Bone Formation after Sinus Membrane Elevation and

Simultaneous Placement of Implants without Grafting

Materials – A Systematic Review

Tamara Thulin

Kristina Mosally

Tutor prof. Stefan Lundgren

Umeå Universitet

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ABSTRACT

Background: Rehabilitation of the atrophied edentulous maxilla is complicated.

Often the residual bone height is insufficient for implant placement due to crestal

bone resorption and pneumatization of the sinus. The most common treatment has

been a two-stage surgery using autogenous or synthetic grafting materials placed in

the maxillary sinus before implant therapy. The sinus lift technique was introduced by

Boyne et al. (1980) and much research has been done to evaluate this technique where

the implants have been placed emerging into the sinus without grafting.

This paper consists of a review of the literature available on sinus membrane

elevation with simultaneous implant placement without the use of grafting materials

and a comparison between lateral approach sinus floor elevation (LASFE) and

osteotome sinus floor elevation (OSFE).

Materials & Methods: PubMed was used as database to search for articles. Also,

relevant journals and systematic reviews were evaluated. Clinical studies with sinus

lift without grafting materials with simultaneous implant placement were included. A

minimum of 6 months follow-up was an inclusion criteria. Experimental studies and

studies with less than ten implants were excluded.

Results: 22 articles were included, nine studies using LASFE and 13 using OSFE.

The implant survival rate was 98.9% and 97.9% respectively. The MBL was 0.4 –

2.1±0.5 mm for LASFE and 0.2±0.8 – 1.4±0.2 mm for OSFE. New bone formation

was 1.7±2.0 – 7.9±3.6 mm and 2.2±1.7 – 4.5±1.9 mm respectively.

Conclusion: This review shows that grafting materials are not necessary to achieve a

high implant survival rate. Some advantages with the less invasive non-grafting

method are a decreased patient discomfort and a shorter treatment time.

Both LASFE and OSFE without grafting have good outcomes. The surgeon should

choose technique considering personal experience and the individual patient situation.

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INTRODUCTION

Tooth loss can be caused by dental caries and periodontal disease, but also by trauma

and other diseases in the oral cavity (Lesolang et al., 2009). The loss of teeth results

in a resorption of the alveolar crestal bone and in the posterior maxilla in some cases

it also triggers the maxillary sinus to expand (Sharan and Madjar, 2008). The crestal

bone resorption in combination with the pneumatisation of the maxillary sinus leads

to a reduced alveolar bone height in the posterior maxilla (Borges et al., 2011).

Implant therapy is a common way of rehabilitating this area. However, to achieve

good primary and secondary implant stability, the treatment is dependent on a certain

amount of crestal bone to be successful (Corbella et al., 2013). Therefore, different

methods have been practiced to reconstruct the edentulous maxilla with a severely

resorbed crestal bone height with implant therapy.

One treatment method is to increase the volume of the bone by either grafting the area

with synthetic or allogen bone, or to use an autogenous transplant. This is a two-stage

method and was introduced by Tatum (1977) and Boyne et al. (1980) among others.

The graft is, after surgery, left to heal and controlled by radiographs before replacing

lost teeth with implants.

Unfortunately, harvesting autogenous bone often causes much discomfort for the

patient and is also related to several risks. One risk is morbidity in the area where the

graft is harvested. Other risks are postoperative bleeding and increased risk for

infection (Boffano and Forouzanfar, 2014). Furthermore, cases of acute maxillary

sinusitis have been reported (Alkan et al., 2008) and also cases of hematomas,

disturbed wound healing and sequestration of bone in the sinus (Timmenga et al.,

2001). A disadvantage using non-autogenous grafting materials such as BioOss;

derived bovine bone, which is very similar to human bone, is the cost. Since the

rehabilitation of the edentulous maxilla with implants is already an expensive

treatment, using grafting materials will add to the cost resulting in a greater financial

burden for the patient (Thor et al., 2007). Treating the edentulous maxilla without

bone grafting would have certain benefits such as a shorter overall treatment time,

more cost efficiency and a less invasive procedure.

