Int. J. Oral Maxillofac. Surg.

2018; 47: 103–116

http://dx.doi.org/10.1016/j.ijom.2017.05.001, available online at http://www.sciencedirect.com

Meta-Analysis
Pre-Implant Surgery

A systematic review and meta- T. Starch-Jensen1, H. Aludden1,

M. Hallman2,3, C. Dahlin4,5,
A.-E. Christensen6, A. Mordenfeld2,3

analysis of long-term studies

1
Department of Oral and Maxillofacial
Surgery, Aalborg University Hospital, Aalborg,
Denmark; 2Department of Oral and
Maxillofacial Surgery, Public Health Service,

(five or more years) assessing Gävle, Sweden; 3Centre for Research and
Development, Uppsala University/Gävleborg
County Council, Gävleborg, Sweden;
4

maxillary sinus floor

Department of Biomaterials, BIOMATCELL
VINN Excellence Centre, Institute for Surgical
Science, The Sahlgrenska Academy,
University of Gothenburg, Gothenburg,

augmentation Sweden; 5Department of Oral and

Maxillofacial Surgery, NU-Hospital
Organization, Trollhättan, Sweden; 6Unit of
Epidemiology and Biostatistics, Aalborg
University Hospital, Aalborg, Denmark
T. Starch-Jensen, H. Aludden, M. Hallman, C. Dahlin, A.-E. Christensen, A.
Mordenfeld: A systematic review and meta-analysis of long-term studies (five or more
years) assessing maxillary sinus floor augmentation. Int. J. Oral Maxillofac. Surg.
2018; 47: 103–116. ã 2017 International Association of Oral and Maxillofacial
Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The objective was to test the hypothesis of no difference in long-term (5
years) implant treatment outcomes after maxillary sinus floor augmentation
(MSFA) with autogenous bone graft compared to a mixture of autogenous bone
graft and bone substitutes or bone substitutes alone. A MEDLINE (PubMed),
Embase, and Cochrane Library search in combination with a hand-search of
relevant journals was conducted. Human studies published in English between
January 1, 1990 and October 1, 2016 were included. Nine studies fulfilled the
inclusion criteria. The survival of suprastructures has never been compared within
the same study. The 5-year implant survival after MSFA with autogenous bone graft
was 97%, compared to 95% for Bio-Oss; the reduction in vertical height of the
augmented sinus was equivalent with the two treatment modalities. Non-
comparative studies demonstrated high survival rates for suprastructures and
implants regardless of the grafting material used. Meta-analysis revealed an overall
estimated patient-based implant survival of 95% (confidence interval 0.92–0.96).
Key words: alveolar ridge augmentation; dental
High implant stability quotient values, high patient satisfaction, and limited peri-
implants; oral surgical procedures; review;
implant marginal bone loss were revealed in non-comparative studies. No long-term sinus floor augmentation.
randomized controlled trial comparing the different treatment modalities was
identified. Hence, the conclusions drawn from the results of this systematic review Accepted for publication 3 May 2017
should be interpreted with caution. Available online 22 May 2017

