 0
Zinner & Small 1996 57 NR NR 2 3.5 NR NR
3252 19.5% 2.9% 1.9%
Range 0–58.3% 0–12.0% 0–17.9%

(po0.001) lower annual failure rates
(1.47%) than bone substitutes used alone
as grafting material with an annual failure
rate of 2.59% (Table 7). Both particulated
autogenous bone and autogenous bone
blocks as grafting materials showed high-
er failure rates than bone substitutes used
alone, with annual failure rates of 5.69%
and 7.41%, respectively. This difference
however, did not reach statistical signifi-
cance (p 5 0.077; 0.090) (Table 7).
When the same analysis was repeated
using bone substitutes alone as the refer-
ence with only rough surface implants
and excluding machined surface
implants, the results changed dramati-
cally (Table 8). Bone substitutes, com-
bination of autogenous bone and bone
substitutes and autogenous bone blocks
all showed similar annual failure rates of
1.13%, 1.10% and 1.27%, respectively.
The particulated autogenous bone graft
showed significantly (p 5 0.008) lower
annual failure rates of 0.06%. It must,
however, be kept in mind that all types
of grafting materials had high survival
rates ranging between 96.3% and 99.8%
after 3 years (Table 8).
Furthermore, the implants were
grouped according to the surgical tech-
nique utilized. Twenty-four studies with
a total of 5672 implants inserted at time
of sinus grafting (one-stage technique)
and 25 studies with a total of 3560
implants inserted 3–12 months after
sinus grafting (two-stage technique).
The implants inserted with the one-stage
technique had a slightly higher annual
failure rate (4.07%) (Table 9), than
implants inserted with the two-stage
technique with a annual failure rate of
3.19% (Table 10), translating into a 3-
year survival of 88.5% and 90.9%,
respectively. This difference, however,
did not reach statistical significance
(p 5 0.461) (Table 15).
Furthermore, the studies were sepa-
rated according to the surgical approach
Journal compilation r 2008 Blackwell Munksgaard
utilized in relation to membrane place-
ment over the lateral window. Thirteen
studies with a total of 4285 implants had
membranes placed over the lateral win-
dow after sinus grafting and 21 studies
with a total of 2990 implants had no
membrane used. For the membrane
group, the annual failure rate was
0.72%, translating into a survival of
97.9% after 3 years (Table 11) and for
the non-membrane group, the annual
failure rate was 4.04%, translating into
a survival of 88.6% after 3 years (Table
12). Investigating the difference in event
rates in a Poisson regression analysis
showed that this difference was highly
significant (p 5 0.001) (Table 15).
In addition, the nine studies that
utilized both rough surface implants
and membrane coverage of the lateral
window were analyzed separately. From
a total of 3579 implants included in
these studies, the incidence of implant
loss before functional loading was only
r 2008 The Authors
 Systematic review of sinus floor elevation 225

Table 3. Annual failure rates and survival of implants inserted in combination with sinus floor elevation grouped by grafting materials
Study Year of Total Mean No. of Before After Total Estimated Estimated
publi- no. of follow-up failure loading loading implant failure rate survival after
cation implants time (years) exposure (per 100 3 years (%)
time implant years)

Autogenous bone block

McCarthy et al. 2003 29 2.4 9 9 0 71 12.68 68.4
Raghoebar et al. 2001 392 4.7 32 18 14 1840 1.74 94.9
Kahnberg et al. 2001 91 3 35 20 15 293 11.95 69.9
Wannfors et al. 2000 76 1 16 11 5 68 23.53 49.4
Khoury 1999 467 2.8 19 0 19 1611 1.18 96.5
Keller et al. 1999 139 4.2 20 14 6 578 3.46 90.1
Johansson et al. 1999 131 3 32 21 11 316 10.13 73.8
Watzek et al. 1998 53 4.5 3 3 0 236 1.27 96.3
Daelemans et al. 1997 121 3.2 8 5 3 384 2.08 93.9
Raghoebar et al. 1997 171 1.6 9 7 2 275 3.27 90.6
Schliephake et al. 1997 85 3.2 20 NR NR 210 9.52 75.1
Blomqvist et al. 1996 171 1.4 30 23 7 241 12.45 68.8
Autogenous particulated bone
Weingart et al. 2005 284 2 0 0 0 556 0 100
Iturriaga & Ruiz 2004 223 1 0 0 0 223 0 100
Peleg et al. 2004 218 1 2 2 0 216 0.93 97.3
McCarthy et al. 2003 47 2.4 7 7 0 114 6.14 83.2
Stricker et al. 2003 183 2.3 1 1 0 416 0.24 99.3
Hallman et al. 2002 33 1 6 NR NR 32 18.75 57.0
Wannfors et al. 2000 74 1 8 7 1 68 11.76 70.3
Van den Bergh et al. 1998 161 2.7 0 0 0 447 0 100
Lundgren et al. 1997 46 1.2 9 5 4 57 15.79 62.3
Combination of autogenous bone and bone substitutes
Bornstein et al. 2008 111 5 2 0 2 502 0.40 98.8
Marchetti et al. 2007 140 2.3 7 6 1 322 2.17 93.7
Galindo-Moreno et al. 2007 263 2 2 2 0 552 0.36 98.9
Peleg et al. 2006a 2132 3.5 44 15 29 7620 0.58 98.3
Krennmair et al. 2007 12 3.7 0 0 0 45 0 100
Ewers 2005 614 5 27 0 27 3070 0.88 97.4
Hatano et al. 2004 361 3 21 4 17 1047 2.01 94.2
Peleg et al. 2004 218 1 1 1 0 217 0.46 98.6
Hallman & Zetterqvist 2004 79 5 9 NR NR 309 2.91 91.6
Mazor et al. 2004 276 1.8 2 0 2 502 0.40 98.8
Engelke et al. 2003 211 2 11 9 2 404 2.72 92.2
McCarthy et al. 2003 5 2.4 0 0 0 12 0 100
Kan et al. 2002 26 3.5 0 0 0 90 0 100
Hising et al. 2001 104 4.6 18 NR NR 475 3.79 89.3
Cordioli et al. 2001 27 1 1 1 0 26 3.85 89.1
Kaptein et al. 1998 357 4.4 44 NR NR 1586 2.77 92.0
Watzek et al. 1998 85 2.6 4 1 3 218 1.83 94.6
Zinner & Small 1996 215 3 3 0 3 645 0.47 98.6
Solely bone substitutes
Karabuda et al. 2006 259 3 11 3 8 752 1.46 95.7
Hallman & Nordin 2004 196 1.6 12 6 6 322 3.73 89.4
Rodriguez et al. 2003 70 1.6 5 0 5 115 4.35 87.8
Mangano et al. 2003 28 3 0 0 0 84 0 100
Valentini & Abensur 2003 187 6.1 10 7 3 1134 0.88 97.4
Kan et al. 2002 202 3.4 23 NR NR 678 3.39 90.3
Hallman et al. 2002 43 1 2 NR NR 43 4.65 87.0
Tawil & Mawla 2001 61 1.7 9 NR NR 101 8.91 76.5
Van den Bergh et al. 2000 69 2.5 0 0 0 171 0 100
Watzek et al. 1998 16 1.7 0 0 0 27 0 100
Zitzmann & Schärer 1998 20 1.4 0 0 0 28 0 100
Mixture of various combinations
Lindenmüller & Lambrecht 2006 201 3.8 20 10 10 764 2.62 92.4
Papa et al. 2005 228 5 17 17 0 1055 1.61 95.3
Baccar et al. 2005 112 3 2 NR NR 335 0.60 98.2
Velich et al. 2004 1482 1 81 NR NR 1482 5.47 84.9
Geurs et al. 2001 349 2.5 20 NR NR 860 2.33 93.3
Wheeler et al. 1996 66 2 5 4 1 132 3.79 89.3
12020 2.8 679 239 206 33,977
Summary estimate (95% CI)n 2.6% 3.48 (2.48–4.88) 90.1 (86.4–92.8)
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
226 Pjetursson et al.

Table 4. Subject-based annual failure rates and percentage of patients without implant failures
Study Year of Total Mean Total No. of Total Estimated Estimated
publi- no. of follow-up no. of failure subject failure rate success after
cation subjects time (years) implants exposure (per 100 3 years (%)
time subject years)

Bornstein et al. 2008 56 5 111 1 253 0.40 98.8

Galindo-Moreno et al. 2007 70 2 263 2 147 1.36 96.0
Krennmair et al. 2007 12 3.7 12 0 45 0 100
Lindenmüller & Lambrecht 2006 80 3.8 201 15 304 4.93 86.2
Weingart et al. 2005 57 2 284 0 112 0 100
Baccar et al. 2005 44 3 112 2 132 1.52 95.6
Iturriaga & Ruiz 2004 58 1 223 0 58 0 100
Hallman & Zetterqvist 2004 20 5 79 6 78 7.69 79.4
Mazor et al. 2004 105 1.8 276 2 191 1.05 96.8
Hallman & Nordin 2004 50 1.6 196 6 82 7.32 80.3
McCarthy et al. 2003 18 2.4 81 9 44 20.45 54.1
Stricker et al. 2003 41 2.3 183 1 93 1.08 96.8
Engelke et al. 2002 83 2 211 11 159 6.92 81.3
Rodriguez et al. 2003 15 1.6 70 4 25 16.0 61.9
Mangano et al. 2003 12 3 28 0 36 0 100
Kan et al. 2002 60 3.4 228 8 202 3.96 88.8
Raghoebar et al. 2001 99 4.7 392 18 465 3.87 89.0
Hising et al. 2001 30 4.6 104 7 137 5.11 85.8
Cordioli et al. 2001 12 1 27 1 12 8.33 77.9
Van den Bergh et al. 2000 24 2.5 69 0 59 0 100
Wannfors et al. 2000 40 1 150 8 36 22.22 51.3
Keller et al. 1999 37 4.2 139 11 154 7.14 80.7
Johansson et al. 1999 39 3 131 24 94 25.53 46.5
Van den Bergh et al. 1998 42 2.7 161 0 117 0 100
Zitzmann & Schärer 1998 10 1.4 20 0 14 0 100
Watzek et al. 1998 20 3.1 154 4 62 6.45 82.4
Raghoebar et al. 1997 43 1.6 171 7 69 10.14 73.8
Zinner & Small 1996 50 3 215 2 150 1.33 96.1
Blomqvist et al. 1996 49 1.4 171 11 69 15.9 62.0
Wheeler et al. 1996 24 2 66 4 48 8.33 77.9
Total 1300 2.7 4528 164 3447
Summary estimate (95% CI)n 6.04 (3.87–9.43) 83.4 (75.4–89.1)
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.

