Bjarni E.

Pjetursson Transalveolar maxillary sinus floor

Diana Ignjatovic
Giedre Matuliene
elevation using osteotomes with or
Urs Brägger without grafting material. Part II:
Kurt Schmidlin
Niklaus P. Lang radiographic tissue remodeling

Authors’ affiliations: Key words: biological complications, bone augmentation, bone grafting, complications,
Bjarni E. Pjetursson, Department of Reconstructive crestal, dental implants, failures, longitudinal, osteotome technique, patients’ satisfaction,
Dentistry, Faculty of Odontology, University of
Iceland, Reykjavik, Iceland peri-implantitis, sinus augmentation, sinus floor elevation, sinus grafting, success, survival,
Bjarni E. Pjetursson, Diana Ignjatovic, Giedre transalveolar technique
Matuliene, Urs Brägger, Niklaus P. Lang, School of
Dental Medicine, University of Bern, Bern,
Switzerland Abstract
Kurt Schmidlin, Research Support Unit, Institute of Objectives: To evaluate the pattern of tissue remodeling after maxillary sinus floor
Social and Preventive Medicine, University of Bern,
Bern, Switzerland elevation using the transalveolar osteotome technique with or without utilizing grafting
Niklaus P. Lang, Prince Philip Dental Hospital, The materials.
University of Hong Kong, Hong Kong s
Methods: During the period of 2000–2005, 252 Straumann dental implants were inserted
Correspondence to: using the transalveolar sinus floor elevation technique in a group of 181 patients. For 88 or
Bjarni E. Pjetursson
35% of those implants, deproteinized bovine bone mineral with a particle size of 0.25–
Department of Reconstructive Dentistry
University of Iceland 1 mm was used as the grafting material, but for the remaining 164 implants, no grafting
Vatnsmyrarvegur 16 material was utilized. Periapical radiographs were obtained with a paralleling technique
IS 101 Reykjavik
Iceland and digitized. Two investigators, who were blinded to whether grafting material was used
Tel.: þ 354 525 4850 or not, subsequently evaluated the pattern of tissue remodeling.
Fax: þ 354 525 4874
Results: The mean residual bone height was 7.5 mm (SD 2.2 mm), ranging from 2 to
e-mail: bep@hi.is
12.7 mm. The mean residual bone height for implants placed with grafting material
(6.4 mm) was significantly less compared with the implants installed without grafting
material (8.1 mm). The implants penetrated on average 3.1 mm (SD 1.7 mm) into the sinus
cavity. The measured mean radiographic bone gain using the transalveolar technique
without grafting material was significantly less, 1.7 mm (SD 2 mm) compared with a mean
bone gain of 4.1 mm (SD 2.4 mm), when grafting material was used. Furthermore, the
probability of gaining 2 mm or more of new bone was 39.1% when no grafting material
was used. The probability increased to 77.9% when the implants were installed with
grafting material.
Conclusion: When the transalveolar sinus floor elevation was performed without utilizing
grafting material, only a moderate gain of new bone could be detected mesial and distal to
the implants. On the other hand, when grafting material was used, a substantial gain of
new bone was usually seen on the radiographs.

Date:
Accepted 28 January 2009
To cite this article:
Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U,
Schmidlin K, Lang NP. Transalveolar maxillary sinus
floor elevation using osteotomes with or without grafting
material. Part II: radiographic tissue remodeling.
Clin. Oral Impl. Res. 20, 2009; 677–683.
doi: 10.1111/j.1600-0501.2009.01721.x
Since the transalveolar osteotome techni-
que for sinus floor elevation was intro-
duced by Tatum (1986), several studies
have reported on this technique. The stu-
dies mainly reported high survival rates of
implant placed utilizing the transalveolar
technique (Tan et al. 2008).
In the original publication (Tatum 1986),
a special instrument known as a ‘socket
former’ was used to infracture the sinus
floor and to move it in a more apical
direction. At the time, the authors used
no grafting material to increase and main-
tain the volume of the elevated area.