0901-5027/00000103 + 014 ã 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
104 Starch-Jensen et al.
Maxillary sinus floor augmentation
(MSFA) using the lateral window tech-
nique was originally developed by Tatum
in the mid-seventies and was later de-
scribed by Boyne and James in 19801,2.
This surgical intervention is still the most
frequently used method to enhance the
alveolar bone height of the posterior part
of the maxilla before or in conjunction
with implant placement, and treatment
outcomes have been reported in several
systematic reviews3–9.
Autogenous bone is generally considered
the preferred graft material10, and oral
implants inserted in sinuses augmented
with autogenous bone grafts have demon-
strated high implant survival rates, as docu-
mented in several reviews3,4,7,9,11,12.
However, the use of autogenous bone grafts
is associated with the risk of donor site
morbidity and unpredictable graft
resorption12–19. Hence, various bone sub-
stitutes are used increasingly to simplify the
surgical procedure by diminishing the need
for bone harvesting. The majority of bone
substitutes display solely osteoconductive
properties, and the capability of the graft
material to promote graft maturation and
provide optimal long-term support to
endosseous implants is one of the critical
factors for a high implant success rate.
Previously published systematic reviews
have reported high short-term survival rates
of suprastructures and implants after MSFA
with different mixtures of autogenous bone
graft and bone substitutes or bone substi-
tutes alone8,9,12. However, very recently
published systematic reviews assessing his-
tomorphometric variables concluded that
autogenous bone grafts result in the highest
amount of newly formed bone in compari-
son with various bone substitutes, although
allografts, alloplastic materials, and xeno-
grafts appear to be good alternatives to
autogenous bone for MSFA20,21. Conse-
quently, the optimal grafting material for
MSFA with regard to the long-term survival
of suprastructures and implants is not pres-
ently clear.
From a clinical and patient perspective,
it would be an advantage if bone substi-
tutes alone or in combination with a lim-
ited amount of autogenous bone could be
used in place of autogenous bone as the
graft material for MSFA. However, long-
term studies assessing MSFA are limited,
and the long-term implant treatment out-
comes after MSFA with particulated au-
togenous bone graft compared to MSFA
with a mixture of particulated autogenous
bone graft and bone substitutes or bone
substitutes alone, has not yet been
assessed specifically in a systematic
review.
Therefore, the objective of the present
systematic review was to test the hypoth-
esis of no difference in long-term (5
years) implant treatment outcomes after
MSFA with particulated autogenous bone
graft compared to MSFA with a mixture of
particulated autogenous bone graft and
bone substitutes or bone substitutes alone.
Materials and methods
This systematic review was conducted in
accordance with the PRISMA statement
for reporting systematic reviews (Pre-
ferred Reporting Items for Systematic
Reviews and Meta-Analyses)22.
Eligibility criteria for study selection
Randomized clinical trials, prospective
cohort studies, and retrospective human
studies comparing the long-term (5
years) implant treatment outcomes after
MSFA with particulated autogenous bone
graft to those of MSFA with a mixture of
particulated autogenous bone graft and
bone substitutes or bone substitutes alone,
were considered. Moreover, human stud-
ies solely assessing MSFA with particu-
lated autogenous bone graft alone, a
mixture of particulated autogenous bone
graft and bone substitutes, or bone sub-
stitutes alone, were also included as non-
comparative studies.
Outcome measures
The primary outcome measures are the
most important measures for evaluating
the long-term implant treatment outcome.
Secondary outcome measures were also
included in this systematic review as sur-
rogate measures. The outcome measures
assessed are outlined in Table 1.
Table 1. Outcome measures.
Primary outcome measures:
 Survival of suprastructures: loss of a suprastructure was defined as a total loss due to a
mechanical and/or biological complication
 Survival of implants: loss of an implant was defined as mobility of a previously clinically
osseointegrated implant, or removal of a non-mobile implant due to progressive peri-implant
marginal bone loss or infection
Secondary outcome measures:
 Implant stability quotient (ISQ): estimated by resonance frequency analysis
 Peri-implant marginal bone loss: evaluated by radiographic measurements
 Bone regeneration: evaluated by radiographic or histological measurements
 Patient-reported outcome measures
 Complications
Search strategy for the identification of
studies
A MEDLINE (PubMed), Embase, and
Cochrane Library search was conducted.
Human studies published in English be-
tween January 1, 1990 and October 1,
2016 were included. The search strategy
utilized a combination of medical subject
heading (MeSH) terms and free text terms:
1. sinus floor augmentation/ (517)
2. (sinus* adj3 (augment* or lift*)).mp.
(1848)
3. 1 or 2 (1848)
4. limit 3 to yr = ‘‘1990-Current’’ (1824)
The search was supplemented by a thor-
ough hand-search page by page of relevant
journals (Table 2). The manual search also
included the bibliographies of all articles
selected for full-text screening, as well as
previously published reviews relevant to
the present systematic review. The search
was performed by two reviewers (TSJ and
HA). In the event of disagreement be-
tween the reviewers, another reviewer
was consulted (AM).
Study selection
The PRISMA flow diagram in Fig. 1 pre-
sents an overview of the selection process.
The titles of identified reports were ini-
tially screened. The abstract was assessed
when the title indicated that the study
fulfilled the inclusion criteria. A full-text
analysis was performed when the abstract
was unavailable or when the abstract in-
dicated that the inclusion criteria were
fulfilled. The references of the identified
papers were cross-checked for unidenti-
fied articles. The study selection was per-
formed by two reviewers (TSJ and HA). In
 Long-term studies on sinus floor augmenta-
tion 105
Table 2. List of journals included in the manual search. Exclusion criteria
British Journal of Oral and Maxillofacial Surgery
Clinical Implant Dentistry and Related Research The following exclusion criteria were ap-
Clinical Oral Implants Research plied: letters to the editor, case reports,
European Journal of Oral Implantology technical reports, conference proceedings,
Implant Dentistry animal or in vitro studies, and review
International Journal of Oral and Maxillofacial Implants papers. Moreover, studies with an insuffi-
International Journal of Oral and Maxillofacial Surgery cient description of the numbers of surgi-
International Journal of Periodontics and Restorative Dentistry cal procedures performed, numbers of
International Journal of Prosthodontics implants inserted, and length of the obser-
Journal of Clinical Periodontology
vation period, as well as studies involving
Journal of Dental Research
Journal of Oral Implantology osteotome-mediated MSFA or autogenous
Journal of Periodontology bone blocks as the graft material, were
Journal of Prosthetic Dentistry excluded. Likewise, studies adding
Journal of Craniofacial Surgery growth factors or platelet-rich plasma to
Journal of Cranio-Maxillo-Facial Surgery the graft material were also excluded.
Journal of Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology Quality assessment
Note: The search engine of each journal was consulted on its Web page. The quality assessment was undertaken by
one review author (TSJ) as part of the data
the event of disagreement, another review- compared to MSFA with a mixture of extraction process. A methodological
er was consulted (AM). particulated autogenous bone graft and quality rating system was used, and the
bone substitutes or with bone substitutes classification of the risk of bias potential
alone, were included if they reported the for each study was based on five criteria,
Study eligibility as outlined in Table 4.
previously described outcome measures.
The inclusion criteria were developed This review focused exclusively on
using the PICOS guidelines (Table 3). long-term studies with a minimum ob-
Data extraction
servation period after functional loading
of 5 years. In addition, at least 10 Data were extracted by one reviewer (TSJ)
Inclusion criteria
patients had to be included in the study, using a pre-prepared data collection form
Human studies assessing the long-term and the number of inserted implants and in order to ensure systematic recording of
implant treatment outcomes after MSFA MSFA procedures had to be clearly the outcome measures. In addition, rele-
with particulated autogenous bone graft specified. vant characteristics of the study were

