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Maxillary sinus augmentation

Tarun Kumar A.B, Ullas Anand1
Bapuji Implant Centre, Bapuji Dental College and Hospital, Davangere, Karnataka, 1Department of Periodontics, Uttranchal Dental and Medical
Research Institute, Dehradun, Uttarakhand, India

ABSTRACT
Placing dental implants in the maxillary posterior region can be both challenging and un-nerving for a regular
implant dentist who is not well versed with advanced surgical procedures. It is vital for a general dentist to
understand the fundamentals of bone grafting the maxillary sinus if he/she is really committed to providing
the best health care for their patients. The dental practice is seeing an increasing group of patients who
are living longer, and this group of older baby boomers often has an edentulous posterior maxilla either
unilateral or bilateral. When edentulous, the posterior maxilla more likely has diminished bone height, which
does not allow for the placement of dental implants without creating additional bone. Through grafting the
maxillary sinus, bone of ideal quality can be created (allowing for placement of dental implants), which Access this article online
offer many advantages over other tooth replacement modalities. The sinus graft offers the dental patient a Website: www.jicdro.org
predictable procedure of regenerating lost osseous structure in the posterior maxilla. This offers the patient DOI: 10.4103/2231-0754.172935
many advantages for long-term success. If dentists understand these concepts, they can better educate Quick Response Code:
their patients and guide them to have the procedure performed. This article outlines bone grafting of the
maxillary sinus for the purpose of placing dental implants. This review will help the readers to understand the
intricacies of sinus augmentation. They can relate their patient’s condition with the available literature and
chalk out the best treatment plan for the patient, especially by using indirect sinus augmentation procedures
which are less invasive and highly successful if done using prescribed technique.

Key words: Dental implants, sinus augmentation, indirect sinus augmentation

INTRODUCTION the placement of longer implants in the posterior maxilla, have

The use of implants has significantly increased prosthetic options
for the edentulous patient. However, implant placement in the
posterior maxillary region is often hampered significantly by
anatomic limitations such as inadequate vertical dimension, poor
bone quality,[1-5] thinning or missing cortex,[6] and undercuts.[7]
For implant placement in the posterior maxillary region, the
maxillary sinus is one of the most important anatomic structures.
Following tooth extraction, the periosteum of the maxillary
sinus can exhibit an increase in osteoclastic activity.[8] The
resulting reduced bone height due to pneumatization of the
maxillary sinus influences the length and location of implants.
Previously, many fixed restorations terminated at the second
premolar due to insufficient alveolar ridge height.[9] Many reports
have also concluded that when shorter implants (<10 mm) are
placed, they are less successful than longer implants.[4,10-13] Thus,
procedures such as sinus floor elevation (SFE), which facilitate
Address for correspondence:
Dr. Tarun Kumar AB, Bapuji Implant Centre, Bapuji Dental College and
Hospital, Davangere, Karnataka, India.
E-mail: tarundental@gmail.com
received a lot of attention in recent years.
The purpose of this review is to enumerate all the techniques
used for sinus augmentation with their advantages
and disadvantages and their indications. Thus, proper
understanding of the anatomy and physiology of the maxillary
sinus is a prerequisite for deciding the treatment plan for
implant placement.
The largest of the paranasal air cavities, the maxillary
sinus includes a medial wall that separates the maxillary
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Cite this article as: Tarun Kumar AB, Anand U. Maxillary sinus augmentation.
J Int Clin Dent Res Organ 2015;7:81-93.

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Tarun and Anand: Maxillary sinus augmentation
sinus from the nasal cavity, a posterior wall facing the
maxillary tuberosity, a mesiovestibular wall containing the
neurovascular bundle, an upper wall constituting the orbit
floor, and a lower wall next to the alveolar process that is
the bottom of the maxillary sinus itself.[14]
The maxillary sinus communicates with the ipsilateral nasal
fossa by means of a natural ostium located posterosuperiorly
on the medial surface. In adults with a full set of teeth,
the maxillary sinus floor is the strongest of the bone walls
surrounding the cavity. However, as aging occurs, the sinus
floor tends to resorb and form dehiscences around the
roots. The root ends may jut into the cavity, covered only
by the Schneiderian membrane and a small bone cortex flap
(which in turn may be missing). Extreme care must be taken
to avoid tearing the membrane when separating it from such
exposed apices. The mesiovestibular and medial bone walls
are the ones most often involved in maxillary sinus surgery.
An accessory ostium may sometimes be found on the medial
wall. When this occurs, it should be identified before any
maxillary sinus elevation procedure is performed to avoid
detaching the mucosa up to this point.
The Schneiderian (mucous) membrane lines the inner walls
of the sinus and in turn is covered by pseudostratified
columnar ciliated epithelium. Serum-mucosa glands are
located in the lamina directly underneath, especially next
to the ostium opening. Normally, the thickness of the
Schneiderian membrane varies from 0.13 mm to 0.5 mm.
However, inflammation or allergic phenomena may cause it
to thicken, either generally or locally.
PROGRESSIVE CHANGE, EDENTULISM, AND BONE
RESORPTION
In cases of maxillary edentulism, progressive resorption of the
alveolar ridge may reduce the bone to a thickness of less than
1 mm. Several causes may contribute to this phenomenon.
