Recent Trends in Sinus Lift Surgery and Their

Clinical Implications
Mahmoud Al-Dajani, DDS, MSc, PhD (OMFS), MSc, FRCD(C) (DPH)

ABSTRACT
Background: Sinus lift procedures are used to allow residual bone to accommodate functional implants in atrophic posterior
maxilla. Numerous anatomical and surgical advancements in sinus lift surgery are still inspiring clinicians.
Purpose: The purpose of this study was to describe the recent trends in sinus lift surgery focusing on implant survival, bone
grafting, anatomical and surgical considerations, and their clinical implications on the practice of implant dentistry in
atrophic posterior maxilla.
Materials and Methods: We performed an extensive search in MEDLINE, Embase, Scopus, Web of Science, Trip, Cochrane
Oral Health Group’s Trials Register, Cochrane Central Register of Controlled Trials, and ProQuest Dissertations & Theses.
Articles were critically reviewed to determine the level of evidence as per the Canadian Task Force on Preventive Health
Care.
Results: Comprehensive assessment of sinus septa, sinus pathology, and bone quality and quantity using three-dimensional
cone beam computed tomography radiographs is important before placing implants in posterior maxilla. With a residual
bone height of less than 5 mm, the survival rate of implant decreases substantially. Lateral window approach can increase
the vertical bone height to greater than 9 mm, while osteotome approach can increase this height from 3 to 9 mm. The
perforation of Schneiderian membrane doubles the risk for the incidence of sinusitis or infection. The use of piezoelectric
surgery allows adequate sinus lift while protecting soft tissues and minimizing patient discomfort.
Conclusions: Although both osteotome and lateral window procedures can help clinicians in overcoming the challenges of
placing implants in atrophic posterior maxilla, pre-implant residual bone height is crucial in determining the survival of
these implants. Future research directions should consider study designs grounded on longitudinal randomized controlled
trials of large sample size.
KEY WORDS: dental implants, lateral window, osteotome intracrestal, sinus augmentation, sinus elevation, sinus lift

INTRODUCTION the floor of maxillary sinus in an upward direction, cre-

Atrophic posterior maxilla is a challenging anatomical ating an appropriate bone height that can accommodate
area for the placement of dental implants. Whenever the appropriately the placement of functional dental
diagnosis reveals insufficient residual bone height in implants. Sinus lift surgery is usually followed by bone
posterior maxilla, sinus lift procedure (or residual bone grafting in order to fill the compartment created
augmentation) is indicated. Sinus lift procedure is a sur- between the osseous floor of the maxillary sinus and the
gical intervention aimed at increasing the height of Schneiderian membrane.
residual bone in the posterior maxilla by repositioning Recent anatomical and surgical advancements in the
understanding and conduct of sinus lift surgery are
Researcher and instructor, Faculty of Dentistry, University of numerous. These advancements remain the main sources
Toronto, Toronto, ON, Canada of inspiration that help clinicians to innovate, develop,
Corresponding Author: Dr. Mahmoud Al-Dajani, Faculty of Den- and maintain a high standard of implant practice out-
tistry, University of Toronto, 124 Edward Street, Toronto, ON M5G comes and expectations as well as patient satisfaction. In
1G6, Canada; e-mail: mahmouddajani@yahoo.com this article, we will review the literature for the recent
Conflict of Interest: No potential conflict of interest relevant to this scientific trends in sinus lift surgery focusing on implant
article was reported.
survival, bone grafting, anatomical and surgical consid-
© 2014 Wiley Periodicals, Inc. erations, and their clinical implications on the practice of
DOI 10.1111/cid.12275 implant dentistry in atrophic posterior maxilla.

