Review

Introduction

The maxillary sinus is the paranasal sinus that impacts most on work of the
dentists and the maxillofacial surgeon when treatment requires bone grafting in
this area. Augmentation of the maxillary sinus floor is well-documented and
considered a conventional procedure, which allows the rehabilitation of the
atrophic posterior maxilla using Osseo integrated dental implants. (1)

Computerized tomography is considered a gold standard for sinus diagnosis

and planning surgery. A conceptual understanding of the anatomic and functional
relationship between the maxillary sinus and upper posterior teeth is important
when dealing with chronic inflammatory diseases and surgery planning. (2)

A significant difference in the bone height of the sinus floor exists between
dentulous and edentulous individuals. In persons with maxillary tooth loss,
pneumatization combined with ridge atrophy leaving thin alveolar bone or only
mucoperiosteum (Schneiderian membrane) between the sinus floor and oral
cavity.(3)

The placement of the dental implants in such patients requires preprosthetic

surgical procedures such as alveolar bone grafting and sinus floor elevation.
Providing dental implants to patients who have lost upper posterior teeth and
surrounding bone requires radiological assessment of the planned implant site. (4)

The opening of the maxillary sinus osteomeatal complex (OMC) is located

high in the medial sinus wall. Compromised maxillary sinus drainage system is
associated with a higher risk of postoperative sinusitis and is a significant area in
examining patient with sinus complaints, there may be a justification to extend
the field of view (FOV) to include the whole of the maxillary sinus including the
OMC. This information allows assessing the risk of the planned procedure.

Reaction to dental treatment, sinus floor elevation and periodontal disease

may cause the mucosal thickening in the floor of the maxillary sinus. Perforation

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of the sinus membrane during sinus floor elevation is the most common
complication, with the incidence rate of approximately 30%. Anatomic variations
within the sinus, such as septa, mucosal thickening of the sinus floor increase the
risk of the sinus membrane perforation during pre-implant surgery in posterior
maxilla.

Computed tomography images allow the location of anatomic structures

and provide information about bone dimensions and morphology. CBCT can
accurately capture, display, and provide 3-dimensional visualization of
maxillofacial anatomy and pathology. In maxillary sinus floor elevation
procedure, it is important to be acquainted with different anatomic and pathologic
findings in sinus, to minimize the risk of postoperative complications.

Sinus Anatomy and Dimensions

Maxillary sinus is the biggest pyramidal-shaped paranasal sinus. The

average dimensions of the maxillary sinus are 36–45 mm in height, 23–25 mm in
width, and 38–45 mm in length (anteroposterior axis). The average volume of the
maxillary sinus is 15 ml.[8] Anterior wall extends from inferior orbital rim to the
maxillary alveolar process containing infraorbital neurovascular bundle. Superior
wall is the floor of orbit and is very thin. Posterior wall separates the maxillary
sinus and pterygopalatine fossa which contains posterior superior alveolar nerve
and blood vessels, the pterygoid plexus of veins and internal maxillary artery.
Medial wall is the lateral wall of the nasal cavity which houses primary ostium.
This ostium serves as the main channel for drainage of secretions. Lateral wall
forms the buccal aspect of the sinus and contributes to the posterior maxillary and
zygomatic process; this wall provides access for the lateral wall sinus graft
procedure. (5)

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Fig. 1. The anatomy and drainage pathway of the maxillary sinus. The
primary ostium is located along the superior medial aspect of the medial wall
of the sinus. Fluids eventually drain into the middle meatus of the nasal
cavity. (From Treadway AL, Bankston SA. Dental implant prosthetic
rehabilitation: sinus grafting. In: Bagheri SC, Bell RB, Khan HA, editors.
Current therapy in oral and maxillofacial surgery. 1st edition. St Louis
(MO): Elsevier Saunders; 2012. p. 168; with permission.)

Maxillary sinus septa

Maxillary sinus septa were first mentioned by Underwood in 1910.[9]

Based on their origin, septa can be further subdivided into primary septa, formed
during maxillary development and tooth growth, or secondary septa which is
acquired during the pneumatization of the maxillary sinus after tooth loss.[10]
The majority of septa are located between the second premolar and first molar
area.[11] Sinus augmentation is usually complicated by the presence of septa. If
there is a full partition of the sinus by a septum, more than one lateral window is
created as part of the sinus opening to circumvent the septa.[12] (6)

Vasculature and Innervation

The infraorbital and posterior superior alveolar arteries, both branches of

the internal maxillary artery, supply the lateral aspect of the maxillary sinus.
Traxler et al., 13 found that branches of these two vessels formed end osseous