Teeth and the masticatory loads they apply stimulate the
alveolar bone and limit its resorption. Immediately after
the avulsion of a tooth, significant bone modeling typically
occurs. Vertical bone loss later tends to stabilize, averaging
about 0.1 mm per year, though large variations can be found
among individuals. However, hormonal imbalances, metabolic
factors, inflammation, and certain systemic pathologies
can cause the bone resorption to accelerate again. Age and
gender may also influence bone loss. The sinus floor tends
to lower craniocaudally as the alveolar ridge is resorbed in
the opposed direction. It is the lack of vertical posterior
maxillary bone that often necessitates the use of bone grafts
or sinus lifting procedures prior to implant rehabilitation.
Progressive resorption of the posterior maxillary edentulous
ridge follows a well-defined path that differs from that of
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the anterior regions and includes repeatable, predictable
morphologic changes. Cawood and Howell’s[15] system for
classifying the degrees of atrophy based on the morphologic
differences in the residual ridge is extremely useful for
presurgical diagnostic assessment, as ridge appearance is
connected to the horizontal and vertical dimensions of bone
available for implants.
BONY SEPTA
Inside the maxillary sinus, bony septa originating in the sinus
floor are often found. Called Underwood’s septa, they may
divide the back part of the sinus into multiple compartments
known as posterior recesses. They may even occasionally
reach from the base to the upper sinus wall, creating two
sinuses.[16] Estimates of the prevalence of such septa have
ranged 16-58%.[17,18] The formation of Underwood’s septa may
be linked to the fact that teeth are lost at different times.
The edentulous areas may resorb in a manner that results
in a difference in level between the two adjacent portions
of the sinus floor. It is thought that a bony septum may
form in the area between the two regressing areas in order
to transfer masticatory loads optimally. After the complete
loss of teeth, the septa sometimes gradually disappear. A
tridimensional (3-D) x-ray diagnosis of septa presence is
important for planning the size, shape, and position of the
antrostomy in maxillary sinus elevation and later separating
the sinus membrane from the septa.
VASCULARIZATION
Three arteries supply blood to the maxillary sinus: The
infraorbital artery, the posterior lateral nasal artery, and
the posterior superior alveolar artery. While their presence
should be investigated to avoid hemorrhages during sinus
grafting surgery, severe hemorrhages tend to be rare, as the
main arteries do not run inside the surgical area.[19] If small
vessels located in the exposed Schneiderian membrane are
broken, it is better to allow hemostasis to occur naturally.
Applying light pressure with gauze may be effective, however,
whereas an electrocoagulator might cause membrane
necrosis.
INNERVATION
Innervation of the maxillary sinus originates directly from the
maxillary nerve, the second branch of the fifth cranial nerve.
With its posterior middle and superior alveolar branches, it
innervates the posterior sinus floor together with the molar
and premolar teeth. The anterior superior alveolar branch
reaches the anterior sinus wall and the superior dental
plexus, running below the Schneiderian membrane. Some
branches starting in the infraorbital nerve branch out from
the trunk before exiting the infraorbital foramen. They then
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Tarun and Anand: Maxillary sinus augmentation

innervate the maxillary sinus medial wall. Branches of the 2002 were updated and expanded to include cone-beam
pterygopalatine ganglion and the sphenopalatine ganglion computed tomography (CBCT).[22,23] CBCT can offer cross-
also innervate the sinus mucosa. sectional imaging and 3-D reconstructions at potentially
lower radiation doses compared to medical multislice CT.
INDICATIONS By using panoramic views of the posterior maxilla, there is
AND CONTRAINDICATIONS the risk of underestimating the amount of bone available
FOR SINUS AUGMENTATION[20]
for implant placement. CBCT provides more accurate
The following are indications for sinus augmentation: measurements of the available bone volume.[24,25] CBCT can
• No history of sinus pathosis. also provide information on arterial channels in the lateral
• Insufficient residual bone height (less than 10 mm of bone sinus wall, the presence of septa, and the pathology of the
height). maxillary sinus.[26]
• Severely atrophic maxilla.
• Poor bone quality and quantity in the posterior maxilla. It is important to review the pertinent maxillary sinus
anatomy and common maxillary sinus findings, including
Sinus augmentation is not indicated when the patient has how to identify the nature of the pathology, and to present
history as below: a framework for decision-making for dentists to use in
• Recent radiation therapy in maxilla. determining the appropriate course of treatment when faced
• Uncontrolled systemic diseases such as diabetes mellitus. with positive sinus findings. Common sinus pathologies such
• Acute/chronic maxillary sinusitis. as mucosal thickening, mucous retention cysts, sinus polyps,
• Heavy smoker. or oroantral communications can be easily recognized using
• Alcohol abuse. proper diagnostic techniques, which in turn will help us
• Psychosis. improve the prognosis of any implant therapy in such cases
• Severe allergic rhinitis. by way of proper treatment planning and execution.
• Tumor or large cyst in the maxillary sinus.
• Oroantral fistula.