1
2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

MATERIALS AND METHODS stability and increased failure rates.1 Several factors
We performed an extensive search of the literature to enhance the loss of posterior maxillary residual bone
identify articles published between 1975 and 2014 after tooth extraction including: long-term tooth loss,
dealing with patients managed with pre-implant sinus trauma, infection, and advanced periodontal disease.
lift procedure through different surgical approaches. An Bone loss problem is further complicated with the asso-
electronic search was conducted in MEDLINE, Embase, ciated downward movement of the sinus floor.1 This
Scopus, Web of Science, Trip, Cochrane Oral Health movement could be explained by the post-extraction
Group’s Trials Register, Cochrane Central Register of change in intra-sinus equilibrium associated with
Controlled Trials, and ProQuest Dissertations & Theses. increased activity of osteoclasts in the Schneiderian
The bibliographies of review articles were also checked. membrane, which fosters the maxillary sinus pneuma-
The last electronic search was performed on April 4, tization phenomena.
2014, entering the following terms: “dental implant” The decreased bone density and increased cortical
AND (“sinus augmentation” OR “sinus lift”). Literature plate porosity in posterior maxilla are additional char-
was also identified through reference lists of selected acteristics that emphasize the need for assessing bone
articles. Only articles in English were included. Articles quality as well as quantity before placing implants in
were critically reviewed to determine the level of evi- posterior maxilla.1 This thorough assessment is essential
dence as per the Canadian Task Force on Preventive in planning the future place of dental implants in pos-
Health Care. terior maxilla, and can be accomplished by the use of
Table 1 shows the key words and their combinations three-dimensional cone beam computed tomography
used in the literature search. Thirty-seven articles were (CBCT) radiographs.2
included in the review tables, and distributed as follows: Beside bone characteristics of posterior maxilla, two
7 retrospective studies, 20 prospective cohort/case series, anatomical structures can importantly interfere with
4 randomized controlled trials, and 6 systematic reviews or even complicate bone grafting in sinus lift surgery:
with/without meta-analyses. maxillary sinus septa and posterior superior alveolar
artery (PSAA). Maxillary sinus septa are usually
Posterior Maxilla: Anatomical Considerations encountered in one out of four sinuses exhibiting a
great degree of morphological and structural variability:
Limitations for placing an implant in the posterior
complete versus partial; single versus multiple; unilat-
maxilla are related not only to the residual bone height
eral versus bilateral; and transverse, sagittal versus hori-
and width but also to the quality of maxillary bone. Poor
zontal.3 CBCT radiography remains the most accurate
bone quantity and quality in posterior maxilla are
tool to diagnose and identify these septa in maxillary
usually blamed for the decreased primary implant
sinus.3
PSAA is the second important anatomical structure
that implantologists need to respect in order to avoid the
TABLE 1 Literature Computerized Search Strategy incidence of severe bleeding during the lateral window
Keywords, search history, Number of sinus lift surgery. PSAA enters the maxillary sinus
Step and criteria articles through the posterior superior alveolar foramen at the
1 “dental implant” 7,153 posterior wall of maxilla. The intra-osseous branch of
2 “sinus augmentation” OR “sinus lift” 1,691 PSAA invaginates on the buccal (lateral) wall of sinus
3 (1 AND 2) 209 following either a straight or U-shaped course,4 and
4 Search limited to humans 184 running at an approximate height of 19 mm away from
5 Search limited to English-language articles 169 the alveolar bone ridge.5,6 This height is usually shortest
6 Relevant articles at title stage 35 in the first molar area.4 We need to keep in our mind that
7 Relevant articles at abstract stage 35 the distance between the intra-osseous branch of PSAA
8 Relevant articles at full copy stage 35
and alveolar bone ridge decreases significantly in eden-
9 Adding three articles from reference lists 37
tulous areas over time.
of selected articles
The normal anatomy of Schneiderian membrane
Articles included in review tables 37
is structurally affected by the presence of potent
 Recent Trends in Sinus Lift Surgery 3

