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As implant dentistry developed, it became more evi- the maxillary sinus floor using the closed technique
dent that the posterior maxillary region was often to provide sufficient quantity of bone for the place-
limited for standard implant placement because the ment of dental implants.
residual vertical bone height was often substantially A transalveolar approach for sinus floor elevation,
reduced as a result of the presence and pneumatiza- with subsequent placement of implants, was first sug-
tion of the maxillary sinus. Several treatment options gested by Tatum, in 1986 (32). A ‘socket former’ for
have been used in the posterior maxilla to overcome the selected implant size was used to prepare the
the problem of inadequate bone quantity. The most implant site. A greenstick fracture of the sinus floor
conservative treatment option would be to place was accomplished by hand tapping the ‘socket for-
short implants to avoid entering the sinus cavity. mer’ in a vertical direction. After preparation of the
However, for the placement of even short implants, implant site, a root-formed implant was placed and
there is still a need for at least 6 mm of residual bone allowed to heal in a submerged manner.
height. Another way of avoiding grafting the maxillary Summers (30) later described a different transalve-
sinus would be to place tilted implants mesially or olar approach using a set of tapered osteotomes with
distally to the sinus cavity if these areas have ade- increasing diameters (Fig. 1). This concept was
quate bone. Furthermore, extra-long zygomatic intended to increase the density of soft (type III and
implants may be placed in the lateral part of the zygo- type IV) maxillary bone, resulting in better primary
matic bone. However, elevation of the maxillary sinus stability of inserted dental implants. Bone was con-
floor is considered as the treatment for solving this served by this osteotome technique because there
problem. was no drilling. Adjacent bone was compressed by
Elevation of the maxillary sinus floor was first pushing and tapping as the sinus membrane was ele-
reported by Boyne in the 1960s. In 1980, Boyne & vated. Then, autogenous, allogenic or xenogenic
James (3) described elevation of the maxillary sinus grafts were added to increase the volume below the
floor in patients with large, pneumatized sinus cavi- elevated sinus membrane.
ties as a preparation for the placement of blade Currently, two main techniques of sinus floor ele-
implants. The authors described a two-stage proce- vation for dental implant placement are in use. The
dure: in the first stage, the maxillary sinus was grafted first is a two-stage technique with a lateral window
using autogenous particulate iliac bone; and, in the approach, followed by implant placement after a
second stage (approximately 3 months later), blade healing period, and a one-stage technique using
implants were placed and later used to support fixed either a lateral or a transalveolar approach. The sec-
or removable reconstructions (3). Such a one- or a ond is the transalveolar approach, also referred to as
two-stage sinus floor elevation with a lateral window ‘osteotome sinus floor elevation’, the ‘Summers tech-
approach is, however, a relatively invasive treatment nique’ or the ‘Crestal approach’, which may be con-
option. sidered as more conservative and less invasive than
In patients with appropriate residual bone height, the conventional lateral approach. In this technique a
augmentation of the sinus floor can also be accom- small osteotomy is performed through the alveolar
plished via transalveolar approach using the osteo- crest of the edentulous ridge at the inferior border of
tome technique (11, 26, 30). The problem of the maxillary sinus. This intrusion osteotomy elevates
inadequate bone height can be overcome by elevating the sinus membrane, thus creating a ‘tent’ and
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Transalveolar sinus floor elevation
allowing for sufficient primary stability of the implant. Using a surgical stent or a distance indicator, the
In addition, an oblique sinus floor (> 45 inclination) implant positions are marked on the alveolar crest
is not suitable for the osteotome technique (Fig. 2). with a small round bur (#1). After locating the
The reason for this is that the osteotomes first enter implant positions exactly, the opening of the prep-
the sinus cavity at the lower level of an oblique sinus arations are widened with two sizes of round burs
floor, whilst still having bone resistance on the higher (#2 and #3) to a diameter about half a millimeter
level. In this situation, there is a high risk of perforat- smaller than the implant diameter intended
ing the sinus membrane with the sharp margin of the (Fig. 3).
osteotome. Absolute local contraindications for sinus The distance from the crestal floor of the ridge to
floor elevation are: acute sinusitis; allergic rhinitis the floor of the maxillary sinus, measured before
and chronic recurrent sinusitis; scarred and hypo- implant site preparation on the pre-operative
functional mucosae; local aggressive benign tumors; radiograph, may, in most cases, be confirmed at
and malignant tumors. the time of surgery by penetrating the opening of
the preparation with a blunt periodontal probe
through the soft trabecular bone (type III or type
Surgical technique IV bone) to the floor of the maxillary sinus.