Table 5. Annual failure rates and survival of machined surface implants inserted in combination with sinus floor elevation
Study Year of Total Mean No. of Before After Total Estimated Estimated
publi- no. of follow-up failure loading loading implant failure rate survival
cation implants time (years) exposure (per 100 after
time implant years) 3 years (%)

Marchetti et al. 2007 78 2.3 5 NR NR 179 2.79 92.0

Hatano et al. 2004 361 3 21 4 17 1047 2.01 94.2
Hallman & Zetterqvist 2004 79 5 9 NR NR 309 2.91 91.6
Valentini & Abensur 2003 54 5.8 7 NR NR 292 2.40 93.1
McCarthy et al. 2003 81 2.4 16 16 9 197 8.12 78.4
Hallman et al. 2002 76 1 8 NR NR 75 10.67 72.6
Tawil & Mawla 2001 61 1.7 9 NR NR 101 8.91 76.5
Raghoebar et al. 2001 392 4.7 32 18 14 1840 1.74 94.9
Kahnberg et al. 2001 91 5 35 20 15 293 11.95 69.9
Wannfors et al. 2000 150 1 24 18 6 136 17.65 58.9
Keller et al. 1999 139 4.2 20 14 6 578 3.46 90.1
Johansson et al. 1999 131 3 32 21 11 316 10.13 73.8
Zitzmann & Schärer 1998 20 1.4 0 0 0 28 0 100
Daelemans et al. 1997 121 3.2 8 5 3 384 2.08 93.9
Raghoebar et al. 1997 171 1.6 9 7 2 275 3.27 90.6
Schliephake et al. 1997 85 3.2 20 NR NR 210 9.52 75.1
Lundgren et al. 1997 46 1.2 9 5 4 57 15.79 62.3
Blomqvist et al. 1996 171 1.4 30 23 7 241 12.45 68.8
Total 2307 2.8 294 151 94 6558
Summary 8.1% 6.86 (4.80–9.80) 81.4 (74.5–86.6)
estimate (95% CI)n
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
 Systematic review of sinus floor elevation 227

Table 6. Annual failure rate and survival of rough surface implants inserted in combination with sinus floor elevation
Study Year of Total no. Mean No. of Before After Total Estimated Estimated
publi- of implants follow-up failure loading loading implant failure rate survival
cation time (years) exposure (per 100 after
time implant years) 3 years (%)

Bornstein et al. 2008 111 5 2 0 2 502 0.40 98.8

Marchetti et al. 2007 62 2.3 2 NR NR 143 1.40 95.9
Galindo-Moreno et al. 2007 263 2 2 2 0 552 0.36 98.9
Krennmair et al. 2007 12 3.7 0 0 0 45 0 100
Peleg et al. 2006a 2132 3.5 44 15 29 7620 0.58 98.3
Karabuda et al. 2006 259 3 11 3 8 752 1.46 95.7
Lindenmüller & Lambrecht 2006 201 3.8 20 10 10 764 2.62 92.4
Weingart et al. 2005 284 2 0 0 0 556 0 100
Baccar et al. 2005 112 3 2 NR NR 335 0.60 98.2
Iturriaga & Ruiz 2004 223 1 0 0 0 223 0 100
Peleg et al. 2004 436 1 3 3 0 433 0.69 97.9
Mazor et al. 2004 276 1.8 2 2 0 502 0.40 98.8
Hallman & Nordin 2004 196 1.6 12 6 6 322 3.73 89.4
Engelke et al. 2003 211 2 11 9 2 404 2.72 92.2
Stricker et al. 2003 183 2.3 1 1 0 416 0.24 99.3
Mangano et al. 2003 28 3 0 0 0 84 0 100
Valentini & Abensur 2003 133 6.8 3 NR NR 842 0.36 98.9
Kan et al. 2002 228 3.4 23 NR NR 768 2.99 91.4
Cordioli et al. 2001 27 1 1 1 0 26 3.85 89.1
Van den Bergh et al. 2000 69 2.5 0 0 0 171 0 100
Watzek et al. 1998 154 3.1 7 4 3 481 1.46 95.7
Van den Bergh et al. 1998 161 2.7 0 0 0 447 0 100
Kaptein et al. 1998 357 4.4 44 NR NR 1586 2.77 92.0
Zinner & Small 1996 215 3 3 0 3 645 0.47 98.6
Wheeler et al. 1996 66 2 5 4 1 132 3.79 89.3
6399 3.0 198 60 64 18,751
Summary estimate (95% CI)n 1.1% 1.19 (0.76–1.86) 96.5 (94.6–97.7)
n
Based on random-effects Poisson regression, test for heterogeneity po0.000.

0.6% and the annual failure rate was
0.6% as well, translating into a survival
of 98.3% after 3 years.
Five studies investigated the influ-
ence of smoking, although not clearly
defined, on implant survival after sinus
floor elevation. The patients were
divided according to their smoking sta-
tus. A group of non-smokers with 2159
implants and a group of smokers who
received 863 implants were analysed.
The group of smokers had a higher
annual failure rate (3.54%) compared
with an annual failure rate of 1.86%
for the non-smokers (Table 13). How-
ever, this difference did not reach sta-
tistical difference (p 5 0.158) in Poisson
regression analysis (Table 15).
Six studies compared, within the
same patient cohort, the survival of
implants inserted in combination with
sinus floor elevation, with implants
inserted in residual neighbouring bone
without bone augmentation. Nine hun-
dred and eighty-nine implants were
placed in sinus floor elevated sites, and
552 implants were inserted in a conven-
tional way. The group of sinus implants
had a higher annual failure rate (8.72%)
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
compared with an annual failure rate of
5.99% for the implants inserted in pris-
tine bone (Table 14). However, in a
Poisson regression analysis, this differ-
ence did not reach statistical difference
(p 5 0.277) (Table 15).
The 26 prospective studies and the 22
retrospective studies were also analyzed
separately. For the prospective studies,
based on 4202 implants, the annual fail-
ure rate was 3.86% (95% CI: 2.28%–
6.54%), and for the retrospective studies,
based on 7647 implants, the annual fail-
ure rate was 3.10% (95% CI: 2.06%–
4.66%) (Table 15). The difference in
event rates in a Poisson regression ana-
lysis confirmed the absence of a study
design effect (p 5 0.553) (Table 15).
Discussion
This systematic review is the first part of
a series addressing the survival and
complication rates of grafts and
implants placed in sinus augmentation
sites via the lateral and transalveolar
techniques.
The main indication for maxillary
sinus floor elevation utilizing a lateral
approach is the reduced residual bone
height, neither allowing standard implant
placement nor placement of implants in
combination with minor sinus floor ele-
vation using the transalveolar approach.
Previous reviews did not consider the
amount of residual bone height in the
selection of studies. In one study (Geurs
et al. 2001), 20 out of 349 implants were
lost. 13 were lost at sites with residual
bone height of o4 mm, while 7 were
lost where residual bone height was
between 4 mm to 8 mm. No implants
were lost when the residual bone height
was 48 mm. This study showed that the
amount of residual bone height signifi-
cantly influenced the implant survival
after sinus floor elevation.
In a recent publication (Lundgren et
al. 2004), 19 implants were inserted in
12 sinuses without any grafting materi-
al. The authors did not report any
implant loss and hence, advocated that
no grafting material was needed for
sinus floor elevation. The authors, how-
ever, stated that the mean residual bone
height was 7 mm. It must, therefore be
questioned whether implant survival
was due to the sinus floor elevation or
228 Pjetursson et al.

Table 7. Summary of annual failure rates, relative failure rates and survival estimates for implants inserted in combination with sinus floor
elevation.
Type of grafting Total Total Mean Estimated 3 year survival Relative p-valuen
materials number implant follow-up annual summary failure
of implants exposure time failure rate estimate raten
time (95% CI)

Bone substitutes alone 1151 3455 3.0 2.59w (1.38–4.85) 92.5%w (86.5%–95.9%) 1.00 (Ref.)
Autogenous bone & bone 5236 17,642 3.4 1.47w (0.98–2.19) 95.7%w (93.6%–97.1%) 0.36 (0.26–0.49) po0.001
substitutes
Autogenous bone 1269 2129 1.7 5.69w (1.50–21.50) 84.3%w (52.5%–95.6%) 0.68 (0.44–1.04) p 5 0.077
particulated
Autogenous bone block 1926 6312 3.2 7.41w (4.44–12.34) 80.1%w (69.1%–87.5%) 0.79 (0.60–1.04) p 5 0.090
n
Based on multivariable random-effect Poisson regression.
w
Based on random-effects Poisson regression.

Table 8. Summary of annual failure rates, relative failure rates and survival estimates for rough surface implants inserted in combination with sinus
floor elevation
Type of grafting Total Total Mean Estimated 3 year survival Relative p-valuen
materials number implant follow-up annual summary failure
of implants exposure time failure rate estimate raten
time (95% CI)

Bone substitutes 701 2198 3.1 1.13w (0.40–3.22) 96.7%w (90.8%–98.8%) 1.00 (Ref.)
alone
w w
Autogenous bone & 3995 12,550 3.1 1.10 (0.66–1.81) 96.8% (94.7%–98.0%) 0.83 (0.49–1.41) p 5 0.492
bone substitutes
Autogenous bone 851 1642 1.9 0.06w (0.01–0.43) 99.8%w (98.7%–100%) 0.07 (0.009–0.49) p 5 0.008
particulated
Autogenous bone 53 236 4.5 1.27w (0.26–3.71) 96.3%w (89.5%–99.2%) 1.00 (0.59–1.70) p 5 0.995
block
n
Based on multivariable random-effect Poisson regression.
w
Based on random-effects Poisson regression.