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Some studies have shown that placement of the implant in to the sinus without

grafting materials can stimulate new bone formation in the sinus cavity (Lundgren et

al., 2004). This is possible when a blood clot is isolated in an enclosed space, where

the grafting materials usually is placed. The blood cells induce new bone formation

by stimulating the bone precursor cells to evolve to osteoclasts. The activated

osteoclasts in their turn activate the bone forming osteoblasts to start producing bone

(Borges et al., 2011). Two techniques have been identified; the lateral technique

(LASFE) and the osteotome technique (OSFE).

With the lateral technique a window is opened in the lateral sinus wall (Figure 2) into

the maxillary sinus with care taken to avoid tearing of the sinus membrane. The sinus

membrane is then carefully dissected off the bone walls and held up while the implant

is placed into the sinus cavity through the alveolar crest. The sinus membrane, also

called the Schniderian membrane, is then positioned to rest on the implant, which will

function as a tent pole. The bony wall is replaced and the mucoperiost flap is sewed

back at its place (Lundgren et al., 2004). The membrane, the sinus floor and the

lateral wall form an enclosed space for the blood clot, which stimulates new bone

formation.

The osteotome technique is based on a crestal approach (Figure 3). This technique is

described in a report by Bruschi et al. (1998). The incision is made on the alveolar

crest and the implant preparation in the bone is made with a regular implant drill.

Different osteotomes are then used to elevate the Schniderian membrane on the sinus

floor through the prepared entrance. When the implant is placed, it lifts the membrane

and holds it up with the aim to keep the membrane intact. All implants have a flat-top

design which reduces the risk of perforating the Schniderian membrane when placing

the implant. However, perforations can be caused while dissecting the membrane

from the bone wall in the sinus if the surgeon is incautious.

In events where the membrane is perforated the size of the perforation decides

whether it needs to be repaired or can be left to heal (Thor et al., 2007). Some studies

have shown that sinus membrane perforations have no impact on the implant survival

rate if treated appropriately. Apart from the membrane perforation, there is no other

evidence of long-term implant or sinus-related complications after sinus elevation

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with simultaneous implant placement when using either the osteotome or the lateral

technique (Al-Almaie et al., 2013).

The residual bone height at the implant placement site is of great importance when

choosing implant length when using both OSFE and LASFE techniques. A lower

RBH requires a shorter implant. According to Fenner et al. (2009), a more predictable

osseointegration is attained if the RBH is higher than 6 mm, although RBH lower than

4 mm did not hinder osseointegration of the implant. Implants placed at sites with a

lower RBH than 6 mm had more failures. Also, the crestal bone loss was significantly

lower at sites where the RBH was higher than 8 mm.

When an implant is installed, there is always some loss of crestal bone at the implant

site. This phenomenon is called “crestal bone loss”. There are no full investigations of

the factors that cause this bone loss but plaque accumulation around the abutment has

been discussed, as well as subgingival placement of the implant abutment interface

(Barboza et al., 2002). In cases where the crestal bone loss is high this can lead to

implant failure.

Different methods can be used when evaluating the stability of a dental implant. To

evaluate the primary stability of the implant, the resonance frequency analysis (RFA)

can be used. Using RFA, the level of osseointegration of the implant is measured. A

transducer is connected to the implant, which produces a vibration at the abutment

site. The vibration that appears in the implant is then analyzed and translated into an

ISQ (implant stability quotient) value (Meredith et al., 1997). ISQ values for implants

that are successfully integrated range from 57 to 82 (Park et al., 2011; Degidi et al.,

2012).

The insertion torque is another method to evaluate primary implant stability. The

torque value is a measurement of the bone quality at the implant site, the cutting

ability of the implant and the friction between the implant surface and the bone. The

torque value is measured in Newton. The insertion torque is measured continuously

whilst inserting the implant. Good bone quality, high friction between the implant and

the bone and a wide diameter of the implant compared to the prepared bone site are

factors that result in a high insertion torque. A high insertion torque signifies good

primary stability of the implant (Park et al., 2011).

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A method to evaluate the secondary implant stability is to measure the mean bone

gain on the sinus floor. The bone height is measured at baseline and thereafter at

different follow-up periods. The bone gain or loss is then possible to calculate. For

these measurements different radiographs are needed. Intraoral radiographs can be

used, although it can be difficult to compare bone height at baseline and at follow-up

as this requires that the radiographs are taken from exactly the same angle. With the

use of a CBCT the precision of the measurements is much higher. Also, it allows for a

3D-analysis of the sinus structures (Fornell et al., 2012).