c 2009 John Wiley & Sons A/S

 677 | Clin. Oral Impl. Res. 20, 2009 / 677–683
Pjetursson et al . Transalveolar sinus floor elevation
Later, another transalveolar technique,
the bone-added osteotome sinus floor ele-
vation, was described by Summers (1994).
Tapered osteotomes with increasing dia-
meters were used to compress the bone
and pushing and tapping it in a vertical
direction as the sinus membrane was ele-
vated. Moreover, autogenous, allogenic or
xenogenic grafting material was added to
maintain the volume below the elevated
sinus membrane.
The majority of authors reporting on the
transalveolar technique utilized grafting
materials. Grafting material is added incre-
mentally to the osteotomy site and con-
densed until the desired graft height is
reached. Pressure from the osteotomes
caused the graft material and trapped fluids
to exert hydraulic pressure on the sinus
membrane, causing elevation over a greater
area (Chen & Cha 2005).
The patterns of tissue remodeling after
placement of 25 implants in 19 patients
were investigated using the transalveolar
technique with composite xenografts and
autografts (Brägger et al. 2004). Intraoral
radiographs were obtained pre-surgically
and post-surgically at 3 and 12 months.
The mean height of the new structure reach-
ing apical and mesial to the implants was
1.52 mm at surgery, but was reduced signif-
icantly to 1.24 mm at 3 months and
0.29 mm after 12 months. The authors
concluded that the grafted area apical to
the implants underwent shrinkage and re-
modeling. The original outline of the sinus
was eventually consolidated and replaced by
a new cortical plate.
On the other hand, studies in monkeys
(Boyne 1993) reported that implants protrud-
ing into the maxillary sinus following eleva-
tion of the sinus membrane, without
grafting material, exhibited spontaneous
bone formation below the sinus membrane.
Implants with rounded apices showed spon-
taneous bone formation extending all around
the implants when they penetrated only 2–
3 mm into the maxillary sinus. When the
same implants penetrated 5 mm into the
maxillary sinus, only a partial (50%) growth
of new bone was seen towards the apex of
the implant. Moreover, the implant design
appeared to influence the amount of sponta-
neous bone formation, because implants
with open apices or deep-threaded config-
urations did not reveal substantial amounts
of new bone formation.
678 | Clin. Oral Impl. Res. 20, 2009 / 677–683
In a clinical study (Leblebicioglu et al.
2005), implants were installed into the
sinuses of 40 patients using the transalveo-
lar technique with no graft or cushion
material. The authors reported a mean
gain of alveolar bone height in scanned
panoramic radiographs of 3.9  1.9 mm.
In a retrospective study assessing radio-
graphically sinus floor remodeling after
implant insertion using a modified transal-
veolar technique without grafting material
(Schmidlin et al. 2008), 24 patients were
available for follow-up. The implant survi-
val rate was 100%. Bone filling around the
implants was measured and compared with
baseline digital radiographs. The mean
height of the newly formed bone was
2.2  1.7 mm mesially and 2.5  1.5
mm distally, or, as a percentage of new
bone formation, 86.3  22.1% and
89.7  13.3%, respectively.
Ellegaard et al. (2006) reported on 131
implants placed using the lateral approach.
The sinus membrane was elevated, im-
plants were inserted and then left to pro-