the presence of 7 mm of residual bone
before the intervention.
In the present systematic review, stu-
dies that did not report the residual bone
height or studies with mean residual
bone height at the site of implant place-
ment of more than 6 mm bone height
were excluded.
Based on 48 studies included and
reporting on 12,020 implants after a
mean follow-up time of 2.8 years, the
annual failure rate was 3.48%, translat-
ing into a 3-year implant survival of
90.1%. This is in agreement with pre-
vious reviews (Jensen et al. 1998, Wal-
lace & Froum 2003) that reported a
survival rate of 90.0% and 91.8%,
respectively. With the use of rough sur-
face implants, however, the 3-year sur-
vival rate increased to 96.5% and the
additional use of a membrane over the
lateral window further improved the
survival rate to 98.3%.
With regards to grafting materials
used, when all machined and rough
surface implants were included in the
analysis, studies utilizing bone substi-
tutes alone or in combination with auto-
genous bone, showed higher survival
rates when compared with studies using
solely autogenous bone. On the other
hand, if only studies reporting on rough
surface implants were included in the
analysis, the 3-year survival rates were
similar for all types of grafting materials
ranging from 96.3% to 99.8%.
One randomized controlled clinical
trial (RCT) (Wannfors et al. 2000)
attempted to compare one- and two-
stage sinus floor elevations. This RCT
based on 40 patients divided into two
groups. The one-stage protocol with
75 implants placed reported a sur-
vival rate of 85.5% as compared with
the two-stage protocol with 90.5%
survival rate for 74 implants placed.
The present systematic review, how-
ever, did not reveal any statistically
significant difference between the two
protocols.
Journal compilation r 2008 Blackwell Munksgaard
When performing sinus floor eleva-
tion, the risk of complications must be
considered and the appropriate treat-
ment provided. The most frequently
encountered complication was the per-
foration of the sinus membrane
which occurred in 19.5% of the inter-
ventions, but it did not seem to influence
implant survival. The prevalence of
membrane perforation is in agreement
with previous studies (Block &
Kent 1997, Timmenga et al. 1997, Pikos
1999) reporting a perforation risk ran-
ging between 10%–40%. In 1.9%
of the procedures, there was excessive
graft resorption resulting in impossible
implant placement.
Instead of performing a formal qual-
ity assessment of the included studies
and sensitivity analysis, this review used
stringent inclusion criteria. In order to
obtain more homogeneity, only studies
reporting on a mean residual bone
height of 6 mm or less were included
in this review. Nevertheless, 48 studies
r 2008 The Authors
 Systematic review of sinus floor elevation 229

Table 9. Annual failure rates and survival of implants inserted simultaneously with sinus floor elevation (one-stage), grouped by grafting materials
Study Year of Total Mean No. of Before After Total Estimated Estimated
publi- no. of follow-up failure loading loading implant failure rate survival
cation implants time (years) exposure (per 100 after
time implant years) 3 years (%)

Autogenous bone block

Raghoebar et al. 2001 86 4.7 7 NR NR 404 1.73 94.9
Kahnberg et al. 2001 91 3 35 20 15 293 11.95 69.9
Wannfors et al. 2000 76 1 16 11 5 68 23.53 49.4
Khoury 1999 467 2.8 19 0 19 1611 1.18 96.5
Keller et al. 1999 139 4.2 20 14 6 578 3.46 90.1
Johansson et al. 1999 131 3 32 21 11 316 10.13 73.8
Daelemans et al. 1997 121 3.2 8 5 3 384 2.08 93.9
Blomqvist et al. 1996 171 1.4 30 23 7 241 12.45 68.8
Autogenous particulated bone
Peleg et al. 2004 218 1 2 2 0 216 0.93 97.3
Combination of autogenous bone and bone substitutes
Marchetti et al. 2007 32 2.3 4 NR NR 74 5.41 85.0
Galindo-Moreno et al. 2007 215 2 1 1 0 427 0.23 99.3
Peleg et al. 2006a 2132 3.5 44 15 29 7620 0.58 98.3
Hatano et al. 2004 361 3 21 4 17 1047 2.01 94.2
Peleg et al. 2004 218 1 1 1 0 217 0.46 98.6
Mazor et al. 2004 276 1.8 2 0 2 502 0.40 98.8
Engelke et al. 2003 175 2 4 NR NR 335 1.19 96.5
Cordioli et al. 2001 27 1 1 1 0 26 3.85 89.1
Solely bone substitutes
Rodriguez et al. 2003 70 1.6 5 0 5 115 4.35 87.8
Mangano et al. 2003 28 3 0 0 0 84 0 100
Valentini & Abensur 2003 55 6 7 4 3 333 2.10 93.9
Tawil & Mawla 2001 41 1.7 8 NR NR 68 11.75 70.3
Zitzmann & Schärer 1998 7 1.4 0 0 0 10 0 100
Zinner & Small 1996 215 3 3 0 3 645 0.47 98.6
Mixture of various combinations
Lindenmüller & Lambrecht 2006 168 3.8 14 NR NR 639 2.19 93.6
Kan et al. 2002 152 3.4 11 NR NR 512 2.15 93.8
5672 3.0 295 122 125 16,765
Summary estimate (95% CI)n 2.4% 4.07 (2.56–6.46) 88.5 (82.4–92.6)
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.

with over 12,000 implants were avail-
able for analysis.
No language restriction was applied
in the present systematic review result-
ing in the initial inclusion of articles in
English, Mandarin, German, Dutch, Ita-
lian and French languages.
In the absence of appropriate RCTs, a
lower level of evidence, i.e., prospec-
tive and retrospective cohort studies
were included in the present syste-
matic review. As prospective and retro-
spective studies were on different
levels of evidence, the results were
also analyzed separately for the two
groups of studies. The annual failure
rate, however, did not reveal signi-
ficant difference between the two
groups indicating an absence of design
effect.
One limitation of the present review
is the assumption of a constant annual
event rate throughout the follow-up time
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
after placement of the reconstruction.
Hence, it must be kept in mind that the
mean observation period was an average
of 2.8 years when interpreting the
results.
The percentage of implant failure was
usually higher in the first year. This, in
turn, means that annual failure rates
based on a mean follow-up time of 3
years should not be extrapolated to
follow-up times measured in decades.
In the present study, the incidence of
implant loss before functional loading
was significantly higher for machined
surface implants compared with rough-
surfaced implants with 8.1% versus
1.1%, respectively. Moreover, the pre-
sent review demonstrated that lon-
gitudinal studies with observation peri-
ods of 10 years or more are completely
lacking.
The studies included were mainly
conducted in an institutional environ-
ment, such as universities or specialists’
clinics. Therefore, the long-term out-
comes observed may not be generalized
to dental services provided in routine
private practice.
Literature based systematic reviews
of prognosis and survival outcomes are
hampered by a variety of problems (Alt-
man 2001). The present systematic
review revealed several shortcomings
in the clinical studies reporting on sinus
floor elevation. Many of the studies on
the survival of implants placed in sinus
grafted sites failed to report the original
residual bone height at the site of pre-
sumptive implant placement and on
graft failures.
There is also a lack of RCTs with
sufficient statistical power comparing
various grafting materials.
Hence, it appears appropriate to make
the following recommendations: Only
studies with rough-surface implants
 230

Table 10. Annual failure rates and survival of implants inserted ‘‘delayed’’ (two-stage) after sinus floor elevation, grouped by grafting materials
Study Year of Total no. of Mean follow-up No. of Before After Total implant Estimated failure rate Estimated survival
publication implants time (years) failure loading loading exposure time (per 100 implant years) after 3 years (%)
Pjetursson et al.

Autogenous bone block

Raghoebar et al. 2001 306 4.7 25 NR NR 1436 1.74 94.9
Watzek et al. 1998 53 4.5 3 3 0 236 1.27 96.3
Autogenous particulated bone
Weingart et al. 2005 284 2 0 0 0 556 0 100
Iturriaga & Ruiz 2004 223 1 0 0 0 223 0 100
Hallman et al. 2002 33 1 6 NR NR 32 18.75 57.0
Wannfors et al. 2000 74 1 8 7 1 68 11.76 70.3
Van den Bergh et al. 1998 161 2.7 0 0 0 447 0 100
Lundgren et al. 1997 46 1.2 9 5 4 57 15.79 62.3
Combination of autogenous bone and bone substitutes
Bornstein et al. 2008 111 5 2 0 2 502 0.40 98.8
Krennmair et al. 2007 12 3.7 0 0 0 45 0 100
Marchetti et al. 2007 108 2.3 3 NR NR 248 1.21 96.4
Galindo-Moreno et al. 2007 48 2 1 2 0 95 1.05 96.9
Ewers 2005 614 5 27 0 27 3070 0.88 97.4
Hallman & Zetterqvist 2004 79 5 9 NR NR 309 2.91 91.6
Engelke et al. 2003 36 2 7 NR NR 69 10.14 73.8
Hising et al. 2001 104 4.6 18 NR NR 475 3.79 89.3
Kaptein et al. 1998 357 4.4 44 NR NR 1586 2.77 92.0
Watzek et al. 1998 85 2.6 4 1 3 218 1.83 94.6
Solely bone substitutes
Hallman & Nordin 2004 196 1.6 12 6 6 322 3.73 89.4
Valentini & Abensur 2003 132 6.4 3 3 0 840 0.36 98.9
Hallman et al. 2002 43 1 2 NR NR 43 4.65 87.0
Tawil & Mawla 2001 20 1.7 1 0 1 33 3.03 91.3
Van den Bergh et al. 2000 69 2.5 0 0 0 171 0 100
Watzek et al. 1998 16 1.7 0 0 0 27 0 100
Zitzmann & Schärer 1998 13 1.4 0 0 0 18 0 100
Mixture of various combinations
Lindenmüller & Lambrecht 2006 33 3.8 6 NR NR 125 4.80 86.6
Papa et al. 2005 228 5 17 17 0 1055 1.61 95.3
Kan et al. 2002 76 3.4 12 NR NR 256 4.69 86.9
3560 3.6 219 44 44 12,562
Summary estimate (95% CI)n 1.8% 3.19 (1.90–5.35) 90.9 (85.2–94.5)
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.

r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard
 Table 11. Annual failure rate and survival of implants inserted in combination with sinus floor elevation where the lateral window was covered with a membrane
Study Year of Total no. of Mean follow-up No. of Before After Total implant Estimated failure rate Estimated survival
publication implants time (years) failure loading loading exposure time (per 100 implant years) after 3 years (%)

Bornstein et al. 2008 111 5 2 0 2 502 0.40 98.8

Galindo-Moreno et al. 2007 263 2 2 2 0 552 0.36 98.9

r 2008 The Authors

Krennmair et al. 2007 12 3.7 0 0 0 45 0 100
Peleg et al. 2006a 2132 3.5 44 15 29 7620 0.58 98.3
Karabuda et al. 2006 259 3 11 3 8 752 1.46 95.7
Weingart et al. 2005 284 2 0 0 0 556 0 100
Ewers 2005 614 5 27 0 27 3070 0.88 97.4
Mazor et al. 2004 276 1.8 2 2 0 502 0.40 98.8
Hallman et al. 2002 43 1 2 NR NR 43 4.65 87.0
Tawil & Mawla 2001 29 1.7 2 NR NR 48 4.17 88.2
Cordioli et al. 2001 27 1 1 1 0 26 3.85 89.1
Zitzmann & Schärer 1998 20 1.4 0 0 0 28 0 100
Zinner & Small 1996 215 3 3 0 3 645 0.47 98.6

Journal compilation r 2008 Blackwell Munksgaard

4285 3.4 96 23 69 14,389
Summary estimate (95% CI)n 0.5% 0.72 (0.52–1.01) 97.9 (96.7–98.6)
n
Based on random-effects Poisson regression, test for heterogeneity p 5 0.0003.