Implants can be either tapered or not. There are also different implant surfaces to

choose from when planning the implant treatment. Some implants are smooth-

surfaced whilst other are rough on the surface. Rough implant surfaces can be

achieved by blasting, acid etching or using different coatings (Cochran DL, 1999).

The implant shape and surface can have an impact on the implant stability and the

amount of new bone formation, which is reflected on in the discussion.

The aim of this study is to investigate the bone formation in the sinus elevation

procedure without the use of grafting materials and simultaneous placement of

implants. It also intends to compare the lateral and the osteotome techniques, to

discuss which of the methods is more preferable and to evaluate the clinical outcome

of the method for sinus membrane elevation with simultaneous implant placement

without the use of grafting materials.

MATERIALS & METHODS

PubMed is a database containing scientific articles, primarily on life science and

biomedical topics. This database was used to search for published articles about the

sinus lift procedure. Different key words were used such as “sinus floor elevation”,

“osseointegration” and “maxillary sinus”. The key words were inserted in the

PubMed search-builder as medical subject headings (MeSH). MeSH-terms are used

when searching for scientific articles as a thesaurus to facilitate the search process.

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Search strategy:

The first search was to find MeSH-terms related to our subject. The MeSH-terms

found and used for further searching were; ”paranasal sinuses”, ”membranes”,

”osteogenesis”, ”dental implants”, ”maxillary sinus”, ”sinus elevation”,

”osseointegrated implants”, ”maxillary sinus floor augmentation”, ”bone formation”,

”sinus membrane”, ”sinus membrane lift” and ”implant therapy”. These MeSH-terms

were combined in different constellations and used in the PubMed search builder. The

combinations used were:

“paranasal sinuses” AND “membranes” AND ”osteogenesis” AND ”dental

implants”

”dental implants” AND ”maxillary sinus” AND “membranes”

“osteogenesis” AND “paranasal sinuses”

“osteogenesis” AND “maxillary sinus” AND “dental implants”

These combinations yielded 413 articles.

The advanced search function in PubMed was also used. Here, the search was

restricted to only “Title/Abstract” in the builder field. The following combinations

were used:

“sinus elevation” AND “dental implants”

“osseointegrated implants” AND “maxillary sinus”

“maxillary sinus floor augmentation” AND “bone formation” AND “sinus

membrane”

“maxillary sinus” AND “sinus membrane elevation” AND “bone formation”

AND “dental implants”

These combinations yielded 72 new articles.

The language of the studies in the search was restricted to English.

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Defining the criteria

Some articles were directly excluded after reading only their titles, as they were not

relevant to the subject. Abstracts of the articles not excluded at the first stage were

read. Thereafter further articles were excluded based on irrelevance. At this stage

there were 51 articles left, and the inclusion and exclusion criteria were defined.

Inclusion criteria

Studies on sinus elevation with and without bone graft were considered. Also, studies

on implants placed in the maxillary sinus regardless of number of implants placed in

the same sinus were considered. Studies made on less than ten implants were

excluded as well as studies with a follow-up period of less than 6 months. Studies on

sinus elevation without simultaneous implant placement were not relevant for this

review and were also excluded, as were experimental studies.

Twenty-five articles were included for full-text reading. After reading these, three

more articles were excluded, as they did not fulfill the inclusion criteria.

After summarizing all articles, a table for the results was made in excel. All data was

inserted in the tables.

Level of evidence

There are different levels of scientific evidence in studies depending on how a study

is designed (Figure 1). The highest level of evidence is a meta-analysis. A meta-

analysis is a statistical method, where the results from different independent original

studies are pooled together. All the studies have the same hypothesis and the same

study design, with the aim to identify patterns and differences of different treatments.

The second highest level of evidence is a systematic review. It differs from the meta-

analysis in the presentation of the studies included. A search strategy is presented for

others to replicate the search and find the same articles. Also, inclusion criteria are

defined to narrow the search. In a systematic review the included studies are

presented individually in a table or a graph (Uman, 2011). When a systematic review

results in several articles with comparable outcomes, a meta-analysis can be made.