trude into the sinus cavity. The sinus
membrane was allowed to settle onto the
apices of the implants, thus creating a
space to be filled with a blood coagulum.
The authors reported new bone formation
below the sinus membrane and after a
mean follow-up time of 5 years, the survi-
val rate of these implants was 90%.
In a systematic review (Emmerich et al.
2005) evaluating the effectiveness of sinus
floor elevation using osteotomes, the authors
concluded that the database was hetero-
genous with regard to the different surgical
techniques, implant types and grafting ma-
terials. Hence, no statistical analysis could
be performed on these parameters.
In summary, the necessity of using graft-
ing material to maintain the space for new
bone formation after elevating the sinus
membrane utilizing the transalveolar os-
teotome technique is still controversial.
The aim of this prospective study was to
evaluate the pattern of tissue remodeling
after maxillary sinus floor elevation using
the transalveolar technique with or with-
out utilizing grafting materials.
Material and methods
During the period of 2000–2005, 181
patients at the Department for Perio-
dontology and Fixed Prosthodontics, Uni-
versity of Bern, Switzerland, had 252
dental implants installed subjacent to the
maxillary sinus floor. The patients pre-
sented with an edentulous space in the
posterior maxilla with a reduced residual
bone height making standard implant pla-
cement unrealistic.
After raising a full-thickness mucoper-
iosteal flap, the implant site was prepared
with drills and a set of tapered and straight
osteotomes of different diameters (Strau-
mann AG, Waldenburg, Switzerland). The
surgical protocol has been described pre-
viously (Pjetursson et al. 2009).
The decision of whether to use grafting
material or not was left to the preference of
the operator. Before placement of any graft-
ing material, the sinus membrane was
tested for any perforations. This was done
with the Valsalva maneuver (nose-blowing
test). If the sinus membrane was not intact,
no grafting material was placed into the
sinus cavity. When indicated, deprotei-
nized bovine bone mineral of a particle
s
size of 0.25–1 mm (BioOss Geistlich
Sons Ltd., Wolhusen, Switzerland) were
used as the grafting material. Two-third
(65%) of the osteotome implants were
placed without utilizing grafting material
and 88 or 35% of the implants were placed
with grafting material.
The post surgical care after the implant
placement with the transalveolar techni-
que was similar to that after standard
implant placement. In addition to the stan-
dard oral home care, antiseptic rinsing with
0.1–0.2% chlorhexidine twice daily for the
first 3 weeks after surgery was recom-
mended. However, if bone substitutes
were used, the patients were placed on a
post-surgical antibiotic regimen (Clamox-
s
yl 750 mg three times daily) for a period of
1 week (Glaxo-Smith-Kline AG, Münch-
enbuchsee, Switzerland).
Radiographic examinations
Periapical intraoperative radiographs were
obtained at the annual examination with a
paralleling technique using a Rinn film
s
holder (XCP Instruments, Rinn Corpora-
tion Elgin, Elgin, IL, USA) with a rigid
film-object X-ray source. No attempts
were made for further standardization.
The radiographs were captured using a
black and white video camera (Canon, Still
Video Products Group, Tokyo, Japan) and
c 2009 John Wiley & Sons A/S