CLASSIFICATION FOR TREATMENT APPROACH
In 1987, Misch developed a classification [Figure 1] for
Maxillary SFE was first described by Dr. Hilt Tatum at an
the treatment of edentulous posterior maxilla based on
Alabama implant conference in 1976.[5] This opened the
the amount of bone available below the antrum and the
doors to various studies and trials to develop a technique
ridge width. Treatment categories ranged from subantral
which is appropriate for implant placement. Nonetheless,
augmentation category 1 (SA1) to SA4 based on bone height
for the success of any procedure in the maxillary posterior
A (>5 mm) and B (2.5-5 mm) based on ridge width.[27]
region, the surgeon should be well versed with its anatomy,
vascularity, and nerve supply, along with their variations. SA1: It has an adequate vertical bone for implants, that is,
12 mm. No manipulation of sinus is required.
DIAGNOSTIC IMAGING AND SINUS LIFT SURGERY
Diagnostic imaging is an essential component of treatment SA2: It has 0-2 mm less than the ideal height of bone and
planning in oral rehabilitation by means of osseointegrated may require surgical correction.
implants. The “E.A.O guidelines for the use of diagnostic
imaging in implant dentistry” was published in the Journal
of Clinical Oral Implant Research in 2002. The guidelines arose
from the proceedings of a consensus workshop held at
Trinity College Dublin, Ireland in 2000 under the auspices of
the European Association for Osseointegration (EAO). The
project was originally initiated because of concerns about the
commercialization and growing use of multislice computed
tomography (CT) scans for the assessment of patients in
need of implants. The absence of any guidelines as to when
or how these images should be used instead of conventional
radiographic investigations was a major concern for the EAO.[21]

In 2011, the EAO held a consensus workshop on radiological

guidelines in implant dentistry. Previous EAO guidelines from Figure 1: classification of maxillary sinus based on residual bone height[67]

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Tarun and Anand: Maxillary sinus augmentation
SA3: It has just 5-10 mm of bone below sinus.
SA4: It has less than 5 mm of bone below sinus.
DIFFERENT TECHNIQUES FOR MAXILLARY SINUS
AUGMENTATION
The reduced vertical bone height in the posterior maxillary
region is often a major obstacle to the placement of dental
implants. Elevation of the maxillary sinus floor is an option
to solve this problem. Various surgical techniques have been
presented to access the sinus cavity and elevate the sinus
membrane.
The two main techniques of SFE for dental implant placement
are: A two-stage technique with a lateral window approach,
followed by implant placement after a healing period; and a one-
stage technique using either a lateral or a transalveolar approach.
The decision to use one- or two-stage techniques is based on
the amount of residual bone available and the possibility of
achieving primary stability for the inserted implants.
Lateral approach with grafting materials
Tatum[5] and Boyne and James[4] were the first authors to
publish studies on elevation of the maxillary sinus floor
in patients with large, pneumatized sinus cavities. They
described a two-stage procedure, where the maxillary sinus
was grafted using autogenous particulate iliac bone in the
first stage of surgery. After approximately 3 months, a second
stage of surgery was performed in which blade implants were
placed and later used to support the prosthetic constructions.
Since then, numerous articles have been published regarding
different grafting materials and modifications of this
technique.
SURGICAL TECHNIQUE
Sinus elevation surgery can be accomplished under local
anesthesia; however, when a patient is apprehensive or
Figure 2: lateral window approach for sinus augmentation[68]
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when a second surgical site is used for harvesting of an
autogenous bone graft, oral sedation or intravenous sedation
or even general anesthesia is sometimes employed. After
administration of the local anesthesia, the maxillary sinus
is exposed by a full-thickness mucoperiosteal flap. The first
incision is usually crestal, and it should be longer than the
future osteotomy in the anteroposterior dimension. Mesial
and distal releasing incisions can be made to facilitate visibility.
Following flap reflection, the dimensions of the osteotomy
are determined based on the clinical and radiographic
examinations. The lower border of the osteotomy should be
approximately 3 mm above the sinus floor. The osteotomy
should be oval or rectangular, and corners and sharp edges
should be obtained using a round diamond or a carbide
bur at low speed with copious saline irrigation. When the
osteotomy is almost complete, the sinus membrane, which is
bluish-purple, can sometimes be observed. After completion
of osteotomy, the bony wall should be mobile and attached
only to the underlying sinus membrane. The bony wall can
now be carefully removed and retained for later incorporation
into the graft material or tapped into the sinus hinging on its
superior margin while still attached to the membrane. If the
sinus wall is tapped into the sinus, it will ultimately serve as
the new sinus floor and the roof of the chamber containing
the bone graft material. Tapping the wall into the sinus or
removing it is a matter of clinical preference.
The sinus membrane is gently reflected and elevated using
special curettes to create space for the graft material. Sinus
membrane reflection should be to the medial wall of the
sinus and superior enough to prevent pressure on the graft
and prevent membrane tearing during graft placement. The
graft material of choice is then packed into the space created.
A synthetic membrane can be used to cover the window or
the lateral wall of the graft. Finally, the mucoperiosteal flap
is repositioned and sutured [Figures 2, 12 and 13].
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Tarun and Anand: Maxillary sinus augmentation
It should be noted that the largest blood vessel in the
lateral wall is from an endosseous anastomosis from the
posterior superior alveolar and the infraorbital artery that
is approximately 1.5 mm in diameter. However, when the
lateral wall is very thin in the edentulous patient, this blood
vessel atrophies and often is not present. Thus, excessive
bleeding is rare. This vessel proceeds in the lateral wall of
the maxilla 15-20 mm from the dentate crest. The horizontal
lines of the access window should not be positioned directly
over this structure. The vertical lines of the access window
often cut through the artery. Because the blood supply may
be from either direction, both vertical access lines may have
bleeding. This is rarely a concern for vision or blood loss
during the procedure. If intraosseous bleeding is a problem,
the high-speed diamond used to score the window may
be used without irrigation and polish the bleeding site,
which cauterizes the vessel from the heat on the bony wall.