The highest level of evidence in an original study is a randomized controlled trial

(RCT) (Bolton, 2001). The study is designed to decrease the risk of bias as the

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participants are randomized into either a test-group or a control group without

knowing which group they belong to. This study design is called a blinded study.

Sometimes RCTs are double-blinded which has an even higher level of evidence. The

clinicians in a double-blinded study are not aware of which participants belong to

which group (Si et al., 2013).

This paper is a systematic review. Due to the different study designs in the included

articles, a meta-analysis could not be made. Of the 22 studies included we had three

randomized controlled trials (RCT), five prospective studies, four retrospective

studies, one case-series report and one follow-up study. In eight of the clinical studies

the study type was not defined. Since this review includes three RCTs, the evidence

level is high (Ib). The highest evidence level (Ia) is reached when including a meta-

analysis of randomized controlled trials, which was not the case in this review

(Shekelle et al., 1999).

Ethical considerations

Since this paper is a systematic review and is based on previous patient studies, there

were no ethical dilemmas in the compilation of the patient data.

RESULTS

A summary of the article selection is shown in Figure 4. After the first search, 51

articles were selected for abstract reading. Thereafter, 25 articles were applicable to

the inclusion criteria. All 25 articles were read in full-text, which lead to an exclusion

of another three articles leaving a total of 22 articles included in this review.

A compilation of all data is presented in Table 1. The studies are divided into two

different tables presenting the different techniques used when elevating the sinus

membrane; LASFE (lateral approach sinus floor elevation) (Table 2) and OSFE

(osteotome sinus floor elevation) (Table 3).

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LASFE

The studies on LASFE are presented in Table 2. Here, a total of nine articles were

included. Two of these were comparative studies of implant installation with and

without grafting in the sinus. The articles studied included a total of 618 implants

placed in sinuses with simultaneous elevation using the lateral technique. Implant

length varied from 9 to 18 mm and the mean residual bone height (RBH) ranged from

4,0 to 7.5±2.2 mm. The mean follow-up time was 23 months with 6 months as the

shortest follow-up time and 5 years as the longest. Marginal bone loss (MBL) was

measured in four of the studies and varied from 0.4 to 2.1±0.5 mm. Bone regeneration

was detected in all studies ranging from 1.7±2,0 to 7.9±3.6. In cases where ISQ was

registered the implants showed good primary stability. Sinus perforations were noted

in three of the studies. The mean implant survival rate was 98.9%.

OSFE

The studies on OSFE are presented in Table 3. Here, a total of 13 articles were

included. Three of the studies compared sinus elevation with and without grafting.

Altogether 542 implants placed using no grafting materials were studied in the

articles. Implant length varied from 6,0 to 14.5 mm and the mean RBH ranged from

2.4±0.9 to 10.4±0.7 mm. The shortest follow-up time was 9 months and the longest

was 5 years, resulting in a mean follow-up time of 23.3 months. After implant

installation the MBL was measured and ranged from 0.2±0.8 to 1.4±0.2 mm, although

this was not measured in two of the studies. Similar to the LASFE technique new

bone formation (NBF) was detected and registered ranging from 2.2±1.7 to 4.5±1.9

mm. In two of the studies NBF was not measured but the results were predictable.

Sinus perforations were noted in seven of the studies (Table 3). All studies together

had an overall mean survival rate of 97.9%.

DISCUSSION

This systematic review, where sinus membrane elevation with simultaneous implant

placement without the use of grafting materials has been studied, shows that a high

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implant survival rate can be achieved without grafting materials (Table 1). New bone

formation around the implant in the sinus cavity can be predicted using either LASFE

or OSFE (Table 2 and 3).

Comparing the two techniques, LASFE and OSFE, this review shows that the

marginal bone loss was greater using the LASFE technique. Using the LASFE

technique the MBL varied from 0.4 to 2.1±0.5 mm, whereas with the OSFE technique

the MBL varied from 0.2±0.8 to 1.4±0.2 mm. Since the LASFE technique requires a

mucoperiostal flap and is more invasive than the OSFE technique, the expected

inflammation during healing is greater than the inflammation after implant placement

with OSFE. This inflammation can cause a more pronounced bone resorption, which

may explain why the MBL was greater in the studies where LASFE technique was

used.