Table 12. Annual failure rate and survival of implants inserted in combination with sinus floor elevation where the lateral window was not covered with a membrane
Study Year of Total no. of Mean follow-up No. of Before After Total implant Estimated failure rate Estimated survival
publication implants time (years) failure loading loading exposure time (per 100 implant years) after 3 years (%)

Marchetti et al. 2007 140 2.3 7 6 1 322 2.17 93.7

Hatano et al. 2004 361 3 21 4 17 1047 2.01 94.2
Hallman & Zetterqvist 2004 79 5 9 NR NR 309 2.91 91.6
Rodriguez et al. 2003 70 1.6 5 0 5 115 4.35 87.8
Mangano et al. 2003 28 3 0 0 0 84 0 100
Valentini & Abensur 2003 187 6.1 10 7 3 1134 0.88 97.4
Stricker et al. 2003 183 2.3 1 1 0 416 0.24 99.3
McCarthy et al. 2003 81 2.4 16 16 9 197 8.12 78.4
Hallman et al. 2002 33 1 6 NR NR 32 18.75 57.0
Kan et al. 2002 26 3.5 0 0 0 90 0 100
Tawil & Mawla 2001 32 1.7 7 NR NR 52 1.35 66.8
Hising et al. 2001 104 4.6 18 NR NR 475 3.79 89.3
Raghoebar et al. 2001 392 4.7 32 18 14 1840 1.74 94.9
Kahnberg et al. 2001 91 5 35 20 15 293 11.95 69.9
Van den Bergh et al. 2000 69 2.5 0 0 0 171 0 100
Keller et al. 1999 139 4.2 20 14 6 578 3.46 90.1
Johansson et al. 1999 131 3 32 21 11 316 10.13 73.8
Watzek et al. 1998 155 3.1 7 4 3 481 1.46 95.7
Van den Bergh et al. 1998 161 2.7 0 0 0 447 0 100
Kaptein et al. 1998 357 4.4 44 NR NR 1586 2.77 92.0
Raghoebar et al. 1997 171 1.6 9 7 2 275 3.27 90.6
Systematic review of sinus floor elevation

2990 3.4 279 118 86 10,260

Summary estimate (95% CI)n 4.9% 4.04 (2.40–6.80) 88.6 (81.5–93.1)
n
231

Based on random-effects Poisson regression, test for heterogeneity po0.0001.

232 Pjetursson et al.

estimated survival

estimated survival
should be included in future analyses, as

after 3 years (%)

after 3 years (%)

94.6 (90.7–96.9)

83.5 (75.7–89.0)
the use of machined surface implants
tended to skew the survival rates due to

94.3
98.5
94.8
93.2
91.2

80.5
71.0
94.8
87.5
82.3
93.1
72.4
low survival rates in sinus grafted sites.
Long-term cohort studies on implants
should be prospective, have complete

Implants in native bone

follow-up information preferentially
with similar lengths of follow-up for
(per 100 implant years)

(per 100 implant years)

estimated failure rate

estimated failure rate

Non- smokers

Table 14. Comparison of annual failure rates and survival of implant inserted in combination with sinus floor elevation and implants inserted in non-augmented residual bone
all patients. This, in turn, means that

1.86 (1.05–3.27)

5.99 (3.87–9.27)
data on well-defined time periods should

7.23

1.80
4.44
6.50
1.37
11.43

10.75
be reported for the entire cohort,
1.96
0.52
1.77
2.34
3.05

especially for the different years after

installation.
The following conclusions can be
drawn from this systematic review:
Table 13. Comparison of annual failure rates and survival of implants inserted in combination with sinus floor elevation, in smokers and non-smokers

total no. of

total no. of
implants

implants
(1) Based on implant-based analysis,
111

119
158
266
1505

2159

138
131

132
552
29
22
33

76
the estimated annual implant failure
rate was 3.5% (95% CI: 2.5%–
4.9%). This translated into a 3-year
implant survival of 90.1% (95% CI:
estimated survival

estimated survival
after 3 years (%)

after 3 years (%)

89.9 (81.2–94.7)

77.0 (65.7–84.9)
86.4%–92.8%) based on implant
level.
91.4
97.9
89.1
84.1
85.7

91.6
89.4
69.9
58.9
73.8
90.6
68.8
(2) However, when failure rates was
analyzed based on subject level, the
Implants with sinus floor elevation

estimated annual failure was 6.04%

(95% CI: 3.87%–9.43%) translating
into 16.6% (95% CI: 10.9%–24.6%)
(per 100 implant years)

(per 100 implant years)

estimated failure rate

estimated failure rate

of the subjects experiencing implant

8.72 (5.44–13.98)
3.54 (1.80–6.95)
Smokers

loss over 3 years.

(3) The annual failure rate of machined
11.95
17.65
10.13

12.45
2.91
3.73

3.27
2.99
0.71
3.85
5.77
5.15

surface implants (6.9%) was signif-

icantly (po0.0001) higher than that
for rough surface implants (1.2%).
(4) The annual failure rate was signifi-
cantly higher (4.0% versus 0.7%)
(p 5 0.001) when no membrane was
total no. of

total no. of
implants

implants

used to cover the lateral window

29

82
70
55

79

91
627

863

196

150
131
171
171
989
Based on random-effects Poisson regression, test for heterogeneity po0.0001.

Based on random-effects Poisson regression, test for heterogeneity po0.0001.

after the grafting procedure.

(5) In rough surface implants the 3-year
survival rates ranged between
96.3% and 99.8% depending on
Mean follow-up

Mean follow-up
time (years)

time (years)

the grafting material used.

2.3
3.5
3.8
3.4
2.5
3.3

1.6

1.6
1.4
1.9
5

3
1
3

(a.) The lowest annual failure rate

(0.1%) of rough surface implants
was observed using autogenous
particulated bone graft.
publication

publication

(b.) The annual failure rates of rough

Year of

Year of
2007

2006
2002
2001
2006b

2004
2004
2001
2000
1999
1997
1996

surface implants were similar using

bone substitutes (1.1%) and combi-
nations of autogenous bone and
bone substitutes (1.1%).
Summary estimate (95% CI)n

Summary estimate (95% CI)n

Lindenmüller & Lambrecht

(6) Perforation of the sinus membrane

Hallman & Zetterqvist

occurring in 19.5% of the procedures

Hallman & Nordin

was the most frequently reported

Raghoebar et al.
Blomqvist et al.
Johansson et al.
Kahnberg et al.
Wannfors et al.
Marchetti et al.

complication. The mean incidence

of post-operative graft infection was
Geurs et al.
Peleg et al.

Kan et al.

2.9%. Graft loss resulting in inability

Study

Study

of implant placement was reported in

1.9% of cases.
n

r 2008 The Authors

Journal compilation r 2008 Blackwell Munksgaard
 Systematic review of sinus floor elevation 233

po0.0001
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p 5 0.461

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p 5 0.158

p 5 0.277

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Papa, F., Cortese, A., Maltarello, M. C.,
Sagliocco, R., Felice, P. & Claudio, P. P.
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r 2008 The Authors