 Pjetursson et al . Transalveolar sinus floor elevation

viewed on a light box. The images were

transferred to a computer and digitized
with a frame grabber hardware (Matrox
Electronic Systems MVP/AT, Dorval,
QC, Canada). Using an image-processing
software, digitized images were stored with
a resolution of 512  512  8 bit pixels GM
GM mes
(256 shades of gray). Stored images were
AP
then displayed on a monitor and linear AP
measurements were performed with the
help of a cursor (Brägger et al. 1996) by
two investigators who were blinded to
whether grafting material was used or not.
The following measurements were made
by two independent examiners: SF
1. Pre-surgical residual bone height –
from the alveolar bone crest (AC) to
the floor of the maxillary sinus (SF)
mesial and distal to the inserted im-
plant. The pre-surgical residual bone
height was then reported as the mean
between the mesial and distal mea-
surements (Fig. 1).
2. Implant penetration into the sinus –
from the maxillary sinus floor (SF) to AC
the apex of the implant (AP) mesial
and distal. The implant penetration S mes
was then reported as the mean be-
tween the mesial and distal measure-
ments (Fig. 1).
3. Height of the graft apically, if applic-
able – from the apex of the implant
(AP) to the border of the graft or new
Fig. 1. A schematic drawing of the linear measurements made on the periapical radiographs by two calibrated
bone (GM) (Fig. 1).
investigators.
4. Height of the graft mesially and dis-
tally – from the implant shoulder (S) to
the border of the graft or new bone
Table 1. Sinus grafting remodeling index (SGRI) introduced by Brägger et al. 2004
(GM) mesial and distal (Fig. 1).
Score 0 No bone/grafting material visible
The radiographic appearance of the ‘peri- Score 1 Cloudy structures with hazy demarcation. Original sinus floor lamina dura still
recognizable
apical’ maturation of the grafting material
Score 2 Clearly visible dense structures apical to the implant and beginning resorption
was also evaluated. For this purpose, the of original lamina dura
sinus grafting remodeling index (SGRI) Score 3 Dense periapical bone graft structures with a new maxillary sinus floor outline
(Brägger et al. 2004) was used (Table 1). with a well-defined new lamina dura and resorbed original lamina dura
These evaluations were made by six cali-
brated examiners. They were also asked to
evaluate to what extent (0%, 1–49%, 50– categorical characteristics. For descriptive implants in the same patient might be
99% and 100%) the apices of the implants graphical display, we used box plots that correlated to some degree. We report
were covered with grafting material or new graphically depict the range, interquartile P-values for the mean difference between
bone. range and median. these two implant groups from these
To formally compare continuous mea- models.
Statistical analysis surements like pre-operative bone height, When these measurements were categor-
We provide descriptive statistical informa- sinus preparation and new bone formation ized, we used multilevel logistic regression
tion on the baseline characteristics of pa- between implants with and without graft- models to derive P-values for the com-
tients and implants: mean and standard ing material, we fitted multilevel linear parison of the distribution in categories
deviation or range for continuous charac- regression models that account for the between these two implant groups. In
teristics and percentage distribution for fact that the measurements at different situations where observations are not

c 2009 John Wiley & Sons A/S

 679 | Clin. Oral Impl. Res. 20, 2009 / 677–683
Pjetursson et al . Transalveolar sinus floor elevation