searching hand-searching
n = 1824 n=0

n = 1824
Screening

Abstracts screened Abstracts excluded

n = 96 n = 70
Eligibility

for eligibility with reasons

n = 26 n = 17
Included

Studies included in

n=9

Fig. 1. PRISMA flow diagram demonstrating the results of the systematic literature search.
106 Starch-Jensen et al.

Table 3. PICOS guidelines.

Patients or population (P) Healthy patients with atrophy of the posterior part of the maxilla receiving MSFA.
Intervention (I) MSFA with a particulated autogenous bone graft using the lateral window technique.
Comparator or control group (C) MSFA with a mixture of particulated autogenous bone graft and bone substitutes, or with
bone substitutes alone.
Outcomes (O) Primary outcome measures were the survival of suprastructures and survival of implants.
Secondary outcome measures were the implant stability quotient, peri-implant marginal bone
loss, bone regeneration, patient-reported outcome measures, and complications.
Study design (S) Long-term human studies (5 years), including randomized controlled trials, controlled
clinical trials, prospective cohort studies, and retrospective studies, with the aim of comparing
MSFA with particulated autogenous bone graft to MSFA with a mixture of particulated
autogenous bone graft and bone substitutes or bone substitutes alone.
Focused question Are there any differences in the long-term implant treatment outcomes between MSFA with
particulated autogenous bone graft and MSFA with a mixture of particulated autogenous bone
graft and bone substitutes or bone substitutes alone?
MSFA, maxillary sinus floor augmentation.