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anastomoses in all specimens. In 44% of specimens there were also extraosseous

anastomoses forming a double arterial arcade. The infraorbital artery, along with
the nerve, runs along the superior wall of the antrum within the sinus mucosa. The
artery gives off the middle and anterior superior alveolar arteries before exiting
the skull. The infraorbital foramen is located on the anterior wall of the antrum.
The medial aspect of the sinus receives blood supply from the posterior lateral
nasal artery, a branch of the sphenopalatine artery. The high vascularity of this
region results in a more favorable environment for graft integration. Innervation
is supplied by branches of the second division of the trigeminal nerve, which
include the infraorbital, superior alveolar, and palatine nerves. The innervation of
the maxillary sinus is outlined in table (1). It represents a distinct connection
between the venous system of the maxillary sinus and the cavernous sinus, which
is significant because it can potentially serve as a pathway for infections spreading
from the sinus to the brain [28-30]. (7)

Table (1): The nerve supply to the maxillary sinus.

PSA: Posterior superior alveolar; MSA: Middle superior alveolar; ASA:

Anterior superior alveolar; IO: Infra orbital; GP: Greater palatine. Adapted from
[28-30]

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Schneiderian membrane

Maxillary sinus is lined by the membrane called as Schneiderian

membrane. This membrane is a pseudostratified columnar respiratory membrane
ciliated epithelium formed by the basal cells, columnar cells, and goblet cells
fixed to the basal membrane. About 100–150 cilia present on each columnar cell
which vibrate at 1000 beats/min. Thickness of the membrane normally varies
from 0.13 to 0.5 mm (average 0.8 mm thick).[13] The membrane should be freed
totally from the caudal area to enable lifting of the sinus; however, the distal side
of the sinus might extend considerably.[14] Chances of sinus membrane
perforation depend on the angle between the lateral and the medial wall of the
sinus. Greater than 60° angle has 0% chances of perforation; 30°–60° angle has
28.6% chances of perforation; and <30° angle has 62.5% chances of
perforation.[15] Thus, narrow angles result in higher perforations. Overfilling of
the maxillary sinus with the bone graft material may cause necrosis of the
membrane as well as sinusitis and the potential loss of the bone graft into the
sinus.

Relationship to Dentition

The maxillary premolars and molars have an intimate relationship with the
inferior aspect of the maxillary sinus. As shown by oral-antral communications
during tooth extraction, the bone separating the apices from the sinus cavity is
often extremely thin. Eberhardt and colleagues found that the mesiobuccal root
apex of the second molar was closest to the sinus wall, with an average distance
of 0.83 mm. The lingual root apex of the first premolar was the furthest from the
sinus wall. In general, the molar roots were closer to the maxillary sinus than
premolar roots.

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Maxillary Sinus Pneumatization

Maxillary sinus is fluid filled at birth and gradually shows pneumatization

with the eruption of permanent teeth. Its volume continues to expand with the
bidirectional action of osteogenesis and osteoclast genesis. However, its growth
slows down with decreased facial development after puberty but continues for a
lifetime. This physiological process is called MS pneumatization (MSP). MSP can
extend to adjacent anatomical structures, with the extension to the alveolar
process the most common one.

Clinical studies have found extensive MSP in young patients, making the
distance between the root apex of the maxillary posterior teeth very close to the
MS, which increases the risk of teeth protrusion into the sinus. Such presentations
were also proved in the study by Huangdi et al. [7]. Thus, extensive MSP can
lead to odontogenic sinusitis, oro-antral communication, cysts, and other clinical
conditions that may deeply affect the quality of life of people [8].

Increased osteoclastic activity within the periosteum of the Schneiderian

membrane results in expansion of the maxillary sinuses. Also, increased positive
pressure is thought to contribute to alveolar bone atrophy. The soft, type IV bone
in the posterior maxilla has low resistance to these processes. The result is a
decrease in vertical bone height (VBH) of the alveolus in the edentulous areas.

In a radiographic study, Sharan and Madjar found that “sinus expansion

was considerably larger in cases of extractions of teeth enveloped by a superiorly
curving sinus floor. Sinus expansion was larger in cases of second molar
extractions (in comparison to first molars) and in cases of extraction of 2 or more
adjacent posterior teeth.”

Davarpanah et.al, classified posterior maxillary bone loss into several categories:
• Vertical bone loss from within the sinus: a reduced distance from the
floor of the sinus to the alveolar ridge crest. However, no loss of
interocclusal distance.
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• Vertical bone loss of the alveolar ridge: loss of alveolar ridge below the
sinus. There is an increase in interocclusal distance.
• Horizontal bone loss of the alveolar ridge: a loss in Bucco palatal width
of alveolar bone.
• Combination sub sinus loss: both vertical and horizontal bone loss.