However, the LASFE technique yielded more new bone formation (7.9±3.6 mm) than

the OSFE technique (4.5±1.9 mm). The dissection of the Schneiderian membrane

from the sinus wall using LASFE technique may yield a larger space for the blood to

accumulate than the space using OSFE technique. A greater amount of blood cells can

result in a higher activation of osteoclasts, which eventually leads to more osteoblast

stimulation, and hence, more new bone formation. The survival rates between the two

techniques were nevertheless comparable.

Perforations of the Schneiderian membrane were not presented in all the studies

(Table 1). Still perforations were observed using both techniques. Smaller

perforations did not seem to affect the implant survival rate (Schmidlin et al., 2008).

Implants in sinus cavities with larger perforations, however, were often excluded from

the studies (Si et al., 2013), meaning that large membrane perforations could have a

negative impact on the implant survival rate.

The OSFE technique seems to be the most comfortable option from a patient point of

view (Nedir et al., 2013). The technique is less invasive and no mucoperiostal flap is

needed, thus the patient discomfort, implant healing time and postoperative pain are

most likely decreased. The disadvantages with the OSFE technique could be a limited

view of the operation field, which can lead to unnoticed accidental membrane

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perforations resulting in a lower survival rate. Also, the OSFE technique makes it

difficult to repair eventual perforations of the sinus membrane.

Using the LASFE technique, the surgeon has a better view of the operation field.

Dissection of the Schneiderian membrane is easier and perforations of the membrane

can easily be noticed and repaired when occurring. Since this technique is more

invasive it is also more technique sensitive and more dependent on the surgeons

skills. Also, the postoperative discomfort for the patient is greater due to the necessity

of a mucoperiostal flap and additional drilling in the bone when creating the lateral

window.

When using grafting materials, the golden standard is to use autogenous bone, which

is correlated with donor-site morbidity, uncontrolled resorption and limited

availability (Borges et al., 2011). However, Nedir et al. (2013) concluded that the use

of grafting materials resulted in a greater bone gain, although it was not a prerequisite

for new bone formation. The study by Lai et al. (2010) showed that the use of grafting

materials had no significant impact on the implant survival rate compared to sinus

elevation without grafting materials, but the grafting material could be used to

maintain the space under the Schneiderian membrane. This review shows that there is

no need for grafting materials to achieve a predictable result with good implant

survival and new bone formation. Also, using the LASFE and OSFE techniques

without grafting materials can reduce additional treatment cost and greater patient

discomfort can be avoided.

The influence of the implant shape and surface on new bone formation and implant

stability has been discussed in some of the articles included in this review. According

to Nedir et al. (2013) the use of tapered implants gave better primary stability and less

crestal bone loss than non-tapered implants. Moreover, the tapered shape of the

implant could prevent the implant from sinking into the sinus when loaded (Kim et

al., 2013). Cochran (1999) concluded that a rough implant surface lead to a better

contact between the bone and the implant compared to smooth surfaces. Still,

Cochrane also reached the conclusion that both smooth and rough titanium implants

could achieve high success rates, as well as hydroxyl apatite-coated implants.

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The choice of technique between LASFE and OSFE has been dependent on the

residual bone height. Some authors (Corbella et al., 2013, Pjetursson et al., 2009)

have shown that the OSFE technique is the method of choice when RBH is greater

than 5 mm and dissuade the use of OSFE when the RBH is less. The limited view of

the operation field has been discussed as a disadvantage with the OSFE technique as

it demands a more experienced surgeon to achieve a successful treatment result if

RBH < 5 mm. The LASFE technique has been the recommended technique when

RBH < 5 mm as it facilitates the implant placement thanks to a better view of the

operation field (Corbella et al., 2013). However, Nedir et al. (2013) showed that the

osteotome technique could be used even in severely atrophic maxilla with good

outcome.

It seems to be more convenient to use OSFE when RBH is > 5 mm, but Nedir et al.