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Timmenga, N. M., Raghoebar, G. M., Boering,
G. & Van Weissenbruch, R. (1997) Maxillary
sinus function after sinus lifts for insertion of
dentalimplants. Journal of Oral and Maxillo-
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sinus grafting with anorganic bovine bone: a
clinical report of long-term results. Interna-
tional Journal of Oral Maxillofacial Implants
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Krekeler, G. & Tuinzing, D. B. (2000)
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substitutes used for sinus floor elevation.
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maxillary sinus augmentation on the sur-
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328–343.
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mized study of 1- and 2-stage sinus inlay
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bone grafts: 1-year follow-up. International
Journal of Oral Maxillofacial Implants 15,
625–632.
Watzek, G., Weber, R., Bernhart, T., Ulm, C. &
Haas, R. (1998) Treatment of patients with
extreme maxillary atrophy using sinus floor
augmentation and implants: preliminary
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Weingart, D., Bublitz, R., Petrin, G., Kalber, J.
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treatment concept for the surgical and
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German).
Wheeler, S. L., Holmes, R. E. & Calhoun, C. J.
(1996) Six-year clinical and histologic study
of sinus-lift grafts. International Journal of
Oral Maxillofacial Implants 11, 26–34.
Zinner, I. D. & Small, S. A. (1996) Sinus-lift
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Zitzmann, N. U. & Schärer, P. (1998) Sinus
elevation procedures in the resorbed posterior
maxilla. Comparison of the crestal and lateral
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ogy 85, 8–17.
List of excluded full text articles and
the reason for exclusion
Ardekian, L., Oved-Peleg, E., Mactei, E. E. &
Peled, M. (2006) The clinical significance of
sinus membrane perforation during augmen-
tation of the maxillary sinus. Journal of Oral
Maxillofacial Surgery 64, 277–282. Exclu-
sion criteria: no information on residual bone
height.
Artzi, Z., Parson, A. & Nemcovsky, C. E.
(2003) Wide-diameter implant placement
and internal sinus membrane elevation in
the immediate postextraction phase: clinical
and radiographic observations in 12 consecu-
tive molar sites. International Journal of Oral
Maxillofacial Implants 18, 242–249. Exclu-
sion criteria: sinus augmentation via trans-
alveolar technique.
Avera, S. P., Stampley, W. A. & McAllister, B.
S. (1997) Histologic and clinical observations
of resorbable and nonresorbable barrier mem-
branes used in maxillary sinus graft contain-
ment. International Journal of Oral
Maxillofacial Implants 12, 88–94. Exclusion
criteria: sample size of less than 10 patients.
Barone, A., Santini, S., Sbordone, L., Crespi, R.
& Covani, U. (2006) A clinical study of the
outcomes and complications associated with
maxillary sinus augmentation. International
Journal of Oral Maxillofacial Implants 21,
81–85. Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
235
Becktor, J. P., Isaksson, S. & Sennerby, L.
(2004) Survival analysis of endosseous
implants in grafted and nongrafted edentu-
lous maxillae. International Journal of Oral
Maxillofacial Implants 19, 107–115. Exclu-
sion criteria: no information on residual bone
height.
Block, M. S., Kent, J. N., Kallukaran, F. U.,
Thunthy, K. & Weinberg, R. (1998) Bone
maintenance 5 to 10 years after sinus graft-
ing. Journal of Oral Maxillofacial Surgery
56, 706–714; discussion 714–705. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Blomqvist, J. E., Alberius, P. & Isaksson, S.
(1998) Two-stage maxillary sinus reconstruc-
tion with endosseous implants: a prospective
study. International Journal of Oral Maxillo-
facial Implants 13, 758–766. Exclusion cri-
teria: no information on residual bone height.
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 longitudinal radiographic case
cohort study. Clinical Oral Implants Research
15, 158–166. Exclusion criteria: sinus aug-
mentation via transalveolar technique.
Bruschi, G. B., Scipioni, A., Calesini, G. &
Bruschi, E. (1998) Localized management of
sinus floor with simultaneous implant place-
ment: a clinical report. International Journal
of Oral Maxillofacial Implants 13, 219–226.
Exclusion criteria: sinus augmentation via
transalveolar technique.
Buchmann, R., Khoury, F., Faust, C. & Lange,
D. E. (1999) Peri-implant conditions in perio-
dontally compromised patients following
maxillary sinus augmentation. A long-term
post-therapy trial. Clinical Oral Implants
Research 10, 103–110. Exclusion criteria:
no survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Butz, S. J. & Huys, L. W. (2005) Long-term
success of sinus augmentation using a syn-
thetic alloplast: a 20 patients, 7 years clinical
report. Implant Dentistry 14, 36–42. Exclu-
sion criteria: no information on residual bone
height.
Cavicchia, F., Bravi, F. & Petrelli, G. (2001)
Localized augmentation of the maxillary
sinus floor through a coronal approach for
the placement of implants. International
Journal of Periodontics and Restorative Den-
tistry 21, 475–485. Exclusion criteria: sinus
augmentation via transalveolar technique.
Chanavaz, M. (1996) Sinus grafting related to
implantology. Statistical analysis of 15 years
of surgical experience (1979–1994). Journal
of Oral Implantology 22, 119–130. Exclusion
criteria: no information on residual bone
height.
Chanavaz, M. (2000) Sinus graft procedures and
implant dentistry: a review of 21 years of
surgical experience (1979–2000). Implant
Dentistry 9, 197–206. Exclusion criteria: no
information on residual bone height.
236 Pjetursson et al.
Chen, L. & Cha, J. (2005) An 8-year retro-
spective study: 1,100 patients receiving 1,557
implants using the minimally invasive
hydraulic sinus condensing technique. Jour-
nal of Periodontology 76, 482–491. Exclu-
sion criteria: sinus augmentation via
transalveolar technique.
Chen, T. W., Chang, H. S., Leung, K. W., Lai,
Y. L. & Kao, S. Y. (2007) Implant placement
immediately after the lateral approach of the
trap door window procedure to create a
maxillary sinus lift without bone grafting: a
2-year retrospective evaluation of 47
implants in 33 patients. Journal of Oral
Maxillofacial Surgery 65, 2324–2328. Exclu-
sion criteria: mean residual bone height
46 mm or majority of implants placed in
sites with residual bone height 46 mm.
Chiapasco, M. & Ronchi, P. (1994) Sinus lift
and endosseous implants–preliminary surgi-
cal and prosthetic results. European Journal
of Prosthodontics and Restorative Dentistry
3, 15–21. Exclusion criteria: mean follow-up
o1 year in function.
Coatoam, G. W. & Krieger, J. T. (1997) A four-
year study examining the results of indirect
sinus augmentation procedures. Journal of
Oral Implantology 23, 117–127. Exclu-
sion criteria: Sinus augmentation via trans-
alveolar technique.
Cordaro, L. (2003) Bilateral simultaneous aug-
mentation of the maxillary sinus floor with
particulated mandible. Report of a technique
and preliminary results. Clinical Oral
Implants Research 14, 201–206. Exclusion
criteria: sample size of less than 10 patients.
Cosci, F. & Luccioli, M. (2000) A new sinus lift
technique in conjunction with placement of
265 implants: a 6-year retrospective study.
Implant Dentistry 9, 363–368. Exclusion
criteria: Sinus augmentation via transalveo-
lar technique.
Cranin, A. N., Russell, D., Andrews, J. P. &
Mehrali, M. (1993) Immediate implantation
into the posterior maxilla after antroplasty:
the Cranin-Russell Operation. Journal of
Oral Implantology 19, 143–150. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
de Lange, G. L., Kuiper, L., Blijdorp, P. A.,
Hutter, W. & Mulder, W. F. (1997) [Five-
year evaluation of implants in the resorbed
maxilla]. Nederlands Tijdschrift Voor Tand-
heelkunde 104, 274–276. (Article in Dutch).
Exclusion criteria: no information on resi-
dual bone height.
De Leonardis, D. & Pecora, G. E. (1999)
Augmentation of the maxillary sinus with
calcium sulfate: one-year clinical report
from a prospective longitudinal study. Inter-
national Journal of Oral Maxillofacial
Implants 14, 869–878. Exclusion criteria:
mean follow-up o1 year in function.
Deporter, D., Todescan, R. & Caudry, S. (2000)
Simplifying management of the posterior
maxilla using short, porous-surfaced dental
implants and simultaneous indirect sinus ele-
vation. International Journal of Periodontics
and Restorative Dentistry 20, 476–485.
Exclusion criteria: sinus augmentation via
transalveolar technique.
Deporter, D. A., Caudry, S., Kermalli, J. &
Adegbembo, A. (2005) Further data on the
predictability of the indirect sinus elevation
procedure used with short, sintered, porous-
surfaced dental implants. International Jour-
nal of Periodontics and Restorative Dentistry
25, 585–593. Exclusion criteria: sinus aug-
mentation via transalveolar technique.
Deporter, D. A., Todescan, R., Watson, P. A.,
Pharoah, M., Pilliar, R. M. & Tomlinson, G.
(2001) A prospective human clinical trial of
Endopore dental implants in restoring the
partially edentulous maxilla using fixed
prostheses. International Journal of Oral
Maxillofacial Implants 16, 527–536. Exclu-
sion criteria: sinus augmentation via trans-
alveolar technique.
Dimonte, M., Inchingolo, F., Di Palma, G. &
Stefanelli, M. (2002) [Maxillary sinus lift in
conjunction with endosseous implants. A
long-term follow-up scintigraphic study].
Minerva Stomatology 51, 161–165 (Article
in Italian). Exclusion criteria: no survival
data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Diserens, V., Mericske, E. & Mericske-Stern, R.
(2005) Radiographic analysis of the tran-
screstal sinus floor elevation: short-term
observations. Clinical Implant Dentistry and
Related Research 7, 70–78. Exclusion criter-
ia: mean follow-up o1 year in function.
Eckert, S. E., Meraw, S. J., Weaver, A. L. &
Lohse, C. M. (2001) Early experience with
Wide-Platform Mk II implants. Part I:
implant survival. Part II: evaluation of risk
factors involving implant survival. Interna-
tional Journal of Oral Maxillofacial Implants
16, 208–216. Exclusion criteria: not report-
ing on sinus floor elevation.
Ellegaard, B., Baelum, V. & Kolsen-Petersen, J.
(2006) Non-grafted sinus implants in perio-
dontally compromised patients: a time-to-
event analysis. Clinical Oral Implants
Research 17, 156–164. Exclusion criteria:
no information on residual bone height.
Ellegaard, B., Kolsen-Petersen, J. & Baelum, V.
(1997) Implant therapy involving maxillary
sinus lift in periodontally compromised
patients. Clinical Oral Implants Research 8,
305–315. Exclusion criteria: no information
on residual bone height.
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 prospec-
tive study on 588 ITI implants. Clinical
Oral Implants Research 17, 194–205. Exclu-
sion criteria: sinus augmentation via trans-
alveolar technique.
Froum, S. J., Tarnow, D. P., Wallace, S. S.,
Rohrer, M. D. & Cho, S. C. (1998) Sinus
floor elevation using anorganic bovine
bone matrix (OsteoGraf/N) with and without
autogenous bone: a clinical, histologic, radio-
graphic, and histomorphometric analysis–
Part 2 of an ongoing prospective study.
International Journal of Periodontics and
Journal compilation r 2008 Blackwell Munksgaard
Restorative Dentistry 18, 528–543. Exclusion
criteria: no information on residual bone
height.
Froum, S. J., Wallace, S. S., Elian, N., Cho, S.
C. & Tarnow, D. P. (2006) Comparison of
mineralized cancellous bone allograft (Puros)
and anorganic bovine bone matrix (Bio-Oss)
for sinus augmentation: histomorphometry at
26 to 32 weeks after grafting. International
Journal of Periodontics and Restorative Den-
tistry 26, 543–551. Exclusion criteria: no
survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Fugazzotto, P. A. (1999) Sinus floor augmentation
at the time of maxillary molar extraction: tech-
nique and report of preliminary results. Inter-
national Journal of Oral Maxillofacial Im-
plants 14, 536–542. Exclusion criteria: sinus
augmentation via transalveolar approach.
Fugazzotto, P. A. (2003) GBR using bovine
bone matrix and resorbable and nonresorb-
able membranes. Part 2: clinical results.
International Journal of Periodontics and
Restorative Dentistry 23, 599–605. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Fugazzotto, P. A. & De, P. S. (2002) Sinus floor
augmentation at the time of maxillary molar
extraction: success and failure rates of 137
implants in function for up to 3 years. Journal
of Periodontology 73, 39–44. Exclusion cri-
teria: sinus augmentation via transalveolar
approach.
Fugazzotto, P. A. & Vlassis, J. (1998) Long-
term success of sinus augmentation using
various surgical approaches and grafting
materials. International Journal of Oral Max-
illofacial Implants 13, 52–58. Exclusion cri-
teria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Goga, D., Romieux, G., Bonin, B., Picard, A. &
Saffarzadeh, A. (2000) [Pre-implantation
iliac graft in the sinus. Retrospective study
of the complications encountered in 100
cases]. Revue de Stomatologie et de Chirur-
gie Maxillofaciale 101, 303–308. (Article in
French) Exclusion criteria: mean follow-up
o1 year in function.
Guarnieri, R., Grassi, R., Ripari, M. & Pecora,
G. (2006) Maxillary sinus augmentation
using granular calcium sulfate (surgiplaster
sinus): radiographic and histologic study at 2
years. International Journal of Periodontics
and Restorative Dentistry 26, 79–85. Exclu-
sion criteria: no survival data or no distinc-
tion of survival data between implants placed
in sites with various grafting techniques.
Guttenberg, S. A. (1993) Longitudinal report
on hydroxyapatite-coated implants and ad-
vanced surgical techniques in a private prac-
tice. Compendium (Suppl. 15), S549–S553;
quiz S565–566. Exclusion criteria: no survi-
val data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Hallman, M., Hedin, M., Sennerby, L. &
Lundgren, S. (2002) A prospective 1-year
r 2008 The Authors