Fig (2) Periapical radiograph showing pneumatization of the maxillary sinus

secondary to loss of all molar teeth. (From Li J, Lee K, Chen H, et al.
Piezoelectric surgery in the maxillary sinus floor elevation with hydraulic
pressure for xenograft and simultaneous implant placement. J Prosthet Dent
2013;110(5):345; with permission.)
Maxillary Sinus Augmentation
Indications

The major indication for sinus augmentation is the atrophic posterior

maxillary alveolus with loss of VBH. Pneumatization of the sinus results in
insufficient bone to house an implant with adequate stability. There are 2 main
approaches to sinus augmentation: trans alveolar approach and lateral antrostomy
(LA).

The decision as to which approach to use is largely based on the amount of

residual maxillary alveolar bone remaining. Rosen and colleagues17 found that
implant survival decreases with the trans alveolar technique when 4 mm or less
of residual bone height is present: “When presurgical bone height beneath the

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sinus is compared to implant survival, the data demonstrate that in sites of 4mm
or less, there was a survival rate of 85.7%, which improved to 96% in locations
with more than 4 mm of initial bone height.” Another study found that the
transalveolar approach is indicated when greater than 6 mm of residual bone is
present, and 3 to 4 mm of bone height gain is planned.

The lateral antrostomy (LA) approach was recommended for cases with
less residual bone or if more bone height is needed.18 If the LA approach is used,
the practitioner can opt to place implants immediately or to delay placement after
graft maturation. This decision is based on several factors. The quality of the bone
(i.e., its density) should be assessed. The amount of residual alveolar bone should
also be evaluated. Immediate placement can be considered if the clinician can
achieve primary stability of the implant. Reports have been published showing
implant success with as little as 3 mm of VBH before sinus augmentation.19
However, it can be difficult to stabilize the implant with less than 3 mm of residual
bone height. It is recommended that a minimum of 4 to 5 mm of residual bone
height be present for immediate implant placement when using the LA technique
(Table 2).20

Table (2) Trans alveolar versus lateral antrostomy

Contraindications

Several factors can increase the risk of implant failure and other adverse
sequelae. Implant placement in bone of poor quality should be avoided because
of the decrease in primary stability. Local or systemic causes can compromise
bone quality.

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Contraindications include active sinus infection, recurrent chronic sinusitis,

recurrent fungal sinusitis, un-controlled diabetes, cystic fibrosis, maxillary sinus
hypoplasia, neoplasms, and history of radiation therapy to the site.20 Smoking
has been linked to an increased risk of complications associated with implant
integration and sinus augmentation. However, it is a relative contraindication
because failure rates were only slightly higher compared with nonsmokers.21

Presurgical Evaluation

A thorough history and physical examination is required before the

initiation of treatment, a comprehensive dental evaluation determines whether the
patient is an appropriate candidate for implant placement with sinus
augmentation. Diagnostic models can be used to evaluate the proposed surgical
site. The patient’s occlusal scheme should be evaluated. In addition to horizontal
measurements, the vertical dimension of the surgical site should be evaluated. An
inadequate or excessive interarch distance can compromise the stability or esthetic
outcome of the implants.11 In addition, the transverse relationship of the maxilla
and mandible should be evaluated.

1- Preoperative radiographic evaluation

I. Cross sectional imaging technique

There is sufficient evidence that cross-sectional imaging (multi-slice

CT/cone-beam CT) can be considered as the gold standard in implant planning
(Jacobs et al. 2009; Guerrero et al. 2006; Van Assche et al. 2007; Lofthag-
Hansen et al. 2009; Veyre-Goulet et al. 2008).

Computed tomography (CT) is the first imaging approach for visualization

of paranasal sinuses because of the method’s superior osseous delineation. CT is
used for evaluation of inflammatory processes in the maxillary and all other
paranasal sinuses. The method is useful for determining the extent of disease, for
surgical planning, and intraoperative guidance (Harnsberger et al., 2011).

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Lately, CBCT has been an alternative imaging modality for paranasal sinus
evaluation due to its reduced radiation dose, image precision, spatial resolution,
and ease of image acquisition (Hodez et al., 2011). However, there are limitations
for the use of CBCT in the visualization of paranasal sinuses in cases such as
invasive tumors, blood effusion, and others. CBCT is helpful in the diagnosis of
acute and chronic inflammatory diseases of the sinuses, mucus retention cysts,
mucocele, antrolith, and trauma (Hodez et al., 2011; Rege et al., 2012; Mossa-
Basha et al., 2013).

Stage 1: Development of the Index

The novel CBCT index with difficulty scores assigned to each parameter.