Table 4. Quality rating system. Results

Classification of the potential risk of bias:
 Random selection in the population (yes/no)
 Definition of inclusion and exclusion criteria (yes/no)
 Report of losses to follow-up (yes/no)
 Validated measurements (yes/no)
 Statistical analysis (yes/no)
The included studies were categorized as follows:
 Low risk of bias (plausible bias unlikely to seriously alter the results) if all the quality criteria
described above were met
 Moderate risk of bias (plausible bias that weakens confidence in the results) if one of these
criteria was not met
 High risk of bias (plausible bias that seriously weakens confidence in the results) if two or
more criteria were not met
recorded. The corresponding author was
contacted by e-mail if important informa-
tion was missing or in the event of ambi-
guity.
Data synthesis
Meta-analyses were to be conducted only
if there were studies of similar compari-
sons, reporting the same outcome mea-
sures. However, the studies included
revealed considerable variations in study
design, i.e. length of the graft healing
period, types of suprastructures and
implants, immediate or delayed implant
placement, different time frames between
implant installation and the start of pros-
thetic loading, lengths of implants, sub-
merged or non-submerged implant
insertion, presence or absence of a barrier
membrane on the lateral window, length
of the observation period, and types of
outcome measure. Therefore, a well-de-
fined meta-analysis was not possible.
However, the differences in the propor-
tions of patient-based implant survival
across nine similar studies were analysed
and forest plots drawn to show a summary
of patient-based implant survival; this was
done for the overall results and for the
results by subgroup according to graft
material and time of implant placement.
The summary patient-based implant sur-
vival rate was expressed as the mean
percentage with the 95% confidence inter-
val (CI).
Assessment of heterogeneity
The significance of any discrepancies in
the estimates of the treatment effects of the
different studies was assessed by means of
Cochran’s test for heterogeneity and the I2
statistic, which describes the percentage of
total variation across studies that is due to
heterogeneity rather than chance. Hetero-
geneity was considered statistically signif-
icant if P < 0.1. A rough guide to the
interpretation of I2 given in the Cochrane
Handbook for Systematic Reviews of
Interventions23 is as follows: (1) at 0–
40% the heterogeneity might not be im-
portant, (2) 30–60% may represent mod-
erate heterogeneity, (3) 50–90% may
represent substantial heterogeneity, and
(4) 75–100% may represent considerable
heterogeneity.
Exclusion of studies
The reasons for excluding studies after
full-text assessment were as follows: the
study could not be excluded before metic-
ulous reading (n = 9), the follow-up period
was less than 5 years (n = 5), insufficient
description of the surgical procedure and
implants inserted (n = 2), the same patient
sample with a 10-year observation period
was reported in another publication
(n = 1).
Characteristics of the studies included
The results of the search strategy are out-
lined in Fig. 1. A total of 1824 titles were
identified and 96 abstracts were reviewed.
The full-text analysis included 26 articles.
Nine studies were finally included in this
systematic review, comprising one com-
parative study and eight non-comparative
studies24–32. No articles were included as a
result of the hand-search. One study was
excluded33, because the same patient sam-
ple with a 10-year observation period was
reported in another included publication30.
The autogenous bone grafts were
harvested locally25, from the chin24,25,30,
tuberosity area29, the ascending mandi-
bular ramus25,32, or posterior ilium25.
Bio-Oss (xenograft) was used in seven
studies24,25,27–31 and Apatos (xenograft)
was used in one study26. Synthetic bone
substitutes (Ceros and BoneCeramic)
were used in two studies25,31. Different
implant systems were used in the
studies: Nobel Biocare24,30,32, Strau-
mann24,25,27,28,31, Friadent24, Astra
Tech24, Zimmer Dental29, and Bone
System26.
Autogenous bone graft from the chin
was compared to Bio-Oss alone in a 5-year
retrospective study24. The non-compara-
tive studies included a 10-year retrospec-
tive study evaluating MSFA with
autogenous bone graft from the ascending
Table 5. Comparative studies assessing maxillary sinus floor augmentation with autogenous bone graft, a mixture of autogenous bone graft and bone substitutes, or bone substitutes alone.
Primary
outcome
Materials and methods measures Secondary outcome measures
Author Patients
Implants Survival of:
MSFA Graft RBH (mm) Prosthetic solution LOP ISQ PIMBL (mm) Bone regeneration PROM
SIP DIP SS Implants GHR >25%:
Lutz et al. 201524 23 23 Bone 100% – 70 3.3 ND 60 ND 97.1% ND ND 8.7% ND
24 24 Bio-Oss 100% – 98 2.7 94.9% 4.2%
DIP, delayed implant placement; GHR, grafted height reduction; ISQ, implant stability quotient; LOP, length of observation period (in months); MSFA, maxillary sinus floor augmentation; ND, no
data; PIMBL, peri-implant marginal bone loss; PROM, patient-reported outcome measures; RBH, residual bone height; SIP, simultaneous implant placement; SS, suprastructures.