Table 2. Frequency analysis and mean values in millimeters of the pre-operative residual IL, USA) and collagen membrane (Bio-
bone height s
Gide Geistlich Sons Ltd., Wolhusen,
Pre-operative All Without With P-value
Switzerland), and in the other two situa-
bone implants grafting grafting
height (mm) materials materials tions the implants were placed without
repair of the perforations. All three im-
o4 11% 5.1% 20.7% Po0.003n
4–5 9.1% 8% 11% plants osseointegrated without any compli-
5–6 15.5% 8% 28% cations and could be used as abutments for
6–7 17.8% 18.3% 17.1% implant-supported reconstructions. Two-
47 46.6% 60.6% 23.2%
third (65%) of the osteotome implants
Mean  SD 7.5  2.2 8.1  2.1 6.4  1.9 Po0.0001w
were placed without utilizing grafting ma-
n
Derived from multilevel logistic regression. terial. In the remaining 35%, deproteinized
wDerived from multilevel linear regression. s
bovine bone mineral (BioOss Geistlich
Sons Ltd.) was used to elevate the max-
illary sinus floor.
Table 3. Frequency analysis and mean values in millimeters of the sinus penetration of the
osteotome implants
Sinus All Without With P-value
Survival and failure rates
penetration implants grafting grafting
of implants (mm) materials materials Of the original 252 implants inserted, six
n
implants were lost. Three implants were
0–2 30.6% 34.3% 24.4% P ¼ 0.046
2–4 37% 40.9% 30.5% lost before loading and the remaining three
44 32.4% 24.8% 45.1% in the first and second year of function,
Mean  SD 3.1  1.7 2.8  1.5 3.6  1.9 P ¼ 0.0005w translating into a survival rate of 97.4%
n
Derived from multilevel logistic regression. (95% confidence interval: 94.4–98.8%) for
wDerived from multilevel linear regression. the osteotome implants after a follow-up
time 3 years.
The survival rate according to residual
bone height was 91.3% for implant sites
nested and not correlated, these P-values ing material (8.1 mm, SD 2.1 mm)
with  4 mm residual bone height, and
correspond exactly to the P-values derived (Po0.0001) (Table 2). The majority
90% for sites with 4 and 5 mm, when
from the w2 statistics used for testing differ- (78.9%) of the implants placed without
compared with that of 100% in sites a
ences in the distribution of categories. grafting material had a residual bone height
with bone height above 5 mm.
For the analysis of the cumulative survi- of 6 mm or more. The residual bone for
val of implants, the Kaplan–Meier method implants placed without grafting material,
was used (Kaplan & Meier 1958). however, was more equally distributed Radiographic tissue remodeling
We calculated the k statistics in order to (Table 2). Linear measurements to evaluate the mar-
describe the degree of agreement between The implants penetrated on average ginal bone levels were performed on digi-
raters who rated radiography results with 3.1 mm (SD 1.7 mm) into the sinus cavity. tized images. The graft apical to the
regard to maturation of the grafting mate- The implants placed with grafting material implants (AP – GM) demonstrated a gra-
rial using the SGRI. surpassed the sinus demarcation signifi- dual reduction in height. For 55% of the
All analyses were conducted using Stata cantly more than the implants placed with- implants inserted without grafting mate-
version 10 (Stata Corporation, College Sta- out grafting material, 3.6 vs. 2.8 mm, res rial, no visible structure was demonstrated
tion, TX, USA). pectively (P ¼ 0.0005) (Table 3). For the apical to the implants after insertion.
implants placed without grafting material, Moreover, in 26.3% of the implants, in-
the majority surpassed the sinus demarca- serted without grafting material, that de-
Results tion between 0 and 4 mm, but implants monstrated a visible radio-opaque structure
placed with grafting material usually pene- after implant installation, no radio-opaque
A total of 181 patients received 252 Strau- trated the sinus cavity of 4 2 mm (Table 3). structure was visible after 1 year. For the
s
mann Solid Screw implants (Straumann During the implant site preparation, remaining implants inserted without graft-
AG) placed in conjunction with maxillary membrane perforation diagnosed by the ing material, the graft height reduced from
sinus floor elevation using the transalveo- Valsalva maneuver was detected in 10.8% 1.8 to 1.3 mm in the first year and at the 3-
lar technique. of the sites. In situations where perfora- year examination, it was down to 1.1 mm
The mean residual bone height was tions were detected, no grafting material (Fig. 2). For implants inserted with grafting
7.5 mm (SD 2.2 mm), ranging from 2 to was utilized. In three situations, the mem- material, only 23.5% showed no visible
12.7 mm. The mean residual bone height brane perforation was detected after inser- radio-opaque structure apical to the im-
for implants placed with grafting material tion of the grafting material. In one of these plants after implant installation. After the
(6.4 mm, SD 1.9 mm) was significantly situations a lateral window was prepared first year, 15.9% of those implants showed
less compared with the residual bone and the perforation was repaired with fibrin no visible radio-opaque structure apically
height for implant insertion without graft- glue (Baxter International Inc., Deerfield, and as for the remaining implants inserted

680 | Clin. Oral Impl. Res. 20, 2009 / 677–683 c 2009 John Wiley & Sons A/S

 Pjetursson et al . Transalveolar sinus floor elevation

from IS to the new sinus floor or the graft

margin (GM) at the last examination. After
an average follow-up time of 3.2 years, the
measured mean radiographic bone gain
using the transalveolar technique without
grafting material was 1.7 mm (SD 2 mm)
compared with a mean bone gain of
4.1 mm (SD 2.4 mm) when grafting mate-
rial was used. This difference was statisti-
cally significant (P ¼ 0.0001) (Table 4).
Baseline 1 year 3 years
The probability of gaining 2 mm or new
bone was 39.1% when no grafting material
Fig. 2. A schematic drawing describing the apical re-modelling of the graft for implants demonstrating visible
radio-opaque structure after implant installation. The dotted line demonstrates implants installed without
was used. The probability of gaining 2 mm
using grafting materials and the continuing line represents implants inserted with grafting materials. or more of new bone increased to 77.9%
when the implants were installed with
grafting material (Table 4).