The index included six key parameters: thickness of the lateral wall of the sinus,
sinus septations Figures 3 (a) and (b), presence of an alveolar antral artery (Figure
4), relationship of the sinus membrane with the roots of the adjacent teeth,

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thickness of the sinus membrane, and the presence of sinus pathologies (Figures 5
(a) and 3(b)).

Fig (3) (a) Sagittal CBCT section showing presence of a small partial septation
above surgical site. (b) Sagittal CBCT section showing large partial septation
above surgical site.

Fig (4) (a) Coronal CBCT section showing evidence of mucosal thickening
(yellow arrow). (b) Coronal CBCT section showing mucous-retention cyst in the
right maxillary sinus proximal to the osteotomy site (yellow circle).

Fig (5) Lateral antral artery (yellow arrow) seen in the lateral wall of the right
maxillary sinus.
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This evaluation determines essential parameters such as 1,) membrane

thickness, 2,) presence of sinus septa, 3,) residual bone height, and 4,) presence
of teeth. The elevation of the maxillary sinus floor carries a risk of jeopardizing
the sinus physiology, and a careful and thorough CBCT evaluation before the
procedure can reduce the chances of intra-operative and post-operative
complications [31,32].

The maxillary sinus is considered healthy when the mucous composition

is normal, mucociliary clearance is efficient, and the sinus ostium is patent. These
criteria are significant because a healthy maxillary sinus is less likely to develop
postsurgical complications, even in the event of a small procedural error, such as
a minimal perforation [33].

The diagnostic features extracted from CBCT images that could be

clinically relevant for performing a successful sinus floor elevation (SFE)
procedure, which could very well remain undetected with 2D imaging, are as
follows:

1- Anatomy of maxillary sinus and alveolar ridge

CBCT imaging provides detailed anatomical information related to sinus

anatomy. These findings allow the surgeon to assess the sinus morphology,
density, and volume of the residual alveolar ridge, which might in turn help to
determine the best approach for accessing the sinus and to evaluate the suitability
of the patient’s bone for grafting [55,65].

Relation of maxillary sinus to the roots of adjacent teeth

If there is an intimate contact between the root(s) of the teeth and the
Schneiderian membrane, the risk of membrane perforation during the sinus lift
procedure is increased. Hence, it is important to evaluate the root proximity to the
sinus during the diagnostic phase through CBCT imaging for decreasing the risk
of perforation [66,67]. Additionally, the health state of adjacent teeth should be

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examined for the presence of pre-existing apical pathology that could result in
sinus graft infection [68].

However, the probability of perforation decreases when two adjacent teeth

are missing. This decreased probability could be due to the presence of sinus
pneumatization in a small area with an irregular sinus floor shape. Figure (6)
shows the relationship between the extraction of teeth and pneumatization of the
maxillary sinus [46].

Fig (6) A panoramic image showing reference lines drawn and perpendicular
distances measured from the crest of the bone to the maxillary sinus floor.
Source: [46].

2- Thickness of the Schneiderian membrane

CBCT has been reported to be a useful tool for assessing the thickness of
the Schneiderian membrane [60,69], which has also been reported to be associated
with the occurrence of membrane perforation [70]. The Schneiderian membrane
is an important parameter during the presurgical analysis [35,36]. Healthy sinus
mucosa has a mean thickness of 1mm, although there is a wide range of variability
among individuals [71]. Meanwhile, it should be noted that the risk of sinusitis
following sinus floor elevation (SFE) increases when the membrane thickness is
over 2 mm [72], and a higher risk of ostium obstruction exists if the membrane

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thickness is over 5 mm [73]. Recent CBCT studies indicate that 1 mm is a

physiological value and 4 mm is pathological [37-40].

3- Maxillary sinus septum [74,75]

Prior evidence suggests that at least one-third of patients have sinus septa,
which are visualized ideally through 3D imaging [76]. The knowledge about septa
location and morphology is a key factor in planning SFE, as it is associated with
an increased risk of sinus membrane perforation during the procedure.
Furthermore, if present, the osteotomy design might also require an alteration
from a single window technique to two smaller windows on either side of the
maxillary sinus floor septum or the use of a W-shaped trapdoor technique. Hence,
CBCT imaging is the key to success in devising a proper treatment plan [77].

4- Maxillary sinus ostium

Sinus healing following SFE is largely dependent on sufficient drainage

of the nasal cavity. If the ostium is not patent, the drainage would be impaired,
which could cause sinusitis or surgical failure [72]. For guaranteeing appropriate
mucociliary drainage and clearance, the ostium patency must be evaluated prior
to surgery. In addition, the sinus should be assessed for the presence of accessory
ostia, which can interfere with sinus ventilation and drainage [78].