After confirming the distance to the sinus floor,
After the presentation of the original Summers tech- small-diameter pilot drills (1–1.5 mm smaller than
nique, only minor modifications have been presented the diameter of the intended implant) are used to
(6, 12, 24, 26). The technique described here is a mod- prepare the implant site to a distance of approxi-
ification of the original technique (24). mately 2 mm from the sinus floor (Fig. 4). In the
Presurgical patient preparation includes oral rin- presence of soft type IV bone and a residual bone
sing with 0.1% chlorhexidine for a period of 1 min. height of 5–6 mm, there is usually no need to use
Local anesthesia is administered into the buccal the pilot drills. It is sufficient to perforate the corti-
and palatal regions of the surgical area. cal bone at the alveolar crest using the round
A mid-crestal incision, with or without a releasing burs.
incision, is made and a full-thickness mucoperio- The first osteotome used in the implant site is a
steal flap is raised. small-diameter tapered osteotome with a rounded
tip (Fig. 5). With light malleting, the osteotome is
pushed toward the compact bone of the sinus
floor (Fig. 6). After reaching the sinus floor, the os-
teotome is pushed about 1 mm further with light
malleting in order to create a ‘greenstick’ fracture
on the compact bone of the sinus floor. A tapered
osteotome with a small diameter is chosen to min-
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Pjetursson & Lang
ture area of the sinus floor (Fig. 7). The second os-
teotome is applied to the same length as the first.
Fig. 5. The first osteotome used in the implant site is a
small-diameter tapered osteotome. Such an osteotome is The third osteotome used is a straight osteotome
chosen to minimize the force needed to fracture the com- with a diameter about 1–1.5 mm smaller than the
pact bone. implant to be placed (Fig. 8). Instead of using the
osteotomes to fracture the sinus floor, piezoelec-
imize the force needed to fracture the compact tric surgery may be used (Fig. 9). The advantage of
bone. this technique is that perforation of the sinus floor
The second tapered osteotome, also with a may be achieved in a more controlled way than
rounded tip and with a diameter slightly larger with osteotomes and thus the risk of membrane
than that of the first, is used to increase the frac- perforation may be reduced (28). Moreover, this
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Transalveolar sinus floor elevation
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or in combination with tissue fibrin glue, to close the lagen in another two studies. Five studies used combi-
membrane perforation. If the perforation occurs nations of grafts consisting of autogenous bone graft
before any grafting material is inserted, the procedure and Bioglassâ; autogenous bone graft and deprotei-
should be aborted and a second attempt to achieve a nized bovine bone mineral; autogenous bone graft
transalveolar sinus floor elevation may be performed and collagen; autogenous bone graft, demineralized
6–9 months later (33, 36). freeze-dried bone allograft and tricalcium phosphate;
Postoperative infection after transalveolar sinus and autogenous bone graft, deminerialized freeze-
floor elevation is a rare complication. Six studies, with dried bone allograft and antibiotics in the graft. Vari-
884 implants, included in the systematic review of ous types of graft were used in two studies. Three
Tan et al. (31), reported on postoperative infection. studies performed the procedure without graft place-
The incidence ranged from 0% to 2.5% with a mean ment and one study did not report on the graft used.
of 0.8%. Other complications reported were postoper- It is still controversial whether or not it is necessary
ative hemorrhage, nasal bleeding, blocked nose, to apply grafting material to maintain the space for
hematomas and loosening of cover screws, resulting new bone formation after elevating the sinus mem-
in suppuration and benign paroxysmal positional ver- brane utilizing the transalveolar osteotome technique.