Table 6. Non-comparative studies assessing maxillary sinus floor augmentation with autogenous bone graft, a mixture of autogenous bone graft and bone substitutes, or bone substitutes alone.
Primary outcome
Materials and methods measures Secondary outcome measures
Author Patients
Implants RBH Prosthetic Survival of Bone
MSFA Graft (mm) solution LOP ISQ PIMBL (mm) regeneration PROM
SIP DIP SS Implants
Bornstein et al. 200825 56 59 Bio-Oss or Ceros 50% – 111 <4 Single or splinted 60 ND 98% ND ND ND ND
and bone 50% crowns
Scarano et al. 201026 113 153 Apatos 100% – 264 2–3 ND 60 ND 92% ND 2.6  1.4 ND ND
Özkan et al. 201127 28 42 Bio-Oss 100% 84 – 5.2 Crown or fixed 60 ND 100% ND 1 year: 0.15 GSH, mm ND
partial denture
5 years: 0.34 Year 0: 6.80

Long-term studies on sinus floor augmentation

Year 5: 5.32
Oliveira et al. 201228 10 13 Bio-Oss 100% – 24 <4 Crown or fixed 96 ND 100% ND ND ND ND
bridge
Cannizzaro et al. 201329 19 19 Bio-Oss 50% and 44 – 4.35  1.7 Fixed prosthesis 60 ND 89% 71.7 1 year: 0.4  0.2 ND ND
bone 50%
5 years: 0.7  0.4
Mordenfeld et al. 201430 14 22 Bio-Oss 80% and – 53 <5 Fixed bridge 120 92.9% 91.4% 70.2 Baseline: 0.4  0.9 GSH, mm ND
bone 20%
5 years: 1.2  1.4 3 months: 15.8
10 years: 1.5  0.9 1 year: 14.7
2 years: 14.0
10 years: 13.3
Mordenfeld et al. 201531 11 11 BoneCeramic 100% – 24 <5 Fixed bridge 60 100% 91.7% ND 1.4  1.2 GHR ND
6 years: 6.6%
11 Bio-Oss 100% – 23 100% 91.3% 1.0  0.7 6 years: 5.8%
Nissen et al. 201632 24 34 Bone 100% 13 24 ND Single crowns 120 84% 100% ND 1 year: 0.5  0.5 GHR PES: 9
10 years: 0.6  0.9 1 year: 6.9% WES: 8
5 years: 14.9% VAS >90
DIP, delayed implant placement; GHR; grafted height reduction; GSH, grafted sinus height; ISQ, implant stability quotient; LOP, length of observation period (in months); MSFA, maxillary sinus floor
augmentation; ND, no data; PES, pink aesthetic score; PIMBL, peri-implant marginal bone loss; PROM, patient-reported outcome measures; RBH, residual bone height; SIP, simultaneous implant
placement; SS, suprastructures; VAS, visual analogue scale; WES, white aesthetic score.

107
108 Starch-Jensen et al.

One fixed bridge lost due New implants and bridge

Suprastructures restored
mandibular ramus32. Different mixtures of

Re-contouring contact

Surgical treatment of
autogenous bone graft and bone substi-

peri-implantitis: 1
Treatment
tutes were assessed in three prospective
studies after 5 and 10 years25,29,30, while

New crown: 1
bone substitutes alone were assessed in
four prospective studies after 5 and 8

point: 1
years26–28,31.