5- Maxillary sinus floor width

The distance and angulation between the lateral and medial maxillary
sinus walls are also important anatomical features to be evaluated with CBCT
imaging. It allows determining the difficulty level of performing SFE, as too
narrow or too large sinuses with sharp angulations are considered complex cases.
Moreover, accurate measurement of the sinus width based on CBCT imaging is
also crucial for deciding the surgical approach; for example, a trapdoor SFE
technique is contraindicated in patients having narrow sinuses [79].

6- Thickness of the lateral maxillary sinus wall

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Maxillary sinus lateral wall thickness is an important parameter to be

assessed using CBCT imaging at the diagnostic stage because SFE through a thick
wall is difficult to perform, takes longer time and is more prone to perforation.
Hence, CBCT imaging is suggested to help with the decision-making process, as
it allows the surgeon to 3D evaluate the sinus wall and select the region with the
least thickness to avoid complications [80].

7- Alveolar antral artery

CBCT imaging allows a clear depiction of the antral artery, allowing for
an optimal planning of the surgical access to the sinus. Alveolar antral arteries
with a diameter more than 0.5 mm can be observed on CBCT, and profuse
bleeding should be expected if the artery has a diameter more than 3 mm [81]. If
present at the osteotomy site, the use of a piezo-surgery device is preferred.
Moreover, changing the osteotomy window design from an oval to a round shape
through either above or below this artery could avoid injury [82].

An intraosseous anastomosis, the alveolar-antral artery, is always present

between the posterior superior alveolar artery and the infraorbital artery. However,
an extraosseous anastomosis exists in only 44% of cases. Hemorrhage of the
alveolar-antral artery is a common complication in sinus lifting procedures. To
avoid this, a posterior approach to the bone antrostomy has been suggested.
Planning should include a careful evaluation of CBCT to ascertain the course of
the artery. Both the diameter and course of the artery are evaluated through CBCT.

8- Estimation of graft volume

Using the combination of CBCT images along with the various planning
software systems available allows for measuring and extracting the sinus volume
necessary to be grafted [83]. Adequate preoperative planning of the graft volume
may help to avoid sinus over-filling and potentially occluding the ostium, decide
on the ratio of bone and bone substitutes to be mixed, and estimate the cost of

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xenografts prior to the actual operation [47,48]. It is worth noting that in cases
where an autogenous graft will be harvested, preoperative knowledge of the
amount of graft required is useful in selecting the optimal donor region, reducing
the time and complexity of the surgical procedures, as well as minimizing
potential postoperative complications [84].

10- Incidental findings

Several studies have reported a high prevalence of Incidental findings (Ifs)

in the maxillary sinus region on CBCT images when acquiring the scan for the
purpose of implant/surgical planning [85,86]. The most common IFs encompass
concha bullosa, mucosal thickening, polyps, altered sinus dimensions, and sinus
opacification. Some IFs may also be suggestive of benign or malignant neoplastic
processes. Hence, it is important for the dental practitioner to be aware of these
findings on CBCT images, which might allow a more appropriate selection of a
treatment plan as patients with IFs might be redisposed to a higher risk of
postoperative complications from SFE and implant placement.

Risk of sinus membrane perforation.

The risk of perforation can be associated with irregularity in the membrane

thickness, sinus septa, the angle between the buccal and palatal wall, and existing
tooth implants or tooth roots adjacent to the sinus [34].

General considerations

Generally, sinus lifting is indicated with a residual bone height of 8 mm

or less (including leaving a space of 1 to 2 mm of bone between the implant apex
and the sinus floor level) [48]. The two basic methods for the sinus lifting
procedure are the trans-alveolar (crestal osteotome) and the lateral window [51].
If more than 5 mm of bone height is present, the crestal osteotome is the treatment
of choice [52]. However, if the ridge height is severely reduced, the use of a lateral
window is indicated. This technique can aid in achieving a height of up to 9 mm,

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which is enough to compensate for the bone shortage [48]. Factors affecting the
prognosis of the maxillary sinus lifting procedure are demonstrated in Table(2).

Table (2): A summary of factors affecting the prognosis of maxillary sinus lifting
procedures. Source: [34]

Virtual Modelling

The most essential step in SFE planning workflows is segmentation, a

process by which the region of interest is extracted from 3D images for generating
3D virtual models. These models are then used for fabricating guides or pre-
surgically assessing the amount of required (bone) graft fig (7) (Figure )(

Fig (7) Example of graft volume estimation in Mimics (version 23.0, Materialise
N.V., Leuven, Belgium) following automated sinus and teeth segmentation
(creator.relu.eu, Relu, BV, Version March 2023).