tigo (37). The benign paroxysmal positional vertigo Studies in monkeys (2) showed, that implants pro-
may cause substantial stress in the patient if not cor- truding into the maxillary sinus following elevation of
rectly identified and properly managed (26). No air the sinus membrane without grafting material, exhib-
embolism was reported in the study using hydraulic ited spontaneous bone formation over more than half
sinus condensing (6). of the height of the implant. Hence, protrusion of an
implant into the maxillary sinus does not appear to be
an indication for bone grafting. In the same study,
Grafting materials it was also seen that the design of the implant
influenced the amount of spontaneous bone forma-
In the original publication (32), the author did not tion. Implants with open apices or deep-threaded
use any grafting material to increase and maintain configurations did not reveal substantial amounts of
the volume of the elevated area. Later on, Summer new-bone formation. On the other hand, implants
(30) described the bone-added osteotome sinus floor with rounded apices tended to show spontaneous
elevation technique, frequently referred to as the bone formation extending all around the implants if
‘Summers technique’. Tapered osteotomes with they only penetrated 2–3 mm into the maxillary sinus.
increasing diameters were used to compress the bone However, when the same implants penetrated 5 mm
and push and tap it in a vertical direction as the sinus into the maxillary sinus, only partial (50%) growth of
membrane was elevated. Autogenous, allogenic or xe- new bone was seen toward the apex of the implant.
nogenic grafting material was added to maintain the A recent clinical study (22) reported similar clinical
volume below the elevated sinus membrane. results. The authors reported on 25, 10-mm dental
Grafting material is added incrementally to the os- implants inserted using the transalveolar approach
teotomy site and condensed until the desired graft without grafting material. The implants protruded, on
height is reached. Pressure from the osteotomes on average, 4.9 1.9 mm into the sinus cavity after sur-
the graft material and trapped fluids exerts hydraulic gery. After a follow-up period of 5 years, the implant
pressure on the sinus membrane, resulting in eleva- protrusion was reduced to 1.5 0.9 mm. Hence,
tion over a larger area (6). A recent study (16) that 3.4 mm (or 70%) of the penetrating part of the
compared the use of the bone-added osteotome sinus implants showed spontaneous bone formation.
floor elevation technique with sinus floor elevation In a clinical study (12), implants were installed into
utilizing the lateral approach, concluded minimal the sinuses of 40 patients using the transalveolar
bone resorption for both methods. The bone resorp- technique with no graft or cushion material. The
tion reported was 1.35 mm for the bone-added osteo- authors reported a mean gain of alveolar bone height,
tome sinus floor elevation technique and 1.36 mm determined from scanned panoramic radiographs, of
for the lateral approach over a period of 2 years after 3.9 1.9 mm.
the procedure was performed. In a retrospective study that assessed, radiographi-
From the 19 studies included in the systematic cally, sinus floor remodeling after implant insertion
review of Tan et al. (31), 15 used grafting material. De- using a modified transalveolar technique without
proteinized bovine bone mineral was used in five grafting material (27), 24 patients were available for
studies, autogenous bone graft in two studies and col- follow up. The implant survival rate was 100%. Bone
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Transalveolar sinus floor elevation
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Table 1. Annual failure rates and survival of implants placed using the transalveolar sinus floor elevation technique
Study Year of Total no. of Mean No. of Before After Total implant Estimated failure Estimated survival
Pjetursson & Lang
publication implants follow-up failures loading loading exposure time rate (per 100 implant years) after 3 years (%)
time (years)
Chen & Cha (6) 2005 1557 3.2 8 8 0 4957 0.16 99.5
Cosci & Luccioli (8) 2000 265 2.4 8 NR NR 626 1.28 96.2
Coatoam & Krieger (7) 1997 123 1.9 6 5 1 169 3.55 89.9
lateral approach, the residual bone height plays a sig- procedure as unpleasant, more than 90% of the
nificant role in implant survival. patients were willing to undergo implant therapy
It is also evident that the failure rate of the implants again, if necessary and dentally indicated.
placed into sites with transalveolar sinus floor aug-
mentation is increased and is correlated to reduced
residual bone height and reduced implant length, as Conclusions and clinical
described in a multicenter retrospective study (26) suggestions
that reported a survival rate of 96% when the residual
bone height was ≥ 5 mm. The survival rate decreased Randomized controlled clinical trials with sufficient
to 85.7% when the residual bone height was ≤ 4 mm. statistical power, comparing transalveolar sinus floor
Similar results were also reported in a recent prospec- elevations with sinus floor elevation utilizing a lateral
tive study (24) in which 20% of the implants were approach on one side, and with short implants on the
placed in sites with a residual bone height of ≤ 5 mm. other side are needed for evidence-based decision
The survival rates were 91.3% for implant sites with a making. Moreover, randomized controlled clinical tri-
residual bone height of ≤ 4 mm and 90% for sites with als comparing transalveolar sinus floor elevation with
a residual bone height of 4–5 mm, compared with a and without grafting materials would be of great
survival rate of 100% if the residual bone height was value.