clinical and radiographic study of implants
placed after maxillary sinus floor augmenta-
tion with bovine hydroxyapatite and autoge-
nous bone. Journal of Oral Maxillofacial
Surgery 60, 277–284; discussion 285–276.
Exclusion criteria: multiple publications on
the same patient cohorts.
Hallman, M., Sennerby, L., Zetterqvist, L. &
Lundgren, S. (2005) A 3-year prospective
follow-up study of implant-supported fixed
prostheses in patients subjected to maxillary
sinus floor augmentation with a 80:20 mix-
ture of deproteinized bovine bone and auto-
genous bone clinical, radiographic and
resonance frequency analysis. International
Journal of Oral Maxillofacial Surgery 34,
273–280. Exclusion criteria: multiple publi-
cations on the same patient cohorts.
Halpern, K. L., Halpern, E. B. & Ruggiero, S.
(2006) Minimally invasive implant and sinus
lift surgery with immediate loading. Journal
of Oral Maxillofacial Surgery 64, 1635–
1638. Exclusion criteria: no survival data
or no distinction of survival data between
implants placed in sites with various grafting
techniques.
Haris, A. G., Szabo, G., Ashman, A., Divinyi,
T., Suba, Z. & Martonffy, K. (1998) Five-
year 224-patient prospective histological
study of clinical applications using a syn-
thetic bone alloplast. Implant Dentistry 7,
287–299. Exclusion criteria: no survival
data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Hürzeler, M. B., Kirsch, A., Ackermann, K. L.
& Quinones, C. R. (1996) Reconstruction of
the severely resorbed maxilla with dental
implants in the augmented maxillary sinus:
a 5-year clinical investigation. International
Journal of Oral Maxillofacial Implants 11,
466–475. Exclusion criteria: mean residual
bone height 46 mm or majority of implants
placed in sites with residual bone height
46 mm.
Jensen, J. & Sindet-Pedersen, S. (1991) Auto-
genous mandibular bone grafts and osseoin-
tegrated implants for reconstruction of the
severely atrophied maxilla: a preliminary
report. Journal of Oral Maxillofacial Surgery
49, 1277–1287. Exclusion criteria: combina-
tion of grafting techniques.
Jensen, J., Sindet-Pedersen, S. & Oliver, A. J.
(1994) Varying treatment strategies for
reconstruction of maxillary atrophy with
implants: results in 98 patients. Journal of
Oral Maxillofacial Surgery 52, 210–216;
discussion 216–218. Exclusion criteria: no
information on residual bone height.
Jian, S., Cheynet, F., Amrouche, M., Chosse-
gros, C., Ferrara, J. J. & Blanc, J. L. (1999)
[Maxillary pre-implant rehabilitation: a study
of 55 cases using autologous bone graft
augmentation]. Revue de Stomatologie et de
Chirurgie Maxillofaciale 100, 214–220.
(Article in French). Exclusion criteria: no
information on residual bone height.
Kan, J. Y., Rungcharassaeng, K., Lozada, J. L.
& Goodacre, C. J. (1999) Effects of smoking
on implant success in grafted maxillary
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
sinuses. Journal of Prosthetic Dentistry 82,
307–311. Exclusion criteria: no information
on residual bone height.
Kaptein, M. L., De Lange, G. L. & Blijdorp, P.
A. (1999) Peri-implant tissue health in recon-
structed atrophic maxillae–report of 88
patients and 470 implants. Journal of Oral
Rehabilitation 26, 464–474. Exclusion criter-
ia: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Karabuda, C., Ozdemir, O., Tosun, T., Anil, A.
& Olgac, V. (2001) Histological and clinical
evaluation of 3 different grafting materials
for sinus lifting procedure based on 8 cases.
Journal of Periodontology 72, 1436–1442.
Exclusion criteria: sample size of less than
10 patients.
Kassolis, J. D., Rosen, P. S. & Reynolds, M. A.
(2000) Alveolar ridge and sinus augmenta-
tion utilizing platelet-rich plasma in combi-
nation with freeze-dried bone allograft: case
series. Journal of Periodontology 71, 1654–
1661. Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Keller, E. E., Eckert, S. E. & Tolman, D. E.
(1994) Maxillary antral and nasal one-stage
inlay composite bone graft: preliminary
report on 30 recipient sites. Journal of Oral
Maxillofacial Surgery 52, 438–447; discus-
sion 447–438. Exclusion criteria: multiple
publications on the same patient cohorts.
Kent, J. N. & Block, M. S. (1989) Simultaneous
maxillary sinus floor bone grafting and place-
ment of hydroxylapatite-coated implants.
Journal of Oral Maxillofacial Surgery 47,
238–242. Exclusion criteria: sample size of
less than 10 patients.
Khatiblou, F. A. (2005) Sinus floor augmenta-
tion and simultaneous implant placement.
Part I: the 1-stage approach. Journal of
Oral Implantology 31, 205–208. Exclusion
criteria: sinus augmentation via transalveo-
lar approach.
Khatiblou, F. A. (2005) Sinus floor augmenta-
tion and simultaneous implant placement.
Part II: the 2-stage approach. Journal of
Oral Implantology 31, 209–212. Exclusion
criteria: sinus augmentation via transalveo-
lar approach.
Komarnyckyj, O. G. & London, R. M. (1998)
Osteotome single-stage dental implant place-
ment with and without sinus elevation: a
clinical report. International Journal of Oral
Maxillofacial Implants 13, 799–804. Exclu-
sion criteria: sinus augmentation via trans-
alveolar technique.
Kübler, N. R., Will, C., Depprich, R., Betz, T.,
Reinhart, E., Bill, J. S. & Reuther, J. F.
(1999) [Comparative studies of sinus floor
elevation with autologous or allogeneic bone
tissue]. Mund Kiefer und Gesichtschirurgie 3
(Suppl 1), S53–S60. Exclusion criteria: no
information on residual bone height.
Lambrecht, J. T., Filippi, A., Kunzel, A. R. &
Schiel, H. J. (2003) Long-term evaluation of
submerged and nonsubmerged ITI solid-
screw titanium implants: a 10-year life table
analysis of 468 implants. International Jour-
237
nal of Oral Maxillofacial Implants 18, 826–
834. Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
Leblebicioglu, B., Ersanli, S., Karabuda, C.,
Tosun, T. & Gokdeniz, H. (2005) Radio-
graphic evaluation of dental implants placed
using an osteotome technique. Journal of
Periodontology 76, 385–390. Exclusion
criteria: sinus augmentation via transalveo-
lar technique.
Lekholm, U., Wannfors, K., Isaksson, S. &
Adielsson, B. (1999) Oral implants in com-
bination with bone grafts. A 3-year retro-
spective multicenter study using the
Branemark implant system. International
Journal of Oral Maxillofacial Surgery 28,
181–187. Exclusion criteria: no information
on residual bone height.
Levin, L. & Schwartz-Arad, D. (2005) The
effect of cigarette smoking on dental implants
and related surgery. Implant Dentistry 14,
357–361. Exclusion criteria: no survival
data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Levine, R. A., Ganeles, J., Jaffin, R. A., Donald,
S. C., Beagle, J. R. & Keller, G. W. (2007)
Multicenter retrospective analysis of wide-
neck dental implants for single molar repla-
cement. International Journal of Oral
Maxillofacial Implants 22, 736–742. Exclu-
sion criteria: sinus augmentation via trans-
alveolar technique.
Lin, Y., Wang, X. & Qiu, L. (1998) [Maxillary
sinus lifting, bone graft, and simultaneously
placement of implants]. Zhonghua Kou
Qiang Yi Xue Za Zhi 33, 326–328. Exclusion
criteria: sample size of less than 10 patients.
Lorenzetti, M., Mozzati, M., Campanino, P. P.
& Valente, G. (1998) Bone augmentation of
the inferior floor of the maxillary sinus with
autogenous bone or composite bone grafts: a
histologic-histomorphometric preliminary
report. International Journal of Oral Max-
illofacial Implants 13, 69–76. Exclusion cri-
teria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Lorenzoni, M., Pertl, C., Wegscheider, W.,
Keil, C., Penkner, K., Polansky, R. &
Bratschko, R. O. (2000) Retrospective analy-
sis of Frialit-2 implants in the augmented
sinus. International Journal of Periodontics
and Restorative Dentistry 20, 255–267.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Lundgren, S., Andersson, S., Gualini, F. &
Sennerby, L. (2004) Bone reformation with
sinus membrane elevation: a new surgical
technique for maxillary sinus floor augmen-
tation. Clinical Implant Dentistry and Related
Research 6, 165–173. Exclusion criteria:
mean residual bone height 46 mm or major-
ity of implants placed in sites with residual
bone height 46 mm.
Maiorana, C., Redemagni, M., Rabagliati, M. &
Salina, S. (2000) Treatment of maxillary
238 Pjetursson et al.
ridge resorption by sinus augmentation with