Electrocautery may also be used on this vessel, if necessary.
A hemostat on the artery may be less effective because it
might fracture the lateral wall and/or perforate the sinus
mucosa. Elevating the head and applying a surgical sponge
to the site for a few minutes is also sufficient to control this
hemorrhage in many cases.
One-stage versus two-stage lateral sinus lift procedures
The advantages of a single stage procedure are reduced
healing time by 50% due to reduction of one operation;
however, the main potential disadvantage with the one-
stage procedure is the possibility of being unable to stabilize
implants in minimal bone heights, with the additional risk
of implants falling inside the sinus. Therefore, if an implant
is unstable or it is suspected that it would be difficult to
stabilize, it is always possible to postpone implant placement
to wait for graft healing and opt for a two-stage procedure.
The choice of procedure is left to the operator (and the
patient).
Felice et al.[28] conducted a multicenter trial with the aim to
understand which procedure, one- or two-stage technique,
Figure 3: a crestal approach for sinus floor elevation[68]
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could be preferable when augmenting sinuses with residual
bone heights of 1-3 mm, using a lateral window technique
for rehabilitating patients with implant-supported fixed
partial prostheses. They only evaluated the outcome of
implants placed in bone heights of 1-3 mm below the
maxillary sinuses up to 1-year postloading follow-up. Both
techniques were able to achieve the planned goals, and no
statistically significant differences were observed. In addition,
complications were similarly distributed between groups. In
this study, only one implant did not obtain sufficient stability
at placement.
INDIRECT SINUS LIFT
The crestal approach consists of elevating the sinus floor
using varying techniques as described below and placing
graft material prior to implant placement [Figure 3].
A crestal approach for sinus floor elevation with subsequent
placement of implants was first suggested by Tatum in 1986.[5]
Utilizing this crestal approach, a “socket former” for the
selected implant size was used to prepare the implant site.
A “green-stick fracture” of the sinus floor was accomplished
by hand tapping the “socket former” in a vertical direction.
After preparation of the implant site, a root-formed implant
was placed and allowed to heal in a submerged way.
Summers (1994) later described another crestal approach,
using tapered osteotomes with increasing diameters. Bone
was conserved by this osteotome technique because drilling
was not performed. Adjacent bone was compressed by
pushing and tapping as the sinus membrane was elevated.
Then, autogenous, allogenic, or xenogenic bone grafts were
added to increase the volume below the elevated sinus
membrane.
Indirect osteotome maxillar y sinus floor elevation
(OMSFE) is generally employed when the residual bone
height is equal to or greater than 6 mm;[29] in cases with
higher resorption, the direct sinus elevation technique
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Tarun and Anand: Maxillary sinus augmentation
is used. [30] The indirect osteotome technique offers a
number of advantages: The surgery is more conservative,
sinus augmentation is localized, there is a low rate of
postoperative morbidity, a shorter time to implant loading
is possible than with the direct technique, and high survival
rates of around 90% are obtained.
Reports relative to amount of elevation achievable with the
osteotome technique are varied. Some suggest restricting
the use of the osteotomes to create minimal amounts of
elevation. Others have reported augmentation of up to
13 mm.[31]
Patient perception of the osteotome procedure is generally
good, with more than 90% of patients reporting being
satisfied with their treatment. Reported complications are
few. One report described the clinical complication of benign
paroxysmal vertigo (4 cases).[32] Small membrane perforations
without clinical significance occurred in 2.2%, 13%, and 25%
of cases in other different studies. Graft shrinkage and
remodeling around the apical area of implants placed by
the osteotome technique were reported to be 19% in one
radiographic study.[33]
In a meta-analysis of studies of cases with osteotome
placement of implant,[29] there was a success/ survival rate
of 98.7%, 98%, 95.7% and 96% after 6, 12 , 24 and 36 months
of loading, respectively, which are outcomes similar to
conventionally placed implants. The type of graft materials
did not appear to affect the results. These success rates
change as the implant length and amount of preoperative
bone decrease. The survival rates were 100% for 12 mm,
98.75% for 10 mm, 98.7% for 8 mm, and only 47.6% for 6 mm
implants. If the pretreatment bone is greater than 5 mm, the
success ranges 96-100%. However, if the bone is less than 5
mm, the rate is only 85.7-91.3%.[34] This evidence suggests
that for optimum implant success, if the preoperative alveolar
bone height is not greater than 5 mm, it must be augmented
to the extent that that at least 5 mm of healed bone exists
before implant placement.
In a systematic review by Massimo et al., cumulative implant
success rates were estimated for each study at the 1-, 2-, 3-,
and 5-year follow-up. Overall weighted mean success rate (SR)
was estimated to be 98.12% at 1-year, 97.40% at 2-year, 96.75%
at 3-year, and 95.81% at 5-year follow-up. Overall implant
survival was 92.7% for 331 implants placed in <5 mm ridge
height and 96.9% for 2525 implants inserted in >5 mm ridge
height. This finding suggests that the prognosis can be more
favorable when the residual ridge height is greater than 5 mm.