(2009, 2013) and Al-Almaie (2013) have shown that OSFE is also applicable in cases

where RBH < 5 mm. This implies that there is no correlation between RBH and

choice of technique. If this is the case, LASFE technique should be used only in cases

where a good view of the operation field is required, since this method is more

invasive and causes more patient discomfort than OSFE. However, the surgeon

should always consider his or hers experience and knowledge before choosing

technique and also take into consideration the number of implants intended to be

placed in the same sinus. The LASFE technique can be preferable when placing

numerous implants, as the view of the operation field is more favorable.

The correlation between implant survival rate and RBH has been discussed in many

articles. In a study by Lai et al. (2010) there was no significant difference in survival

rate with implants placed in sites with RBH < 4 mm and implants placed in sites with

a greater RBH. However, Pjetursson et al. (2008) reported that the implant survival

rate was significantly lower in sites with RBH < 4 mm. This was also shown earlier in

a study by Rosen et al. (1999) where the survival rate dropped from 96% to 85.7%

when RBH was < 4 mm. A study made by Summers (1998) showed similar results,

where two out of six implants placed in sites with RBH lower than 4 mm where lost.

In conclusion, the implant survival rate can be affected by many different factors and

RBH cannot be singled out as the only factor for implant survival.

Some authors have shown in their studies that the RBH can affect the outcome of

NBF as the new bone formation is dependent on the amount of pressure that the

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crestal bone is exposed to during implant installation. The pressure is measured in

microstrains. According to Kim et al. (2013), the bone formation is greater than the

bone resorption when the pressure on the bone is between 1500 and 3000

microstrains, which will result in a more pronounced NBF. However, microstrains

ranging from 50 to 1500 result in equilibrium between bone formation and bone

resorption, leading to a less pronounced NBF. Kim et al. (2013) and Balleri et al.

(2010) have both shown in their studies that RBH < 5 mm resulted in greater NBF

than in sites with RBH > 5 mm. In sites with RBH < 5 mm the occlusal load was in

the range favourable for new bone formation. A thicker bone (> 5 mm RBH) is more

tolerate to pressure, hence the load will not be enough to reach microstrains favorable

to new bone formation.

In this systematic review, there was no significant difference in implant survival rate

between implants placed in sites with RBH < 4 mm and implants placed in sites with

RBH > 4 mm. Also, a more reduced RBH may result in greater NBF. However, there

are yet relatively few publications on LASFE and OSFE compared to the traditional

two-stage technique involving grafting materials.

Conclusion

Both LASFE and OSFE without the use of grafting materials have good outcomes and

are predictable. The advantages with these graftless techniques are many. For one,

they are less invasive as no graft needs to be harvested in another area of the body,

which leads to less morbidity and a decreased risk for complications. Also, the overall

treatment time is shorter and the techniques are more cost effective compared to the

traditional technique using grafting materials. The implant survival rates are high and

there is no need for grafting materials to achieve new bone formation. The surgeon

should choose technique, LASFE or OSFE, considering personal experience and

knowledge and also take into account the individual patient situation.

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ACKNOWLEDGEMENTS

We would like to thank our supervisor professor Stefan Lundgren for guidance and

help throughout this process. He has been helpful and supportive whenever we have

encountered obstacles during the compilation of this review. We would also like to

thank Sofia Lundgren for providing us with information that facilitated our work

process.

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Artikel Year Study Type No. of

Patients No. of

Implants Technique w/wo graft Mean RBH (mm)

Mean Follow-up (months)

Implant Length (mm) MBL (mm) NBF (mm) ISR Perf

Balleri P 2010 Clinical 15 28 LASFE wo 6.2 12 11-15 0.4 5.5 100% 20%

Borges FL 2011 Pros RCT 17 28 LASFE w/wo 5.9±2.9 6 15-18 8.3±2.6/7.9 ± 3.6 96,4%

Cricchio G 2013 Case series report 10 21 LASFE wo 4.4±1.5 24 11.5-13 1.3 6.3±3.3 100% 0%

Cricchio G 2011 Follow-up 84 189 LASFE wo 5.7±2.3 26 13 1.3±0.7 5.2±2.1 98,7% 11,5%