pathology, which reflects negatively on the outcomes of Surgical Considerations

sinus lift surgery.7 For example, preoperative chronic
sinusitis can produce pathological and pathophysiologi- Sinus lift procedure has increasingly become a common
cal changes in Schneiderian membrane, hindering the practice especially when the insufficient heights of
normal ability of injured Schneiderian membrane to residual bone prevent the placement of dental implants
recover after surgery, and consequently increasing the in maxillary posterior alveolar ridge. Sinus lift procedure
risk for complications, bone graft loss, and even implant is usually indicated, whenever the residual bone reveals a
failure.7,8 Therefore, implantologists should pay special height of 10 mm or less in posterior maxilla.12 The two
attention to evaluate the anatomical and physiological surgical approaches that have been contemporarily used
status of maxillary sinus to ensure the readiness of to manage the atrophic posterior maxilla are (1) lateral
Schneiderian membrane for sinus lift surgery. window/direct approach and (2) osteotome transcrestal/
The controversy surrounding the minimal neces- indirect approach.
sary distance between the tip of implants and the floor The first lateral window procedure was performed
of maxillary sinus has drawn continuous debate. by Tatum13 in 1975. A window opening is created surgi-
Although there is no clear evidence that implants with cally in the lateral sinus wall followed by elevating the
tips placed within or with less than 1 mm away from the Schneiderian membrane to allow placing implant(s) of
sinus floor level would fail, the preference among clini- appropriate length. The use of lateral approach can
cians is to leave 1 to 2 mm of bone before the radio- increase the vertical bone height greater than 9 mm,
graphically estimated sinus floor level. which is necessary when we have large bone shortages.
To prevent the perforation of Schneiderian mem-
Survival Rates and Pre-Implant Residual brane, piezoelectric ultrasonic surgery has been intro-
Bone Height duced to provide safe membrane lifting and to support
In general, success rates are used to describe implants hand instrumentation during lateral window proce-
that have an ideal quality of health with marginal bone dure.14 The piezoelectric handpiece allows adequate
loss of less than 2 mm, while survival rates are used to bone removal while maintaining the integrity of sur-
describe implants that are stable in the mouth even rounding soft tissues (i.e., the Schneiderian membrane
with the presence of 2 to 4 mm of marginal bone loss.9 and PSAA).14,15 Although early results sound promising,
According to the Implant Quality of Health Scale further studies are still needed to prove evidently the
adopted by the International Congress of Oral clinical effectiveness of this innovative technique in
Implantologists, Pisa, Italy, Consensus Conference, sinus lift surgery.
2007, implant “satisfactory” survival is defined based on On the other hand, osteotome approach was first
the presence of the following four criteria: (1) absence used by Summers16 in 1994. A transalveolar elevation of
of pain on function; (2) absence of mobility; (3) less the maxillary sinus floor is performed to provide easier
than 4-mm radiographic marginal bone loss; and (4) surgical intervention, shorter surgical time, lesser com-
absence of peri-implant infection with suppuration.9 plications, and slighter morbidity as well as greater
Therefore, we prefer to use the survival rate as a clinical patient satisfaction. The use of osteotome approach can
indicator to describe the practical criterion of implant produce an approximate increase in vertical bone height
success. that ranges from 3 to 9 mm (Table 2).12,17–20
Based on the results of a multicenter retrospective Recently, several minimal invasive techniques have
study, whenever the pre-implant residual bone height been developed to enhance the outcomes of osteotome
decreases, the implant survival rate decreases.10 Most of approach, to provide less invasive surgical intervention,
this decrease in survival rate is expected when the pre- and to maximize patient satisfaction. The antral mem-
implant bone height is less than 5 mm.10,11 This brane balloon elevation (AMBE) is a minimally invasive
observed correlation between pre-implant residual technique used to elevate gradually the Schneiderian
bone height and survival rate reveals an important membrane while optimally maintaining its integrity. A
clinical point that requires further consideration when steady gentle pressure is applied to detach the mem-
we develop treatment plans for implants placed in brane when the latex balloon is inflated. This technique
posterior maxilla. is relatively safe with less postoperative bleeding, pain, or
4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

vertical bone height

Mean increase in TABLE 3 Sinus Lift Procedures Indicated in Posterior
Maxilla according to the Available Residual Bone