There is still controversy regarding the necessity of a grafting
material in order to maintain the space for new bone
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formation after elevating the sinus membrane utilizing the
transalveolar technique. Nedir et al.[35] found that implant
protrusion into the sinus decreased from 4.9 ± 1.9 mm
after surgery to 1.5 ± 0.9 mm after 5 years when no grafting
material was used.
Pjetursson et al.[36] compared a group of 164 implants
installed by the transalveolar technique with no grafting
materials being placed with another group of 88 implants
installed by the transalveolar technique where deproteinized
bone material was placed. The authors reported a gain in
radiographic bone height of 1.7 mm and 4.1 mm, respectively,
when assessing these parameters on digitized periapical
radiographs.
Esposito et al.[37] found in a review that if residual alveolar
bone height is 3-6 mm, a crestal approach to lift the sinus
lining and place 8-mm implants may possibly lead to fewer
complications than a lateral window approach to place
implants at least 10 mm long.
The next advancement in the transcrestal sinus lift procedure
was the use of trephine drill for atraumatic sinus lift [Figure 9].
Cosci and Luccioli[38] introduced a series of atraumatic lifting
drills of varying lengths to avoid perforation of the sinus
barrier during drilling of the implant site, and this is called
the crestal approach technique.
The Cosci technique is performed as follows: If the residual
bone height is 6-7 mm, a dedicated trephine drill of 3 mm
diameter is initially used for the first 2-4 mm, then the
dedicated 3 mm long and 2 mm diameter pilot drill is used,
followed by the 3 mm long intermediate and 3.1 mm diameter
drill, and by one or more atraumatic lifting drills of the
actual heights of the ridge as measured on the radiograph.
If the residual bone height is 4-5 mm, then the trephine
drill is not used and the site is initially prepared with the
dedicated 3 mm long and 2 mm diameter pilot drill, the rest
of the preparation procedure remaining identical. The site is
probed with a blunt instrument to feel the presence of the
Schneider membrane, after using the first atraumatic lifting
drill. If the presence of bone is felt, a 1 mm longer atraumatic
lifting drill is used, and so on, until the sinus lining is felt.
Osteotomes are not used. The integrity of the maxillary sinus
epithelium is carefully checked with a blunt instrument, then
it is gently lifted, and graft material placement followed by
implant placement is done.
There is a risk of instability of the implant in the initial stage
and that of postoperative complications as the osteotome
technique may perforate the maxillary sinus membrane or
form an excessive bony cavity at the implant placement area.
Lalo et al.[39] proposed a device for diminishing the sinus
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Tarun and Anand: Maxillary sinus augmentation
membrane perforation by an osteotome and drilling with
a stopper, whereas Tilotta et al.[40] reported on a surgical
procedure using an osteotome equipped with a trephine bur
and stopper. The perforation rate in sinus membrane elevation
using the osteotome technique was reported to be 0-21.4%
(mean, 3.8%), and the 3-year survival rate of the implants
placed in the sinus lift area was reportedly 87.4-96.0% (mean,
92.8%). Kolhatkar et al.[41] reported a 97.0-97.1% success rate
for the implant placed in the sinus lift area with a crestal
approach. To prevent perforation, Nkenke et al.[31] suggested
that the sinus membrane elevation be limited on average to
3.0 ± 0.8 mm using the osteotome technique. The residual
bone height is the most important factor for the success of
a sinus bone graft. In the initial stage, as another limitation
of the osteotome technique, at least 5.0 mm residual bone
height is suggested in order to fix the implant properly. A
clinical guideline recommended that the lateral approach
was to be used with delayed implant placement for less
than 4.0 mm of residual bone height, the lateral approach
and simultaneous implant placement for 4.0-6.0 mm, and
the crestal approach for more than 5.0-6.0 mm,[42] on sinus
membrane elevation and implant placement in relation to
the residual bone height.
MINIMALLY INVASIVE SURGERY
A minimally invasive surgical procedure has been defined
in general surgery as a procedure that is carried out with
the least damage possible to the patient. The procedure is
called “minimally invasive” when there is minimal damage to
biological tissues at the point of entrance of the instrument.[43]
Today, minimally invasive surgeons continue to determine
and redefine how much can be achieved through smaller
incisions and with minimal surgical stress. There are some
obvious advantages with a less invasive surgical approach for
the patient, such as quicker recovery, less postoperative pain,
Figure 4: LS reamer for sinus lateral approach (SLA, NeoBiotech, Seoul, South
Korea)
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and economic gain due to shorter recuperation. However,
the safety and effectiveness of each procedure must be
demonstrated with randomized controlled trials.