Fermergård R 2008 Retro 36 53 OSFE wo 6.3±0.3 12 9-13 0.4±0.1 96%

Fermergård R 2012 Retro 36 53 OSFE wo 6.3±0.3 36 9-13 0.5±0.1 94%

Fornell J 2012 Pros 14 21 OSFE wo 5.6±2.1 12 10 None 3±2.1 100% 0%

Lai HC 2010 Clinical 202

89/191 OSFE w/wo 4.7±2.1/5.6±2.5 9 6-12 1.2±0.5 2.7±0.9 95,7% 4,3%

Leblebicioglu B 2005 Clinical 40 75 OSFE wo 7 ±1.3 (29)/10.4±0.7(46) 24 11,0±1.7/ 13.5±1.1 3.9±1.9/2.9±1.2 97,3% 3,7%

Lin IC 2011 Clinical 44 80 LASFE wo 5.1±1.5 60 12-15 2.1±0.5 7.4±1.9 100%

Lundgren S 2004 Clinical 10 19 LASFE wo 7±3 12 10-15 Yes 100%

Nedir R 2009 Pros pilot 17 25 OSFE wo 5.4±2.3 36 6 -10 0.9±0.8 3.1±1.5 100% 16%

Nedir R 2013 Pros RCT 12 37 OSFE w/wo 2.4 ±0.9 12 8 0.4±0.7 /0.6±0.8 5.0±1.3/3.9±1.0 90%/100% 0%

Nedir R 2009 Clinical 32 54 OSFE wo 3.8±1.2 12 8-10 0.2±0.8 2.5 ±1.7 100% 9,3%

Nedir R 2010 Prospective 17 25 OSFE wo 5.4±2.3 60 6-10 0.8±0.8 3.2±1.3 100% 16%

Nedir R 2006 Prospective pilot 17 25 OSFE wo 5.4±2.3 12 10 1.2±0.7 2.5±1.2 100% 16%

Pjetursson BE 2009 Clinical 181

88/164 LASFE w/wo 7.5± 2.2 36 4.1 ±2.4/1.7 ±2 97,4% 10,8%

Rajkumar GC 2013 Prospective 28 45 LASFE wo 4-7.5 24 1.2 4.1±1.0 100%

Schleier P 2008 Descriptive retro 30 62 OSFE wo 7.3±3.1 24 10-14 1.5 4.5±1.9 94% 4,8%

Schmidlin PR 2007 Retro 24 24 OSFE wo 5±1.5 17.6±8.4 8.6±1.3 M2.2±1.7/ D2.5±1.5 100% 8,3%

Si MS 2013 RCT 45 21/20 OSFE w/wo 4.6±1.3 36 6-10 1.3 ± 0.5/ 1.4 ± 0.2 3.2±2,0/ 3.1±1.7 95,1% 6,7%

Thor A 2007 Clinical 20 44 LASFE wo 4.6 27.5 9-15 6.5 ± 2.4 97,7% 41%

Table 1: A compilation of the 22 articles. W/wo = with/without graft; all data in orange represent cases with graft. RBH = residual bone height, MBL = marginal bone loss, NBF =

new bone formation, ISR = implant survival rate, perf = number of perforations of the Schneiderian membrane. Numbers in red mark patients and data where grafting materials

have been used.

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Artikel Year Study Type No. of

Patients No. of Implants Technique w/wo graft Mean RBH

(mm) Mean Follow-up (months)

Implant Length (mm) MBL (mm) NBF (mm) ISR Perf

Balleri P 2010 Clinical 15 28 LASFE wo 6.2 12 11-15 0.4 5.5 100% 20%

Borges FL 2011 Pros RCT 17 28 LASFE w/wo 5.9±2.9 6 15-18 8.3±2.6/7.9±3.6 96,4%

Cricchio G 2013 Case series report 10 21 LASFE wo 4.4±1.5 24 11.5-13 1.3 6.3±3.3 100% 0%

Cricchio G 2011 Follow-up 84 189 LASFE wo 5.7±2.3 26 13 1.3±0.7 5.2±2.1 98,7% 11,5%

Lin IC 2011 Clinical 44 80 LASFE wo 5.1±1.5 60 12-15 2.1±0.5 7.4±1.9 100%

Lundgren S 2004 Clinical 10 19 LASFE wo 7±3 12 10-15 Yes 100%

Pjetursson BE 2009 Clinical 181 88/164 LASFE w/wo 7.5±2.2 36 4.1±2.4/ 1.7±2 97,4% 10,8%

Rajkumar GC 2013 Prospective 28 45 LASFE wo 4-7.5 24 1.2 4.1±1.0 100%

Thor A 2007 Clinical 20 44 LASFE wo 4.6 27.5 9-15 6.5±2.4 97,7% 41%

Table 2: A compilation of studies made using the lateral approach sinus floor elevation technique. W/wo = with/without graft; all data in orange represent cases with graft. RBH =

residual bone height, MBL = marginal bone loss, NBF = new bone formation, ISR = implant survival rate, perf = number of perforations of the Schneiderian membrane. Numbers

in red mark patients and data where grafting materials have been used.