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Recently, artificial intelligence (AI) in the form of deep learning has been
employed for automated segmentation to overcome the limitations associated
with both manual and semi-automated segmentation approaches. In deep learning,
convolutional neural networks (CNNs) have demonstrated excellent performance
with the employment of multi-layer neural computational connections for sinus
segmentation on CBCT images [95,96,97]. The application of such deep learning-
based approaches might enhance the quality and predictability of presurgical graft
planning, enable a more precise treatment planning process and volumetric
quantification of sinus/graft changes, and may further improve the standard of
care. Yet, a lack of evidence exists related to the application of AI in the SFE
treatment planning workflows.

Surgical Guidance

In SFE procedures, CBCT-based guidance has played a vital role in

improving the precision of the surgical procedure with a reduction in
complications. The guidance can be static or dynamic in nature. The procedures
performed via these guides are referred to as “guided sinus lift [98]” or “guided
bone grafting [99]”.

a) Static Surgical Guides

Static guides are designed via 3D planning software programs following

the integration of intraoral scanned images with CBCT datasets and later
fabricated using 3D printers. Such surgical templates act as a support aid and offer
the advantages of time-efficiency, better working ergonomics, less operator stress,
and greater predictability of the procedure [98,100,101]. Moreover, this procedure
can also be combined with concurrent implant placement planning.

In 2008, Manderales and Rosenfeld [99] pioneered computer-guided

SFE. They proposed using CAD/CAM surgical cutting guides for exact lateral

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wall outlining to considerably improve the quality and outcomes of the SFE
procedure.

Considering trans-crestal sinus augmentation, Pozzi et al. [103] and An et

al. [104] combined static guide-based flapless maxillary crestal sinus
augmentation with an immediate nonfunctional loading of dental implants,
reporting a 98.53% and 100% survival rate at 3 years and 37 months, respectively.

b) Dynamic Surgical Guides

Another type of surgical guidance is dynamic navigation, which is based

on computer-guided surgery planning. Here, a physical surgical guide is
unnecessary [105]. A dynamic navigation system combined with CBCT imaging
has been proposed for improving the intraoperative precision of implant
placement. Recently, dynamic navigation has been used for posterior maxilla
implant surgery via trans-crestal SFE using piezoelectric devices [107].

Considering the intraoperative use of CBCT imaging, Blake et al. [108]

performed one case trial of using a C-arm-based CBCT scanner during sinus
augmentation surgery under general anesthesia with iliac crest grafting. The
images were taken prior to wound closure to immediately verify the surgery result.
However, there is no solid evidence regarding such procedures for surgeries
performed under local anesthesia.

Radiological sinus lift using minimally invasive CT-guided procedure.

An interventional radiological CT-guided alternative to the more traumatic

classic surgical lateral antrostomy approach, which has an equivalent success rate
and to confirm any mucosal perforation, the mucosal elevation was monitored in
real time with a 30-degree rigid endoscope (Hopkins II; Karl Storz endoscopy,
Tuttlingen, Germany) inserted into the sinus via a hole made below the inferior
orbital rim. The combination of isotropic volume CT and endoscopic control

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provides high definition views during the elevation procedure and increase the
accuracy for detection of any perforation.

Panoramic Radiographic Technique

Panoramic radiographs less reliable and clearly inferior to multi-slice

computer tomography (CT) or cone-beam CT, Nedbalski & Laskin (2008)
considered a panoramic radiograph not reliable to diagnose a sinus involvement
following extraction of maxillary premolars and molars.

Several factors exert a negative impact on the reliability of panoramic

radiographs. The correct positioning of the patient’s head while scanning is of
utmost importance because malpositioning will automatically lead to
discrepancies and distortion of shape (Mckee et al. 2001). Moreover, a panoramic
radiograph remains a two-dimensional image of a three-dimensional (3-D) object,
with superimposition of neighboring anatomical structures, rendering a correct
diagnosis more difficult (Yeo et al. 2002). Panoramic radiographs are further
degraded, to a variable degree, by shadows of soft tissues and surrounding air.

Inherent to the arch-wise image built-up, panoramic radiographs show a

variable degree of overlap in the upper premolar region. This overlap can probably
be explained by the difference in curvature of the upper and lower jaws in this
region, where the panoramic unit is programmed for the shape of the mandible
(Rushton & Horner 1996, 2003; Gijbels et al. 2000) Such an overlap could
result in an underestimation of the available mesiodistal bone size in front of the
maxillary sinus. Other drawbacks are as follows: limited resolution (≤6-line
pairs/mm as opposed to 12– 22-line pairs/mm for intra-oral sensors) and oblique
projection geometry hampering a correct visualization of the anatomical
relationships. All the above-mentioned factors may hamper presurgical planning.