Various minimally invasive sinus lift devices on the market
can be clustered according to the drilling speed. Low-speed
drilling is recommended for the Hatch Reamer (Sinustech
America, Calabasas, CA, USA), Bone Compression Kit (MIS,
Tel Aviv, Israel), Cowellmedi Sinus Lift Kit (Cowellmedi Co.,
Busan, South Korea), Sinu-Lift System (Innovative Implant
Technology, Aventura, FL, USA), Disc-up Sinus Reamer
(Dentimate Co., Seoul, South Korea), and Sinus Master
(Mr. Curette Tech., Seongnam, South Korea); on the other
hand, high-speed drilling is to be applied when using the Sinus
Crestal Approach (SCA) Kit (NeoBiotech, Seoul, South Korea),
Dentium Advanced Sinus Kit (Dentium, Suwon, South Korea),
Sinus Lateral Approach (SLA) Kit (NeoBiotech, Seoul, South
Korea) [Figures 4 and 5], Samuel Lee’s Internal Sinus Grafting
System (MegaGen, Daegu, South Korea), Santa System (Dentis,
Daegu, South Korea). Devices that allow for both high- and
low-speed drilling are the Dr. Cosci drill (Dentech Co., Tokyo,
Japan), and Sinus Lift Drill (SSI, Seongnam, South Korea). Cho
et al.[44] and Kang and Lee[45] reported that sinus membrane
elevation using the Hatch Reamer showed a very high success
rate with rapid sinus membrane elevation. Lee and Kim
reported that quick and safe sinus membrane elevation was
possible even at the septum area by using the SCA kit, which
was a high-speed drill with a special blade, reducing the risk
of sinus membrane perforation.
The antral membrane balloon elevation (AMBE) technique
[Figure 6] is another minimally invasive technique to elevate
the sinus membrane. An inflatable balloon is used to elevate
the sinus membrane.
The AMBE technique was introduced by Soltan et al.[46]
It is used to elevate the membrane easily and make the
Figure 5: LS reamer
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Tarun and Anand: Maxillary sinus augmentation
antral floor accessible for augmentation with grafting
materials. The use of AMBE allows the surgeon to elevate
the sinus membrane with minimal risk of tearing and with a
conservative, tissue-sparing surgical approach. This reduces
postoperative pain, bleeding, possibilities of infection, and
the other morbid symptoms often associated with sinus
lift procedures. The technique is especially beneficial when
access is difficult and when adjacent teeth are present
next to the edentulous area. However, this technique as
described by Soltan et al. requires a buccal fenestration
and a larger incision than do other, alternative operations.
Kfir et al. introduced a minimally invasive method of sinus
lift [Figures 7 and 10] using an upward-expanding balloon
deployed via a 3 mm osteotomy.­[47] This procedure has
several advantages. It is brief (less than 60 min), performed
under local anesthesia, and leaves the patient with very
little operative and postoperative discomfort. Although this
procedure is minimally invasive, it can be applied to the vast
majority of patient subsets and practically all maxillary and
sinus pathology variants, with 97.3% procedural success.
Moreover, the procedure can be accomplished in outpatient
settings, requires considerably less surgical skill than the
lateral window, and has an outstanding efficacy and safety
record (consistent incremental bone height >8 mm and 95%
implant survival). In 98% of the cases listed in the registry,
implants were placed immediately after the sinus lift and
bone augmentation. Complications are negligible and mostly
limited to minimal (8%) and major (2.7%) membrane tears.[48]
The piezoelectric minimally invasive system involves the use
of piezoelectric tips to elevate the sinus membrane, thereby
completely eliminating chances of sinus perforation. This
technique has been proposed for lateral osteotomies.
Vercellotti et al.[49] in 2001 introduced the piezoelectric
system. The piezoelectric system, a relatively newer
technique, radically simplifies the maxillary sinus elevation
Figure 6: antral membrane balloon
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by completely eliminating the chances of sinus perforation.
The advantage of piezoelectric osteotomy lies in being able
to cut the bony window with great simplicity and precision
while ensuring the membrane’s integrity. This is due to the
cessation of the surgical action when the piezosurgery tips
come in contact with nonmineralized tissue. The separation
of the periosteum is also achieved by the ultrasonic vibrations
of the piezoelectric elevator working on the internal wall
of the sinus walls and by hydro-pneumatic pressure of a
physiologic solution subjected to the piezoelectric cavitation.
Microvibration of 20-60 μm from 25-29 KHz with sterile
water is safer, aseptic, and prevents Schneiderian membrane
perforations.[50,51]
Torrella et al.[52] proposed the use of piezoelectric surgery
for lateral osteotomies. These are performed with a
bone-preserving incision so that they are less traumatic
and the risk of perforation of the Schneiderian membrane
is reduced, and a better view is achieved during surgery.
Based on the use of piezoelectric surgery, attempts have
been made to simplify the sinus lift technique to offer
patients an intervention as atraumatic as possible, with
milder postoperative discomfort. To this end, Troedhan et
al.[53] in conjunction with the Acteon Group (France) have
developed the Intralift™ (Mérignac, Aquitaine, France)
technique, a minimally invasive technique for lifting the
maxillary sinus floor using piezoelectric surgery based
on a specific set of tips for the application of ultrasound.
They state that this technique opens up a wide range
of possibilities in terms of reducing the complexity and
morbidity of the open sinus lift.
The preparation of the hole to access the floor of the sinus
floor is performed at the crest, sequencing the Intralift™
system of pints and the Piezotome/Implant Center 2™ (Acteon
Satelec, France), to control the vibration of the tips and their
Figure 7: a minimally invasive ambe. adapted from the percrestal sinuslift by
georg watzek
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Tarun and Anand: Maxillary sinus augmentation
irrigation. The Piezotome makes it possible to work with
these ultrasonic tips in four power modes, D1 to D4, which
correspond to the classification of bone quality (1 = Dense
bone, 4 = Very spongy bone). D1-D2 power is used at the
beginning, for cortical bone, and D3-D4 at the end of the
procedure for cancellous bone and to lift the sinus membrane.