Artikel Year Study Type No. of

Patients No. of Implants Technique w/wo graft Mean RBH

(mm) Mean Follow-up (months)

Implant Length (mm) MBL (mm)

NBF (mm) ISR Perf

Fermergård R 2008 Retro 36 53 OSFE wo 6.3±0.3 12 9-13 0.4±0.1 96%

Fermergård R 2012 Retro 36 53 OSFE wo 6.3±0.3 36 9-13 0.5±0.1 94%

Fornell J 2012 Pros 14 21 OSFE wo 5.6±2.1 12 10 None 3±2.1 100% 0%

Lai HC 2010 Clinical 202 89/191 OSFE w/wo 4.7±2.1/ 5.6±2.5 9 6 -12 1.2±0.5 2.7±0.9 95,7% 4,3%

Leblebicioglu B 2005 Clinical 40 75 OSFE wo 7±1.3(29)/

10.4±0.7(46) 24 11±1.7/ 13.5±1.06 3.9±1.9/2.9±1.2 97,3% 3,7%

Nedir R 2009 Pros pilot 17 25 OSFE wo 5.4±2.3 36 6-10 0.9±0.8 3.1±1.5 100% 16%

Nedir R 2013 Pros RCT 12 20/17 OSFE w/wo 2.4±0.9 12 8 0.4±0.7/ 0.6±0.8 5.0±1.3/3.9±1.0 90%/100% 0%

Nedir R 2009 Clinical 32 54 OSFE wo 3.8±1.2 12 8-10 0.2±0.8 2.5 ±1.7 100% 9,3%

Nedir R 2010 Prospective 17 25 OSFE wo 5.4±2.3 60 6-10 0.8±0.8 3.2±1.3 100% 16%

Nedir R 2006 Prospective pilot 17 25 OSFE wo 5.4±2.3 12 10 1.2±0.7 2.5±1.2 100% 16%

Schleier P 2008 Descriptive retro 30 62 OSFE wo 7.3±3.1 24 10-14 1.5 4.5 ±1.9 94% 4,8%

Schmidlin PR 2007 Retro 24 24 OSFE wo 5.0±1.5 17.6±8.4 8.6±1.3 M2.2±1.7 / D2.5±1.5 100% 8,3%

Si MS 2013 RCT 45 21/20 OSFE w/wo 4.6±1.3 36 6-10 1.3±0.5/ 1.4±0.2 3.2±2,0/ 3.1±1.7 95,1% 6,7%

Table 3: A compilation of studies made using the osteotome sinus floor elevation technique. W/wo = with/without graft; all data in orange represent cases with graft. RBH = residual bone

height, MBL = marginal bone loss, NBF = new bone formation, ISR = implant survival rate, perf = number of perforations of the Schneiderian membrane. Numbers in red mark patients

and data where grafting materials have been used.

Figure 1: Level of evidence of different study types.

Figure 2: Illustration of the lateral technique in five steps. A bone window is removed from the lateral

wall of the sinus. The Schneiderian membrane is carefully dissected from the sinus floor. The implant

is then placed emerging into the sinus cavity with care taken not to perforate the membrane. The bone

window is put back and a blood clot is isolated in the enclosed space. After the follow-up time new

bone formation is detected.

Figure 3: Illustration of the osteotome technique in six steps. A hole is drilled in the crestal bone. An

osteotome is inserted through the hole and used to dissect the Schneiderian membrane from the sinus

floor. The implant is then placed emerging into the sinus cavity with care taken not to perforate the

membrane. A blood clot is isolated in the enclosed space. After the follow-up time new bone formation

is detected.

26

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Figure 4: A summary of the article search process.