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Direct Digital Paralleling Periapical Radiographic Technique

Intraoral periapical (PA) radiography is the primary diagnostic and most

used method for measuring the remaining crestal bone height while screening for
implant treatment in the posterior maxillary area.1A significant drawback of
conventional PA radiographs, however, is that 3-dimensional (3D) objects (e.g.,
tooth or ridge) are compressed and superimposed into 2-dimensional (2D) images
that are often distorted. 2 The use of PA radiographs to assess alveolar ridge height
can minimize cost and reduce radiation exposure compared with CBCT scans.

Larheim et al reported that from a clinical point of view the mean

difference between periapical radiographic measurements for tooth lengths before
extraction and real lengths measured with calipers after extraction was not
significant.

The paralleling technique is popular because it provides inherently less

distortion and greater accuracy in measurement than the bisecting
technique.13 This is especially critical in the field of endodontics for root length
determination. However, this characteristic is not applicable in implant dentistry
because there is an absence of key identifiers or measurement points such as
incisal edge or root apex making it difficult to measure the ridge height and
eliminating any repeatability in measurements, and, thus, introducing error.

A review by Sharan and Madjar discussed multiple variations of the

shape of the maxillary sinus floor in relation to teeth roots.15 The shape of the
floor may affect the prevalence of over-or underestimation on PA based on the
degree of superimposition or lack thereof.

If the sinus extends between the roots in a triangular shape, this often
creates insufficient radiolucency for detection on periapical radiographs, like
incipient decay on buccal/lingual surfaces of teeth. This, therefore, can cause an
overestimation when measuring the alveolar ridge height.

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Also, alveolar ridge height may appear longer on a PA radiograph than in

a cross-sectional image, as superimposition will show the height to be as high as
the highest point of the ridge. However, the area of interest for implant placement
may have inadequate ridge height for conventional surgical placement.

Intraoperative PA radiographs should be captured using extension cone

paralleling (XCP) to ensure proper long cone paralleling technique. After the
initial osteotomy (2 mm twist drill) is performed, a direction indicator should be
used to confirm positioning, and the radiographic measurement could confirm
whether there is any distortion in the radiograph as the length of the indicator is
predetermined from the implant manufacturer.

fig (.8) PA shows the height like #1 due to superimposition, however the area of
interest, #4, is the true length of the ridge available for implant placement CBCT
cross-section view that long that long axes of tooth and alveolar ridge are
dissimilar.

Graft should fill the cavity loosely. Overpacking th e site can compromise
angiogenesis into the graft or obstruct the primary ostium.3,20 As stated
previously, sufficient VBH should be present if the decision is made to place
implants at the time of sinus augmentation.

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Fig. (9). A coronal section through the maxillary sinuses. The lateral window is
infractured and elevated superiorly. A space is created inferior to the elevated bone
window. (From Boyne PJ. Augmentation of the posterior maxilla by way of sinus
grafting procedures: recent research and clinical observations. Oral Maxillofac
Surg Clin North Am 2004;16(1):24; with permission.)

Schneiderian Membrane Perforation

The most common complication of sinus augmentation is perforation of

the Schneiderian membrane, especially if the LA technique is used. The most
frequently cited cause for membrane tears is vigorous elevation. Vlassis and
Fugazatto 30,31 proposed a classification system for evaluation and treatment
Box (1).

Hernandez-Alfaro and colleagues32 found that implants placed under

reconstructed sinus membranes have a higher failure rate. They concluded that
implant failure rates increase proportionately with the size of the perforation.
Sinus perforation also increased rates of postoperative sinusitis, infection, and
graft failure.33

Postoperative CBCT Findings

Ideally, imaging guidelines for the follow-up of sinus augmentation with

or without immediate implant placement should follow the same regulations as
those for post-surgical implant placement. Based on the AAOMR
recommendations [55] and the guidelines for the use of diagnostic imaging in
implant dentistry published by the E.A.O. [56],
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1- Intraoral periapical radiography should be performed for the

postoperative assessment of implants in the absence of clinical signs or
symptoms.
2- Panoramic radiographs may be indicated for more extensive implant
therapy cases.
3- Meanwhile, CBCT [109,112,115] has become the standard imaging
technique for 3D visualization and improved assessment prior to implant
placement in the case of staged sinus augmentation.
• Assess bone healing by visualizing how the material has integrated
with the surrounding bone as well as if any signs of early resorption
exist.
• Providing information about the volume, extent, and density of the
augmented region. [56]
• Monitor any complications, which are not visible to the naked eye,
such as mucosal changes, infection, and/or inflammation.
• The quantification of the resorption rate of different grafting
materials [124,125,126]
• Monitor sinus changes at follow-up stages like post-surgical edema
of Schneiderian membrane, which increases the mucosal thickness,
the patency and obstruction of the ostium and infundibulum which
may cause acute or chronic sinusitis [127].