iliac cancellous bone, anorganic bovine bone,
and endosseous implants: a clinical and his-
tologic report. International Journal of Oral
Maxillofacial Implants 15, 873–878. Exclu-
sion criteria: mean follow-up o1 year in
function.
Maiorana, C., Sigurta, D., Mirandola, A., Garli-
ni, G. & Santoro, F. (2005) Bone resorption
around dental implants placed in grafted
sinuses: clinical and radiologic follow-up
after up to 4 years. International Journal of
Oral Maxillofacial Implants 20, 261–266.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Maiorana, C., Sigurta, D., Mirandola, A., Garli-
ni, G. & Santoro, F. (2006) Sinus elevation
with alloplasts or xenogenic materials and
implants: an up-to-4-year clinical and radi-
ologic follow-up. International Journal of
Oral Maxillofacial Implants 21, 426–432.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Maiorana, C., Sommariva, L., Brivio, P., Sigur-
ta, D. & Santoro, F. (2003) Maxillary sinus
augmentation with anorganic bovine bone
(Bio-Oss) and autologous platelet-rich
plasma: preliminary clinical and histologic
evaluations. International Journal of Perio-
dontics and Restorative Dentistry 23, 227–
235. Exclusion criteria: no information on
residual bone height.
Mayfield, L. J., Skoglund, A., Hising, P., Lang,
N. P. & Attstrom, R. (2001) Evaluation
following functional loading of titanium fix-
tures placed in ridges augmented by depro-
teinized bone mineral. A human case study.
Clinical Oral Implants Research 12, 508–
514. Exclusion criteria: sample size of less
than 10 patients.
Mazor, Z., Peleg, M., Garg, A. K. & Chaushu,
G. (2000) The use of hydroxyapatite bone
cement for sinus floor augmentation with
simultaneous implant placement in the
atrophic maxilla. A report of 10 cases. Jour-
nal of Periodontology 71, 1187–1194. Exclu-
sion criteria: no information on residual bone
height.
Mazor, Z., Peleg, M. & Gross, M. (1999) Sinus
augmentation for single-tooth replacement in
the posterior maxilla: a 3-year follow-up
clinical report. International Journal of Oral
Maxillofacial Implants 14, 55–60. Exclusion
criteria: multiple publications on the same
patient cohorts.
McDermott, N. E., Chuang, S. K., Woo, V. V. &
Dodson, T. B. (2006) Maxillary sinus aug-
mentation as a risk factor for implant failure.
International Journal of Oral Maxillofacial
Implants 21, 366–374. Exclusion criteria: no
survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Misch, C. E. & Dietsh, F. (1994) Endosteal
implants and iliac crest grafts to restore
severely resorbed totally edentulous maxil-
lae–a retrospective study. Journal of Oral
Implantology 20, 100–110. Exclusion criter-
ia: no information on residual bone height.
Nedir, R., Bischof, M., Vazquez, L., Szmukler-
Moncler, S. & Bernard, J. P. (2006) Osteo-
tome sinus floor elevation without grafting
material: a 1-year prospective pilot study with
ITI implants. Clinical Oral Implants Research
17, 679–686. Exclusion criteria: sinus aug-
mentation via transalveolar technique.
Nemcovsky, C. E., Winocur, E., Pupkin, J. &
Artzi, Z. (2004) Sinus floor augmentation
through a rotated palatal flap at the time of
tooth extraction. International Journal of
Periodontics and Restorative Dentistry 24,
177–183. Exclusion criteria: Sinus augmen-
tation via transalveolar technique.
Neyt, L. F., De Clercq, C. A., Abeloos, J. V. &
Mommaerts, M. Y. (1997) Reconstruction of
the severely resorbed maxilla with a combi-
nation of sinus augmentation, onlay bone
grafting, and implants. Journal of Oral Max-
illofacial Surgery 55, 1397–1401. Exclusion
criteria: combination of grafting techniques.
Nkenke, E., Schlegel, A., Schultze-Mosgau, S.,
Neukam, F. W. & Wiltfang, J. (2002) The
endoscopically controlled osteotome sinus
floor elevation: a preliminary prospective
study. International Journal of Oral Maxillo-
facial Implants 17, 557–566. Exclusion cri-
teria: Sinus augmentation via transalveolar
technique.
Noumbissi, S. S., Lozada, J. L., Boyne, P. J.,
Rohrer, M. D., Clem, D., Kim, J. S. & Prasad,
H. (2005) Clinical, histologic, and histomor-
phometric evaluation of mineralized solvent-
dehydrated bone allograf (Puros) in human
maxillary sinus grafts. Journal of Oral
Implantology 31, 171–179. Exclusion criter-
ia: sample size of less than 10 patients.
Oliva, J., Oliva, X. & Oliva, J. D. (2007) One-
year follow-up of first consecutive 100 zirco-
nia dental implants in humans: a comparison
of 2 different rough surfaces. International
Journal of Oral Maxillofacial Implants 22,
430–435. Exclusion criteria: no information
on residual bone height.
Olson, J. W., Dent, C. D., Dominici, J. T.,
Lambert, P. M., Bellome, J., Bichara, J. &
Morris, H. F. (1997) The influence of max-
illary sinus augmentation on the success of
dental implants through second-stage sur-
gery. lmplant Dentistry 6, 225–228. Exclu-
sion criteria: mean follow-up o1 year in
function.
Olson, J. W., Dent, C. D., Morris, H. F. & Ochi,
S. (2000) Long-term assessment (5 to 71
months) of endosseous dental implants
placed in the augmented maxillary sinus.
Annuals of Periodontology 5, 152–156.
Exclusion criteria: no information on resi-
dual bone height.
Ormianer, Z., Palti, A. & Shifman, A. (2006)
Survival of immediately loaded dental
implants in deficient alveolar bone sites aug-
mented with beta-tricalcium phosphate.
Implant Dentistry 15, 395–403. Exclusion
criteria: no survival data or no distinction
of survival data between implants placed in
sites with various grafting techniques.
Journal compilation r 2008 Blackwell Munksgaard
Peleg, M., Garg, A. K. & Mazor, Z. (2006)
Healing in smokers versus nonsmokers: sur-
vival rates for sinus floor augmentation with
simultaneous implant placement. Interna-
tional Journal of Oral Maxillofacial Implants
21, 551–559. Exclusion criteria: multiple
publications on the same patient cohorts.
Peleg, M., Mazor, Z., Chaushu, G. & Garg, A.
K. (1998) Sinus floor augmentation with
simultaneous implant placement in the
severely atrophic maxilla. Journal of Perio-
dontology 69, 1397–1403. Exclusion criteria:
multiple publications on the same patient
cohorts.
Peleg, M., Mazor, Z. & Garg, A. K. (1999)
Augmentation grafting of the maxillary sinus
and simultaneous implant placement in
patients with 3 to 5 mm of residual alveolar
bone height. International Journal of Oral
Maxillofacial Implants 14, 549–556. Exclu-
sion criteria: multiple publications on the
same patient cohorts.
Petrungaro, P. S. (2005) Implant placement and
provisionalization in extraction, edentulous,
and sinus grafted sites: a clinical report on
1,500 sites. Compendium of Continuing Edu-
cation in Dentistry 26, 879–890. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Pinholt, E. M. (2003) Branemark and ITI dental
implants in the human bone-grafted maxilla:
a comparative evaluation. Clinical Oral
Implants Research 14, 584–592. Exclusion
criteria: no information on residual bone
height.
Pjetursson, B. E., Rast, C., Brägger, U., Zwati-
len, M. & Lang, N.P. (2008) Maxillary sinus
floor elevation using the osteotome technique
with or without grafting material. Part 1 –
implant survival and patient’s perception.
Clinical Oral Implants Research (in press).
Raghoebar, G. M., Brouwer, T. J., Reintsema,
H. & Van Oort, R. P. (1993) Augmentation of
the maxillary sinus floor with autogenous
bone for the placement of endosseous
implants: a preliminary report. Journal of
Oral Maxillofacial Surgery 51, 1198–1203;
discussion 1203–1195. Exclusion criteria:
multiple publications on the same patient
cohorts.
Reinert, S., Konig, S., Bremerich, A., Eufinger,
H. & Krimmel, M. (2003) Stability of bone
grafting and placement of implants in the
severely atrophic maxilla. British Journal of
Oral Maxillofacial Surgery 41, 249–255.
Exclusion criteria: combination of grafting
techniques.
Regev, E., Smith, R. A., Perrott, D. H. & Pogrel,
M. A. (1995) Maxillary sinus complications
related to endosseous implants. International
Journal of Oral Maxillofacial Implants 10,
451–461. Exclusion criteria: no survival data
or no distinction of survival data between
implants placed in sites with various grafting
techniques.
Rodoni, L. R., Glauser, R., Feloutzis, A. &
Hammerle, C. H. (2005) Implants in the
posterior maxilla: a comparative clinical and
radiologic study. International Journal of
r 2008 The Authors