At this point it is necessary to follow the manufacturer’s
instructions, using the following drill sequences.[53]
1. “Pilot drilling”: A conical diamond tip (TKW 1, Ø 1.35 mm)
is used in D2 mode, with irrigation of 70-100 mL/min.
2. “Preliminary drilling”: A cylindrical diamond tip (TKW 2,
Ø 2.1 mm) is used in D2-D3 mode with an irrigation of
70-100 mL/min.
3. “Preliminary drilling”: A cylindrical diamond tip (TKW
3, Ø 2.35mm) is used in D2-D3 mode with irrigation of
70-100 mL/min.
4. “Secondary drilling”: A cylindrical diamond tip (TKW 4,
Ø 2.80 mm) is used in D2-D3 mode with an irrigation of
70-100 mL/min.
A trumpet, a nondiamond tip (TKW 5) is used. This is a
noncutting tip that sprays sterile irrigation, causing internal
sinus membrane elevation by microcavitation [Figure 8]. It
is used in D3-D4 mode with an irrigation of 30-40 mL/min. It
can also be used in nonactivated mode to compact material,
using it only as a manual instrument. The tip should never
be placed in direct contact with the Schneiderian membrane,
therefore hemostatic collagen sponges should be inserted
for protection.
The first four drills are only used for widening the preparation,
and drill 5 (trumpet) is the only one that really elevates the
Schneiderian membrane.
Velázquez-Cayón et al.[54] stated that this technique has many
advantages. Simplifying the procedure by using piezoelectric
surgery tips minimizes the risk of introducing instruments
into the sinus cavity, and by using ultrasound cavitation,
patient discomfort is reduced — There is no hammering
osteotome or lifting of large flaps. The use of ultrasound
to perform these surgeries means that we can carry out
less traumatic and conservative bone incisions, reducing
Figure 8: hydrodynamic ultrasonic cavitational sinus lift[69]
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
bleeding and achieving better visibility during surgery. In
addition, there is a reduction in the risk of perforation of
the Schneiderian membrane: Accidental instrument contact
with the membrane, as the instruments used are less
aggressive than rotary instruments, carries less risk of injury.
This problem can be controlled at all times and membrane
integrity can be checked using the Valsalva maneuver. Even
if small perforations are caused, surgery can be completed
using a small collagen sponge or collagen membrane to
close them.
Among its advantages, this technique proved more effective
in achieving greater and more homogeneous membrane
elevation compared to other conventional techniques of
indirect sinus augmentation. Regeneration material is seen
very distal and mesial to the preparation. Furthermore, the
incision does not depend on the force exerted by the surgeon,
the ultrasound does all the work. While the membrane
undergoes tensile forces when the balloon technique or
Summers’ technique are used, when the Intralift™ technique
is used there is no traction because microcavitation gently
detaches the membrane in all directions, not just at a pressure
point.
MINIMALLY INVASIVE TRANSCRESTAL (MITSA)
APPROACH USING CPS PUTTY TO ELEVATE THE
SINUS MEMBRANE
Another novel technique as documented by Kher et al. 2014[55]
evaluated a simplified minimally invasive transalveolar
sinus elevation technique utilizing calcium phosphosilicate
(CPS) putty for hydraulic sinus membrane elevation. In
this technique, transcrestal SFEs are performed using
a modification of Summers’ technique. Full-thickness
mucoperiosteal flaps are elevated in order to gain access to
the alveolar crest. An osteotomy is initiated at the ridge crest
using a 2.0 mm pilot drill. The drill is stopped 1 mm short
of the estimated height of the sinus floor, following which a
periapical x-ray is obtained to verify the exact position of the
drill in proximity to the sinus floor. The osteotomy is then
Figure 9: trephine drill mediated transcrestal sinus floor elevation
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Tarun and Anand: Maxillary sinus augmentation
further widened using the drilling sequence recommended by
the implant manufacturer. A small quantity of approximately
0.2 cm of CPS putty is delivered in the osteotomy via a narrow-
tipped cartridge delivery system to act as a cushion prior to
tapping the sinus floor, and a 3 mm concave osteotome with
depth markings and a mallet are used to carefully fracture the
floor of the sinus. Care is taken not to push the osteotome
into the sinus cavity to avoid inadvertent perforation of the
sinus lining.
Following the green-stick fracture of the floor of the sinus, the
bone substitute is directly injected into the prepared sinus
cavity via the cartridge delivery system. Once the cartridge
tip fits tightly in the osteotomy, allowing the insertion
pressure to be delivered directly to the fractured inferior
border of the sinus floor, 0.5 cm of CPS putty is carefully
injected into the osteotomy. The hydrostatic pressure
exerted by the putty results in an atraumatic elevation of
the sinus floor. CPS putty can be added in increments until
adequate elevation of the Schneiderian membrane is seen on
intraoperative radiographs. An appropriately sized implant is
subsequently placed at the level of the osseous crest using
a manual torque wrench for enhanced tactile sensation.
The implants are initially engaged into the remaining native
bone at the crest of the ridge and then slowly twisted in to
engage in the viscous CPS putty at the apical aspect of the
Figure 10: transcrestal sinus floor elevation using antral membrane mini baloon
Figure 12: lateral sinus augmentation using LS reamer, neobiotec and
augmentation using CPS putty
S90
osteotomy. Cover screws are later placed and flap closure
achieved [Figure 11].