9.1 1 0.3 mm

3.2 1 1.5 mm
2.2 1 1.7 mm
2.5 1 1.8 mm
4.4 1 0.2 mm

8 1 1.5 mm
3.5 mm
10 mm
12.7 mm
9.1 mm
Height and the Amount of Postsurgical Increase in
Bone Height Needed

*
Residual bone Required increase
Intervention indicated height in bone height

Sinus lift procedure 210 mm >3 mm

>5 mm
Survival

Osteotome approach 3–9 mm

95.81%
91.4%
95.7%
97.3%
92.8%
97.1%
rate

25 mm >9 mm

100%

100%
94%
95%

100%
Lateral approach

discomfort.21,22 Longitudinal studies of large sample

≈2 years
Follow-up

3 years
≈2 years
3 years

≈1.5 years

5 years
3 years

13 years
2.5 years
duration

1 year
1 year

sizes are still needed to prove the clinical effectiveness

and prognosis of the AMBE.
Using the piezoelectric ultrasound surgical technol-
With and without

With and without

With and without

Bone grafting

ogy, Intralift™ technique has been developed recently to

simplify osteotome approach, allowing adequate sinus
Without

Without

Without
Without
Without

Without

lift while minimizing patient discomfort. TKW-5 tip,

With
With

which is a “trumpet” with non-cutting head, is used to

spray sterile irrigation that detach the Schneiderian
membrane by microcavitation.23 More importantly, this
Number of patients

* (1,197)

2,830 (4,388)

1,822 (3,131)

technique reduces notably the risk of perforation of

(implants)

34 (58)

40 (75)

20 (35)
30 (79)

32 (54)
36 (53)

53 (68)
24 (*)

Schneiderian membrane, because the surgical instru-

ments used in sinus lifting are less aggressive and
maintain the least physical contact with Schneiderian
membrane.23
Selecting the appropriate sinus lift surgical technique
evidence
Level of
TABLE 2 Effects of Sinus Lift Surgery in Vertical Residual Bone Height

II-3

II-3

II-3
II-3
II-3

II-3
II-3

II-3

is largely based on the height of pre-implant residual

I

bone. With a residual bone height of more than 5 mm,

the transcrestal approach is usually indicated; otherwise,
Systematic review

Systematic review

Systematic review
Study design

when the residual bone height is 5 mm or less, lateral

Retrospective

Retrospective
Prospective

Prospective
Prospective

Prospective
Prospective

Prospective

window approach is indicated (Table 3).16,20,24–26

Placing implants in posterior maxilla using thinner
drills can improve the primary implant stability, help in
*Number(s) not available or calculated because of data variability.

overcoming the poor quality of bone and, more impor-

Lateral 2 steps
Lateral 1 step

tantly, increase the survival rates of dental implants in

approach
Surgical

Osteotome

Osteotome
Osteotome

Osteotome
Osteotome
Osteotome
Osteotome

Osteotome
Osteotome

Osteotome

Osteotome

posterior maxilla.27 Rough surface implants with mem-

brane coverage of lateral window can provide higher
survival rates.28 We advise that sinus lift procedures
should remain simple, fast, and safe with low morbidity
Fermergard and Astrand (2012)12
Zitzmann and Schärer (1998)55

in order to maintain the highest patient satisfaction.

Leblebicioglu et al. (2005)19

Future studies should be directed toward eliciting

Del Fabbro et al. (2012)20
Emmerich et al. (2005)24

Schmidlin et al. (2008)57

patient preferences and their satisfaction following sinus

Bruschi et al. (2013)17
Winter et al. (2002)18

Nedir et al. (2009)58

lift surgery when different types of bone grafts or surgi-

Diss et al. (2008)56
Tan et al. (2008)25

cal approaches are implemented.