Limitations in Detection of Schneiderian Membrane Perforations

Detection of membrane perforation relying only Valsalva maneuver as an

intraoperative test which suffer from low specificity and limited sensitivity,
inaccurate detection, patient discomfort due to forceful exhalation against a closed
airway, and operator dependency where less experienced clinicians may have
difficulties in correctly interpreting the results.

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Attempts were made to develop innovative methods to identify membrane

perforations other than the Valsalva maneuver and its variants, including, the
direct visualization of the sinus membrane during TSFE using endoscopy [36–
38], monitoring of pressure change during TSFE procedure using the Jeder-
System [39], the use of operating microscope or micro-camera [40], and the use
of a contrast medium [22, 41].

Contrast Medium.

Radiographic contrast media were used historically in the radiographic

study of the maxillary sinuses where it was injected into the lumen of the sinus to
fill it completely and the drainage of the contrast medium occurred over the period
of a few days [42].

Iohexol is a nonionic low-osmolar agent that has an osmolality like that

of the plasma, this low osmolality in addition to its inert nature and water
solubility reduce the risk of contrast-induced pneumonitis in case of aspiration
[50]. The palatability of iohexol is an added benefit making it one of the preferred
orally administered contrast agents [44, 51].

Pommer and Watzek [41], and Kim et al. [22], have previously suggested
the use of a contrast medium during TSFE. A recent study uses hydraulic contrast
lift (HCL) protocol, that incorporates an iodinated contrast medium instead of
saline in fresh in refrigerated ex-vivo sheep maxillae. One of the major findings
of this study was that the examiners were able to correctly identify successful
sinus membrane lifts and membrane perforations more easily and with a much
higher rate of correct diagnoses when interpreting the radiographs resulting from
the HCL protocol. The examiners reported a significantly higher level of
diagnostic confidence that positively correlated with the HCL protocol.

In addition, the diagnostic reliability, diagnostic validity, and diagnostic

accuracy of this protocol were shown to be substantial and statistically significant.

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So, it can be stated that these results establish the scientific basis for the use of
this protocol to reduce operator uncertainty when performing TSFE by providing
a more reliable detection of membrane perforation.

When the membrane is intact, the contrast medium is enclosed between

the flexible membrane and the sinus floor, not being able to escape thanks to the
presence of a plug sealing the osteotomy. The membrane is inflated and makes its
characteristic convex or dome shape protruding into the lumen of the sinus. On
the other hand, that inflated shape would not hold in case of major or even a minor
perforation.

Limitations of This Technique

1- Air bubbles would sometimes become trapped within the contrast medium,
along with the use of radiolucent plugs. Both had the effect of causing areas
of radiolucency within the area of radio opacity in both contexts.
2- In this ex-vivo model, there is no bleeding associated with the dissection of
the sinus membrane, it remains to be seen if such bleeding could hamper the
radio-opacity of the contrast medium when injected below the sinus
membrane.
3- Hypersensitivity to contrast medium.

Scintigraphy (Bone Scan)

Bone scan with technetium-99m methylene bis-phosphonate (99mTc-

MDP) is a very sensitive radionuclide imaging technique for detection of
osteoblastic activity in the bony skeleton and the maxillofacial region.19,20 This
method has also been suggested to be a useful tool for the evaluation of bone
healing around end osseous dental implants placed in the maxillary sinuses
augmented with a mixture of BBM and ABG or with BBM alone. The highest
bone activity detected through bone scans has been found to take place 1 to 4
months after sinus lifting.21,22 Therefore it can be proposed that bone scans may

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reflect the overall bone activity in the augmented sinuses that cannot be achieved
by histologic analyses of biopsy specimens.

Figure (10) Scintigraphy of augmented sinus regions on scintigrams (A, BBM +

ABG–augmented site; B, BBM-augmented site). Regions of interest are drawn on
the scintigrams to indicate the maxillary sinus augmentation site (a) and the
temporal bone of the calvaria (b). Pikdöken et al. Bovine Bone Mineral in Sinus
Floor Augmentation. J Oral Maxillofac Surg 2011.

Bone scintigraphy would be a reliable method for investigation of

osteoblastic activity within augmented sinus sites. Although its resolution and
specificity are low, bone scintigraphy is a very sensitive method and an
approximately 10% increase in osteoblastic activity above normal, which cannot
be seen on conventional radiographs, can be determined by scintigrams.38

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