The authors claim that the most significant benefit from the
use of this technique is that it can achieve a gain in bone
height comparable with that achieved with the use of the
lateral window approach, while maintaining the advantage
of the less invasive transalveolar approach. It also overcomes
the need to purchase the specialized equipment required to
apply hydraulic pressure for the elevation of the Schneiderian
membrane, while simultaneously placing an adequate volume
of the graft material in the site to allow for placement
of the implants. Its atraumatic nature, reduced chairside
times, reduced overall treatment duration, improved
patient comfort, and minimal graft wastage are additionally
beneficial. The limitations of the technique proposed are the
operator skill and experience necessary for success, and the
minimum 3 mm of available bone height needed for achieving
primary stability for the implant.
The computer-aided design/computer-aided manufacturing
(CAD/CAM) approach has also been used for sinus elevation.
Pozzi and Moy[56] described a new procedure for sinus
elevation using computer-guided planning and a guided
surgical approach through the use of CAD/CAM-generated
surgical template in combination with expander-condensing
Figure 11: MITSA hydrolic membrane elevation using CPS putty
Figure 13: lateral sinus augmentation using sinus trephine, neobiotec and
grafting using CPS putty
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Tarun and Anand: Maxillary sinus augmentation
osteotomes, thus ensuring a minimally invasive surgical
technique.
COMPLICATIONS IN SINUS LIFT SURGERY
General considerations
The incidence of development of maxillary sinusitis after
an augmentation of the sinus floor ranges from 0% to 20%
as documented in available literature.[57,58] Various studies
have documented minimal incidence of postsurgical sinusitis,
predominantly among patients with preexisting disease or
a predisposition for the same. The common complications
are listed below.
Timmenga et al.[59,60] found that the incidence of maxillary
sinusitis after bone grafting was very low in patients without
preexisting sinus problems. Transient sinusitis only developed
in patients with a predisposition for sinusitis but these
symptoms ceased after appropriate treatment. Sinus drainage
does not seem to be compromised in healthy persons after
sinus floor augmentation. The authors also found that an
accidental perforation of the mucous lining of the maxillary
sinus did not result in sinusitis postsurgically. The authors also
concluded that only patients suffering from previous symptoms
of sinusitis or predisposing factors should be evaluated
preoperatively to rule out structural drainage problems.
Pommer et al.[61] found that the maxillary sinus membrane,
even in healthy clinical conditions, undergoes morphologic
modifications after SFE, yet membrane reactions demonstrate
significant variability. They recommended conduction of
future research on the effect of augmentation surgery on
maxillary sinus physiology.
The various intraoperative, early postoperative, and late
postoperative complications of maxillary sinus augmentation
with identification of their possible cause(s) are:[20]
1. Intraoperative
• Bleeding.
• Buccal flap tear.
• Infraorbital nerve injury.
• Membrane perforation.
2. Early Postoperative
• Incision line opening.
• Bleeding.
• Barrier membrane exposure.
• Infraorbital nerve paresthesia.
3. Late Postoperative
• Graft loss/failure.
• Implant failure.
• Oroantral fistula.
• Implant migration.
• Inadequate graft fill.
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
The sinus membrane rupture and other intraoperative and
postoperative complications of surgery can decrease the
predictability of the procedure and affect the success rate
of the implants. The most common complication involving
sinus elevation is membrane perforation. The incidence of
this occurrence has been reported to range 10-56%. Various
techniques proposed to manage these perforations include
suturing, the use of collagen membrane, fibrin sealants,
freeze dried human lamellar bone sheets.[62-65] The “Loma
Linda pouch” technique involves the use of a slow-resorbing
collagen membrane with external tack fixation, which
results in complete coverage of all the internal bony walls.[66]
The complications can be largely reduced when the
technique is performed with great care and all the necessary
preoperative and postoperative protocols are followed. A
considerable amount of bone formation takes place around
the apical region of the implant, which predicts the long-term
stability of the implant. Thus, we can conclude that, being
aware of the complications associated with the implant
treatment of posterior maxilla, the indirect or internal sinus
lift can be considered as a promising method to restore the
same.
CONCLUSION
The placement of dental implants in the atrophic posterior
maxilla is an exigent procedure in the presence of lower
maxillary bone height. Numerous clinical procedures and
materials have emerged to solve the problem of lower bone
volume. The most commonly used surgical intervention for
obtaining appropriate bone height prior to the placement of
endosseous implants in the posterior maxilla is grafting to
the floor of the maxillary sinus. Now with years of research
that has already been done in lieu of perfecting this technique
it will be rather safe to say that this has now become a very
predictable procedure. The major part of success with implant
placement in this region lies in treatment planning. It is of
utmost importance that the preoperative evaluations are
done perfectly and the most suitable technique is decided
accordingly for that particular situation, to improve the
prognosis of that treatment. As with everything else, this
procedure must also have a learning curve, which every
budding Implantologist will have to go through, but once those
initial difficulties and glitches are resolved, this is certainly a
great method for placing implants in the posterior maxilla,
arguably the most challenging situation in the oral cavity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Tarun and Anand: Maxillary sinus augmentation
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69. Figure 8: (adopted) Available from: http://www.WAUPS.org
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