Table 4. Frequency analysis and mean values in millimeters of new bone formation by test SGRI
and control implants
Six calibrated examiners evaluated the
New bone All Without With P-value
formation implants grafting grafting ‘periapical’ maturation of the grafting ma-
materials materials terial using SGRI. All six examiners graded
No bone gain 14% 20.6% 3.7% P ¼ 0.0002n implants inserted with transalveolar sinus
0–2 mm 31.7% 40.3% 18.4% floor elevation, together with grafting ma-
42 mm 54.3% 39.1% 77.9% terial clearly higher than implants inserted
Mean  SD (mm) 1.7  2 4.1  2.4 Po0.0001w
without utilizing grafting material (Fig. 3)
n
Derived from multilevel logistic regression. (Table 5). On the other hand, the interex-
wDerived from multilevel linear regression. aminer agreement was very low based on a
k statistic of only 0.26. Moreover, the
examiners were also asked the extent to
which the apices of the implants were
Index
covered with grafting material or new
all raters
bone. Five of the six examiners reported
3
significantly less coverage of the implant
apices when the implants were installed
without grafting materials (Fig. 4). The
2 sixth examiner reported much higher in-
index

cidence of implant apex coverage in both

groups and also no significant difference
1 between implants installed with or without
grafting materials.

0
Discussion
without with
graft material
The present study has demonstrated that
Fig. 3. The ‘periapical’ maturation of the grafting material evaluated by six calibrated examiners using the the simultaneous application of an osteo-
sinus graft remodelling index.
conductive filler at the time of transalveo-
lar sinus floor augmentation resulted in
improved outcomes and higher volumes
with grafting material, the graft height was when the initial graft height was 4 2 mm, of newly generated bone in the sinus cav-
reduced from 2.7 mm down to 2.1 mm. At this probability was reduced to 10.5%. ity. Consequently, the bony anchorage of
the 3-year examination, the graft height In order to evaluate whether the new oral implants in the maxillary posterior
was further reduced to 1.9 mm (Fig. 2). If sinus floor or the graft margin was moved region may be improved substantially by
the height of the graft after implant inser- apical (bone gain) using the transalveolar creating a space between the Schneiderian
tion was below 2 mm, the probability of technique, the distance from implant membrane and the floor of the sinus cavity,
having no visible radio-opaque structure shoulder (IS) to the sinus floor (SF) at thus providing the necessary scaffold for
apically after 1 year was 44.8%; however, baseline was compared with the distance bone regeneration in this region.

c 2009 John Wiley & Sons A/S

 681 | Clin. Oral Impl. Res. 20, 2009 / 677–683
Pjetursson et al . Transalveolar sinus floor elevation

Table 5. Ranges of sinus graft remodeling index ratings from the six examiners even a mean gain of alveolar bone height of
SGRI Range of percentages over all six raters 3.9  1.9 mm was reported (Leblebicioglu
Without grafting material With grafting material et al. 2005).
When no grafting material was used,
0 21.6–66.3 7.8–30.7
1 17.1–53.5 4.9–45.3 some dense structure was often visible
2 5–32.4 20–33.3 apical to the implant immediately after
3 2–21.6 19.4–45.5 implant placement in the present study.
However, after at least 1 year of remodel-
ing, this structure was no longer detectable
in 26.8% of those implants.
Apex coverage When grafting material was used, a
all raters cloudy dome structure with a hazy demar-
3
cation was usually visible after implant
placement. The size of this dome was
usually reduced after remodeling but still
2 yielded a mean bone gain of 4.1 mm, after
at least 1 year of remodeling, thus docu-
apex