Oral Maxillofacial Implants 20, 231–237.
Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
Rosen, P. S., Summers, R., Mellado, J. R.,
Salkin, L. M., Shanaman, R. H., Marks, M.
H. & Fugazzotto, P. A. (1999) The bone-
added osteotome sinus floor elevation tech-
nique: multicenter retrospective report of
consecutively treated patients. International
Journal of Oral Maxillofacial Implants 14,
853–858. Exclusion criteria: sinus augmen-
tation via transalveolar technique.
Schwartz-Arad, D., Herzberg, R. & Dolev, E.
(2004) The prevalence of surgical complica-
tions of the sinus graft procedure and their
impact on implant survival. Journal of Perio-
dontology 75, 511–516. Exclusion criteria:
no information on residual bone height.
Simion, M., Fontana, F., Rasperini, G. & Maior-
ana, C. (2004) Long-term evaluation of
osseointegrated implants placed in sites aug-
mented with sinus floor elevation associated
with vertical ridge augmentation: a retro-
spective study of 38 consecutive implants
with 1- to 7-year follow-up. International
Journal of Periodontics and Restorative Den-
tistry 24, 208–221. Exclusion criteria: com-
bination of grafting techniques.
Small, S. A., Zinner, I. D., Panno, F. V.,
Shapiro, H. J. & Stein, J. I. (1993) Augment-
ing the maxillary sinus for implants: report of
27 patients. International Journal of Oral
Maxillofacial Implants 8, 523–528. Exclusion
criteria: multiple publications on the same
patient cohorts.
Smedberg, J. I., Johansson, P., Ekenback, D. &
Wannfors, D. (2001) Implants and sinus-inlay
graft in a 1-stage procedure in severely
atrophied maxillae: prosthodontic aspects in
a 3-year follow-up study. International Jour-
nal of Oral Maxillofacial Implants 16, 668–
674. Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
Sotirakis, E. G. & Gonshor, A. (2005) Elevation
of the maxillary sinus floor with hydraulic
pressure. Journal of Oral Implantology 31,
197–204. Exclusion criteria: Sinus augmen-
tation via transalveolar technique.
Stavropoulos, A., Karring, T. & Kostopoulos, L.
(2007) Fully vs. partially rough implants in
maxillary sinus floor augmentation: a rando-
mized-controlled clinical trial. Clinical Oral
Implants Research 18, 95–102. Exclusion
criteria: sinus augmentation via transalveo-
lar technique.
Steigmann, M. & Garg, A. K. (2005) A com-
parative study of bilateral sinus lifts per-
formed with platelet-rich plasma alone
versus alloplastic graft material reconstituted
with blood. Implant Dentistry 14, 261–266.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Stricker, A., Voss, P. J., Gutwald, R., Schramm,
A. & Schmelzeisen, R. (2003) Maxillary
sinus floor augmention with autogenous
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
bone grafts to enable placement of SLA-
surfaced implants: preliminary results after
15-40 months. Clinical Oral Implants
Research 14, 207–212. Exclusion criteria:
no information on residual bone height.
Strietzel, F. P. & Nowak, M. (1999) Höhenver-
lauf des Limbus alveolaris bei Implantationen
mit der Osteotomtechnik. Retrospective
Untersuchung. Mund Kiefer und Gesichts-
Chirurgie 3, 309–313. Exclusion criteria:
Not reporting on sinus floor elevation.
Szabo, G., Huys, L., Coulthard, P., Maiorana,
C., Garagiola, U., Barabas, J., Nemeth, Z.,
Hrabak, K. & Suba, Z. (2005) A prospective
multicenter randomized clinical trial of auto-
genous bone versus beta-tricalcium phosphate
graft alone for bilateral sinus elevation: his-
tologic and histomorphometric evaluation.
International Journal of Oral Maxillofacial
Implants 20, 371–381. Exclusion criteria:
combination of grafting techniques.
Szabo, G., Suba, Z., Hrabak, K., Barabas, J. &
Nemeth, Z. (2001) Autogenous bone versus
beta-tricalcium phosphate graft alone for
bilateral sinus elevations (2- and 3-dimen-
sional computed tomographic, histologic, and
histomorphometric evaluations): preliminary
results. International Journal of Oral Max-
illofacial Implants 16, 681–692. Exclusion
criteria: sample size of less than 10 patients.
Tadjoedin, E. S., de Lange, G. L., Lyaruu, D.
M., Kuiper, L. & Burger, E. H. (2002) High
concentrations of bioactive glass material
(BioGran) vs. autogenous bone for sinus floor
elevation. Clinical Oral Implants Research
13, 428–436. Exclusion criteria: sample size
of less than 10 patients.
Tarnow, D. P., Wallace, S. S., Froum, S. J.,
Rohrer, M. D. & Cho, S. C. (2000) Histologic
and clinical comparison of bilateral sinus
floor elevations with and without barrier
membrane placement in 12 patients: part 3
of an ongoing prospective study. Internatio-
nal Journal of Periodontics and Restorative
Dentistry 20, 117–125. Exclusion criteria: no
information on residual bone height.
Tatum, O. H. Jr., Lebowitz, M. S., Tatum, C. A.
& Borgner, R. A. (1993) Sinus augmentation.
Rationale, development, long-term results.
New York State Dental Journal 59, 43–48.
Exclusion criteria: no survival data or no
distinction of survival data between im-
plants placed in sites with various grafting
techniques.
Thor, A., Wannfors, K., Sennerby, L. & Ras-
musson, L. (2005) Reconstruction of the
severely resorbed maxilla with autogenous
bone, platelet-rich plasma, and implants: 1-
year results of a controlled prospective 5-year
study. Clinical Implant Dentistry and Related
Research 7, 209–220. Exclusion criteria:
combination of grafting techniques.
Tidwell, J. K., Blijdorp, P. A., Stoelinga, P. J.,
Brouns, J. B. & Hinderks, F. (1992) Compo-
site grafting of the maxillary sinus for place-
ment of endosteal implants. A preliminary
report of 48 patients. International Journal of
Oral Maxillofacial Surgery 21, 204–209.
Exclusion criteria: combination of grafting
techniques.
239
Timmenga, N. M., Raghoebar, G. M., van
Weissenbruch, R. & Vissink, A. (2003) Max-
illary sinus floor elevation surgery. A clinical,
radiographic and endoscopic evaluation.
Clinical Oral Implants Research 14, 322–
328. Exclusion criteria: mean follow-up o1
year in function.
Toffler, M. (2004) Osteotome-mediated sinus
floor elevation: a clinical report. Interna-
tional Journal of Oral Maxillofacial Implants
19, 266–273. Exclusion criteria: sinus aug-
mentation via transalveolar technique.
Turunen, T., Peltola, J., Yli-Urpo, A. & Hap-
ponen, R. P. (2004) Bioactive glass granules
as a bone adjunctive material in maxillary
sinus floor augmentation. Clinical Oral
Implants Research 15, 135–141. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Valentini, P. & Abensur, D. (1997) Maxillary
sinus floor elevation for implant placement
with demineralized freeze-dried bone and
bovine bone (Bio-Oss): a clinical study of
20 patients. International Journal of Perio-
dontics and Restorative Dentistry 17, 232–
241. Exclusion criteria: multiple publications
on the same patient cohorts.
Valentini, P., Abensur, D., Wenz, B., Peetz, M.
& Schenk, R. (2000) Sinus grafting with
porous bone mineral (Bio-Oss) for implant
placement: a 5-year study on 15 patients.
International Journal of Periodontics and
Restorative Dentistry 20, 245–253. Exclusion
criteria: multiple publications on the same
patient cohorts.
van Steenberghe, D., Naert, I., Bossuyt, M., De
Mars, G., Calberson, L., Ghyselen, J. &
Branemark, P. I. (1997) The rehabilitation
of the severely resorbed maxilla by simulta-
neous placement of autogenous bone grafts
and implants: a 10-year evaluation. Clinical
Oral Investigations 1, 102–108. Exclusion
criteria: sample size of less than 10 patients.
Vitkov, L., Gellrich, N. C. & Hannig, M. (2005)
Sinus floor augmentation via hydraulic
detachment and elevation of the Schneiderian
membrane. Clinical Oral Implants Research
16, 615–621. Exclusion criteria: sinus aug-
mentation via transalveolar technique.
Wallace, S. S., Froum, S. J., Cho, S. C., Elian,
N., Monteiro, D., Kim, B. S. & Tarnow, D. P.
(2005) Sinus augmentation utilizing anorgan-
ic bovine bone (Bio-Oss) with absorbable and
nonabsorbable membranes placed over the
lateral window: histomorphometric and clin-
ical analyses. International Journal of Perio-
dontics and Restorative Dentistry 25, 551–
559. Exclusion criteria: no information on
residual bone height.
Williamson, R. A. (1996) Rehabilitation of the
resorbed maxilla and mandible using auto-
genous bone grafts and osseointegrated
implants. International Journal of Oral Max-
illofacial Implants 11, 476–488. Exclusion
criteria: no survival data or no distinction
of survival data between implants placed in
sites with various grafting techniques.
Winter, A. A., Pollack, A. S. & Odrich, R. B.
(2002) Placement of implants in the severely
240 Pjetursson et al.
atrophic posterior maxilla using localized
management of the sinus floor: a preliminary
study. International Journal of Oral Maxillo-
facial Implants 17, 687–695. Exclusion cri-
teria: sinus augmentation via transalveolar
technique.
Wood, R. M. & Moore, D. L. (1988) Grafting of
the maxillary sinus with intraorally harvested
autogenous bone prior to implant placement.
International Journal of Oral Maxillofacial
Implants 3, 209–214. Exclusion criteria: no
survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Yildirim, M., Spiekermann, H., Biesterfeld, S.
& Edelhoff, D. (2000) Maxillary sinus aug-
mentation using xenogenic bone substitute
material Bio-Oss in combination with venous
blood. A histologic and histomorphometric
study in humans. Clinical Oral Implants
Clinical Relevance
Scientific rationale for the study: In
maxillary sites with residual bone
height of 6 mm or less, implant pla-
cement with lateral approach sinus
floor elevation is a possible option.
Implant survival rate and complica-
tions related to the procedure, with
Research 11, 217–229. Exclusion criteria:
mean follow-up o1 year in function or no
loading time.
Yildirim, M., Spiekermann, H., Handt, S. &
Edelhoff, D. (2001) Maxillary sinus augmen-
tation with the xenograft Bio-Oss and auto-
genous intraoral bone for qualitative
improvement of the implant site: a histologic
and histomorphometric clinical study in
humans. International Journal of Oral Max-
illofacial Implants 16, 23–33. Exclusion cri-
teria: mean follow-up o1 year in function.
Zhao, B. D., Wang, Y. H., Xu, J. S., Zheng, J.,
Gong, D. L. & Yu, Y. (2007) [Clinical study
of maxillary sinus floor elevation with simul-
taneous placement of implants from the top
of alveoli.]. Shanghai Kou Qiang Yi Xue 16,
480–483. (Article in Chinese) Exclusion
criteria: sinus augmentation via transalveo-
lar technique.
factors affecting implant survival
were examined.
Principal findings: Despite the lim-
ited amount of residual bone height,
the estimated 3-year implant survival
in lateral approach sinus augmented
sites is predictable. Incidences of
surgical complications are low.
Journal compilation r 2008 Blackwell Munksgaard
Zijderveld, S. A., Zerbo, I. R., van den Bergh, J.
P., Schulten, E. A. & ten Bruggenkate, C. M.
(2005) Maxillary sinus floor augmentation
using a beta-tricalcium phosphate (Cerasorb)
alone compared to autogenous bone grafts.
International Journal of Oral Maxillofacial
Implants 20, 432–440. Exclusion criteria:
mean follow-up o1 year in function.
Address:
Bjarni E. Pjetursson
Department of Reconstructive Dentistry
University of Iceland
Vatnsmyrarvegur 16
IS 101 Reykjavik
Iceland
E-mail: bep@hi.is
Practical implications: In maxillary
edentulous sites with a mean height
of 6 mm or less, implant installation
is predictable with lateral approach
sinus floor elevation, especially when
rough textured implants are used.
r 2008 The Authors