Study (year)

Sinus Bone Grafting

Autogenous bone graft taken from the same patient has
a long track of clinical success in sinus augmentation
 Recent Trends in Sinus Lift Surgery 5

due to its unique osteoconductive, osteogenic, and

The success of the procedure, its complications,

There was no significant difference between the

Implant success rate was not dependent on the

or implant survival is not dependent on the

No evidence of difference in clinical outcomes

osteoinductive properties.29 Although autogenous bone

TABLE 4 The Effect of Using Different Bone Graft Biomaterials on Implant Osseointegration and Marginal Bone Loss Following Sinus Augmentation
graft remains the “gold standard,” easier substitutes

between different bone graft materials.

biomaterial used for maxillary sinus

made of synthetic or bovine-derived bone grafts are
available for sinus augmentation.30–33 Neither implant

two types of bone graft used.

osseointegration nor marginal bone loss is dependent

Outcome

type of bone graft used.

on the type of bone graft used in sinus augmentation
(Table 4).32–35 Longitudinal randomized controlled trials
of large sample size are still needed to evaluate clinical

augmentation.
outcomes and efficacies between the different types of
bone grafting materials used in sinus augmentation.
Likewise, cost-effectiveness analysis or cost-utility analy-
sis is also needed to determine the most efficient sinus
bone graft material with the best implant survival

histomorphometric
rate.

Type of evaluation
Sinus augmentation can be enhanced by the clinical

radiographical

radiographical
Histological and
application of biologic modifiers and growth factors

Clinical and

Clinical and
mainly, recombinant human platelet-derived growth

Clinical
factor BB (rhPDGF-BB) and recombinant human bone
morphogenetic proteins (rhBMPs).36 Out of the trans-
forming growth factor-β family, rhBMPs (including

Biphasic calcium phosphate versus

beta-tricalcium phosphate graft
BMP-2, BMP-7, and growth differentiation factor 5) have
been widely used to prepare implant bed for osseoin-

deproteinized bovine bone

Type of bone graft

tegration, to accelerate wound healing, and to enhance Autogenous bone versus

regenerative activities in residual alveolar bone ridge.36
Different materials

Different materials
Despite their predictable therapeutic effects, the use
of rhBMPs should follow strict clinical guidelines.
rhBMPs should be applied in a pharmaceutical form
that assures a controlled and sustained release in order
to prevent any undesirable side effects, as these proteins
in very high doses can induce cancer.37 One of the
evidence
Level of

methods used to control rhBMP release is to have

I

I
I

rhBMP molecules contained within an absorbable col-

lagen sponge, which will be placed in the compartment
after lifting the Schneiderian membrane. Similar to
randomized control trial

rhBMPs, the use of rhPDGF-BBs is also suggested

Prospective randomized
Prospective multicenter

to improve the outcomes of sinus lift surgery and to

Study design

Systematic review

Systematic review

controlled trial

decrease patient morbidity; however, there is still a lack

of evidence to support the clinical efficacy and effective-
ness of using rhPDGF-BBs in sinus augmentation.
Platelet-rich plasma (PRP) has been used as a
potential source for growth factors that can accelerate
bone healing. Currently, there is no evidence to prove
Stelzle (2009)35

that using PRP in sinus lift surgery has positive enhance-

Lindgren et al.
Esposito et al.
Study (year)

Nkenke and

ments on bone graft healing, especially in terms of clini-

(2005)32

(2010)33

(2012)34
Szabo et al.
Surgery

cal outcomes and effectiveness.38,39

Mononuclear stem cells (MSCs), which are isolated
from human adult bone marrow, appear as a promising
6 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2014

bioactive material. MSCs induce bone formation in a

New bone formation occurs with or without grafting, but

way that mimics the clinical efficacy of autogenous bone

Bone formation occurs following sinus lift surgery with

Bone formation occurs after sinus lift surgery without

Osteotome without grafting is sufficient to create new

Bone formation can occur following sinus membrane
graft.40 In a randomized controlled split-mouth trial,

TABLE 5 Healing and Bone Formation at the Floor of Maxillary Sinus Following Membrane Elevation and Simultaneous Implant Placement Without

simultaneously placed dental implants without

“bovine bone mineral (BioOss®) seeded with MSCs har-

larger bone gain was recorded with grafting.