menting substantial bone augmentation

1 after this observation period.
There is a definitive need for a clinical
study on the highest evidence level, as to
date, there are no randomized-controlled
0
clinical trials, comparing implants placed
without with
using the transalveolar sinus floor eleva-
graft material
tion with and without grafting material.
Fig. 4. The apical coverage of the inserted implants evaluated by six calibrated examiners. 0, no coverage;
Obviously, this is a major shortcoming if
1, some coverage but less then half of the implant apex is coverage; 2, more than half of the apex is coverage
but not a complete coverage and 3, complete apical coverage.
these procedures are to be selected on the
basis of scientific evidence. The present
study represents a prospective cohort study
without a randomized allocation of the two
Although implants with rounded apices form augmentations with the simulta- procedures used. Hence, it is clear that the
protruding 2–3 mm into the maxillary neous application of scaffolds. evidence for the statements made above is
sinus following elevation of the sinus The mean bone gain was evaluated by not on the highest level. Nevertheless, the
membrane without grafting material may two different methods. Firstly, the ‘peria- sample size and the design of the clinical
have resulted in spontaneous bone forma- pical’ maturation around the implant study allow some conclusions in favor of
tion extending all around the implants in apices was evaluated by six calibrated ex- the application of grafting material in con-
animals (Boyne 1993), the predictability of aminers on a light board using magnifying junction with the transalveolar sinus floor
such bone regeneration without the appli- glasses and assessing according to the cri- elevation.
cation of grafting material may be ques- teria of the SGRI (Brägger et al. 2004). While performing sinus floor elevation,
tioned. When the similar implants Although a very low interexaminer agree- the risks for complications must be con-
penetrated 5 mm into the maxillary sinus, ment as revealed by a k statistic of 0.26 was sidered, and the therapist must be prepared
only a partial growth of new bone was achieved, all six examiners recorded signif- for the appropriate treatment. The major
observed towards the apices of the implants icantly more new bone formation using disadvantage of the transalveolar sinus
(Boyne 1993). Hence, the necessity of ap- grafting material compared with sites ele- floor elevation is the lack of an overview
plying grafting of bone or bone substitutes vated without grafting material. Based on during the elevation of the Schneiderian
concomitantly with the transmucosal si- the relatively poor k statistics for the SGRI, membrane. In the present study, the pre-
nus floor elevation remains controversial. the value of this evaluation system must be valence of membrane perforation detected
In a recent systematic review (Tan et al. questioned. by the Vasalva maneuver was 10.8%. Be-
2008) only two out of the 19 included Secondly, the mean bone gain, measured fore placing any grafting material the con-
studies did not use any grafting material at the mesial and distal aspects of the dition of the Schneiderian membrane has
at all, while performing the transalveolar implants, was 1.7 mm. This was similar to be checked. In situations of membrane
sinus floor elevation. This clearly indicated to what had been reported in a recent study perforations, implant insertion should be
that clinicians preferred the application of (Schmidlin et al. 2008), namely a mean aborted, or the implant should be placed
grafting material when augmenting max- bone gain of 2.2 mm mesially and 2.5 mm without using grafting material. Membrane
illary sinus cavities using the osteotome distally after performing transalveolar sinus perforation has been identified as the most
technique. The results of the present study floor elevation without grafting material. frequent complication encountered (3.8%)
support the notion of the necessity to per- Utilizing scanned panoramic radiographs, with transalveolar sinus floor elevation,

682 | Clin. Oral Impl. Res. 20, 2009 / 677–683 c 2009 John Wiley & Sons A/S


while post-operative infection was rare
(0.8 %) (Tan et al. 2008).
In conclusion, from the results of the
present study it may be concluded that
transalveolar sinus floor augmentation
should be performed in conjunction
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Acknowledgements: This study has
been supported by the Clinical
Research Foundation (CRF) for the
promotion of Oral Health, University of
Bern, Switzerland.
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