> 5 mm. Moreover, for short 6-mm implants, the sur- In the posterior maxilla with residual bone height
vival rate was only 48%. This clearly demonstrates 5–8 mm and a relatively flat sinus floor, elevation of
that the transalveolar sinus floor elevation technique the maxillary sinus floor using the transalveolar tech-
was most predictable with a residual alveolar bone nique, with or without grafting material, is indicated
height of ≥ 5 mm and with implants of ≥ 8 mm. (Fig. 17). Implants with morphometry designed to
achieve high initial stability and with moderately
rough surface geometry giving a high percentage of
Patient-centered outcomes bone-to-implant contact during the initial healing
phase (1), should be preferred. Implants with slightly
In the study of Pjetursson et al. (24), 163 patients conical morphometry, or implants with a wider
were examined at their follow-up visit and asked to implant neck, tend to give better primary stability in
give their opinion on nine statements related to the the event of reduced residual bone height and soft
treatment. The first two statements dealt with general bone geometry.
satisfaction with the treatment. The patients were
asked if they would undergo a similar treatment
again, if needed, and the results were recorded on a
visual analog scale. The mean visual analog scale
score was 91 17 and the median (range) was 98 (0–
100). The patients were also asked if they would rec-
ommend this treatment to a friend or a relative, if
indicated. The mean visual analog scale score was
90 17 and the median (range) was 97 (0–100). For
both statements, only five (3%) patients stated that
they would not be willing to undergo such a treat-
ment again.
Approximately 23% of the patients found the surgi-
cal experience unpleasant. When asked about other
surgical complications, 5% of the patients felt that
their head was tilted too far back during the surgery
and 5% of the patients experienced vertigo, nausea Fig. 17. The ideal indication for transalveolar sinus floor
and felt disoriented after the surgical procedure, but elevation is a site with a residual bone height of 5–7 mm
no patient had any problem with unusual eye move- and relatively flat sinus floor anatomy. The radiograph,
ments. A small group of five patients had psychologi- taken after implant placement, shows a dome-shape con-
figuration of the graft. In this instance, 0.25 g of grafting
cal problems after the treatment and had to seek
material (xenograft) was used to elevate the sinus mem-
medical assistance (24). The authors concluded that brane (the dotted lines represent the outlines of the resid-
even though 23% of the patients reported the surgical ual bone).
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Transalveolar sinus floor elevation
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clinical report. Int J Oral Maxillofac Implants 2004: 19: 266– the severely atrophic posterior maxilla using localized man-
273. agement of the sinus floor: a preliminary study. Int J Oral
35. Ulm CW, Solar P, Gsellmann B, Matejka M, Watzek G. The Maxillofac Implants 2002: 17: 687–695.
edentulous maxillary alveolar process in the region of the 39. Zhao BD, Wang YH, Xu JS, Zheng J, Gong DL, Yu Y. Clinical
maxillary sinus – a study of physical dimension. Int J Oral study of maxillary sinus floor elevation with simultaneous
Maxillofac Surg 1995: 24: 279–282. placement of implants from the top of alveoli. Shanghai
36. Van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing Kou Qiang Yi Xue 2007: 16: 480–483.
DB. Anatomical aspects of sinus floor elevations. Clin Oral 40. Zitzmann NU, Scha €rer P. Sinus elevation procedures in the
Implants Res 2000: 11: 256–265. resorbed posterior maxilla. Comparison of the crestal and
37. Vernamonte S, Mauro V, Vernamonte S, Messina AM. An lateral approaches. Oral Surg Oral Med Oral Path Oral
unusual complication of osteotome sinus floor elevation: Radiol Endod 1998: 85: 8–17.
benign paroxysmal positional vertigo. Int J Oral Maxillofac
Surg 2011: 40: 216–218.
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