vested from the posterior iliac crest” improved evidently

Bone formation occurs without grafting.

bone formation after sinus lift surgery.41
On the other hand, several studies have intensified

Outcome
the debate over the necessity of bone grafting after

elevation without grafting.

sinus lift procedures, whether these procedures were
lateral window approach42–44 or osteotome transcrestal
approach45–47 (Table 5). Once the compartment is

bone formation.
created between the elevated Schneiderian membrane,
implant, and the osseous floor of the sinus, new bone

grafting.

grafting.
formation will spontaneously fill this compartment.
Further histological studies are needed to understand
the mechanisms of sinus bone healing without the pres-
ence of bone grafting, as well as longitudinal studies to

Type of evaluation

radiographical

radiographical

radiographical
Radiographical

Radiographical

Radiographical
evaluate the clinical prognosis of this newly formed

Clinical and

Clinical and

Clinical and
bone.

Perforation of Schneiderian Membrane

The perforation of Schneiderian membrane is one of the
Bone Grafting

most common sinus lift complications. This perforation

without
With and
Without
Without

Without

Without

Without
has an important impact on sinus integrity and can
compromise the bone graft survival. In a recent longi-
tudinal study of 359 sinus lift procedures, 7 out of every
10 failed sinus grafts were accompanied by a perforated
evidence
Level of

II-3
II-3

II-3

II-3

II-3
Schneiderian membrane during sinus lift surgery.48 The

I
sinus membrane perforation doubled noticeably the risk
for the incidence of sinusitis or infection.48 However,
both marginal bone loss around implant and sinus bone Prospective randomized
Study design

graft absorption were not increased by the perforation controlled trial

of Schneiderian membrane.49
Prospective
Prospective

Prospective

Prospective

Prospective

The management of perforated Schneiderian mem-

brane is performed intraoperatively depending primar-
ily on the location and size of perforation.50 Once the
perforation happened, implantologist should avoid
Surgical approach

Lateral window
Lateral window

Lateral window

applying any unnecessary pressure that could increase

Grafting in Sinus Lift Procedures

Osteotome

Osteotome

Osteotome

the size of perforation. In minor perforations, folding

the membrane on itself can be sufficient. Small perfora-
tions can be managed using a small collagen tape and a
bioabsorbable membrane. In large perforations, careful
Astrand (2008)45

suturing or application of fibrin adhesive should be con-

Fermergard and

Pjetursson et al.

sidered to close the perforation. Also, a bioabsorbable

Lundgren et al.
(2004)42

(2007)43

(2007)44

(2009)46

(2009)47
Hatano et al.
Study (year)

membrane should be placed only on the surface of

Nedir et al.
Thor et al.

sutured Schneiderian membrane.50 The walls of the

sinus are not covered in order to maintain continuous
blood supply to the bone graft.
 Recent Trends in Sinus Lift Surgery 7

To dodge the undesirable complications of sinus • Use a combination of autogenous and alternative
lift procedures, several studies explored placing bone grafts as needed.
nonconventional tilted, nasal, or zygomatic implants • Exert every effort to avoid the perforation of
without any bone grafting in atrophic posterior Schneiderian membrane.
maxilla.51–54 Although the primary outcomes are prom-
Although both osteotome and lateral window pro-
ising, longitudinal randomized controlled trials with
cedures can help clinicians in overcoming the challenges
larger sample size are still necessary to prove the efficacy
of placing implants in atrophic posterior maxilla,
of these innovative interventions.33
pre-implant residual bone height is crucial in determin-
Aside from the many benefits associated with the
ing the survival of these implants. Future research direc-
sinus lift surgery, there are also risks to consider from the
tions should consider study designs grounded on
perforation of Schneiderian membrane. Therefore, an
longitudinal randomized controlled trials of large
appropriate training on sinus lift surgery is mandatory
sample size.
to increase the clinical outcome and to control the
potential of complications. Keeping in mind that
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