ND

ND

ND

ND

ND

ND
The residual vertical height of the alve-
olar process was less than 5.2 mm in all of
the included studies24–32. Immediate im-

Peri-implant mucositis:
Fracture of connecting

cementation failure: 6
Food accumulation: 1

Ceramic fracture and

plant installation was performed in three

Crown loosening: 1
Ceramic fracture: 4
Washout cement: 6
complications

to loss of implants
studies27,29,32, while delayed installation

Prosthetic
after 4 to 8 months was performed in seven
studies24–26,28,30–32. The prosthetic solu-

screw: 1
tions were fixed restorations25,27–32, but
the type of prosthetic solution was not

ND

Most of graft ND

ND

ND

ND
reported in two studies24,26. The compar-

1
ative study only evaluated implant surviv- Consequence

material lost
al and the reduction in graft height, while

implants: 4
the non-comparative studies reported on

Loss of
all outcome measures. The main results
ND

ND

ND

ND

Antibiotics ND

ND
ND
are described below and are summarized
in Tables 5–7.
Treatment

Incised,
drained

Methodological quality
ND

ND

ND

ND

ND

ND
ND
The quality of the review studies is sum-
marized in Table 824–32. A moderate risk

oedema, pain: 38%

complications
Postoperative

Acute infection

of bias was found in the comparative

regeneration: 2
Nose bleed: 5

complications

infection: 7%
Postoperative

Postoperative
with abscess

study, since no randomization was per-

Sinusitis: 1
No clinical

Abscess: 1
formed24. The risk of bias was found to
No bone

be low for two of the non-comparative

Table 7. Reported complications after maxillary sinus floor augmentation in the studies included.

ND

ND

ND
studies, one assessing two different bone
substitutes31 and the other assessing the
Consequence

installation of standard length implants in

Uneventful

conjunction with MSFA compared to

short implants29. All of the other non-
healing

comparative studies demonstrated a high

ND

ND

ND

ND

ND

ND

ND
risk of bias25–28,30,32. ND
Smaller SMP sealed with

or resorbable membrane
SMP sealed with fibrin

Arterial bleeding: 2 Handled with cautery

resorbable membrane

resorbable membrane

resorbable membrane

Outcome measures
Treatment

SMP sealed with

SMP sealed with

SMP sealed with

For each outcome measure, the results of

collagen fleece

the comparative study on MSFA with

autogenous bone graft compared to the
bone substitute alone are presented first
ND

ND

ND

ND

(Table 5). The results of the non-compar-

ative studies involving solely MSFA with
ND, no data; SMP, sinus membrane perforation.

autogenous bone graft, a mixture of

Intraoperative
complications

autogenous bone graft and bone substi-

complications

tutes, or bone substitutes alone then follow

SMP: 31%

SMP: 13%

SMP: 10%

Mordenfeld et al. 201430 SMP: 30%

SMP: 32%

(Table 6). Finally, a summary is provided

No major

No SMP

for each outcome measure. All reported

numerical values are presented as mean
ND

Mordenfeld et al. 201531 ND

values.
Cannizzaro et al. 201329
Bornstein et al. 200825

Oliveira et al. 201228

Scarano et al. 201026

Primary outcome measures

Nissen et al. 201632
Özkan et al. 201127
Lutz et al. 201524
Author

Survival of suprastructures
No comparative studies reporting the sur-
vival of suprastructures were identified.
In the non-comparative studies, the 10-
year survival of suprastructures was 84%
 Long-term studies on sinus floor augmentation 109

Random selection in the population Definition of inclusion and exclusion criteria Report of losses to follow-up Validated measurements Statistical analysis Risk of bias
after MSFA with autogenous bone graft was 91.4%30. The study included 14

Moderate
from the ascending mandibular ramus32. patients and the delayed placement of
High All patients were rehabilitated with fixed 53 implants in 22 augmented sinuses.
High
High
High

High

High
Low

Low
single crowns. All suprastructures were in
function at the 10-year follow-up exami-
nation, but six suprastructures had previ-
ously been restored due to ceramic
fracture and cementation failure32.
The 10-year survival of suprastructures
Yes
Yes
Yes
The 5-year implant survival rate after
MSFA with a mixture of 50% autogenous
bone graft and 50% bone substitute in two
different studies was 89% and 98%, re-
spectively25,29.
The 5-year implant survival rate after

Yes
Yes
Yes
Yes
Yes
No

was 92.9% after MSFA with a mixture of MSFA with different bone substitutes
20% autogenous bone graft from the chin alone varied between 92% and
and 80% Bio-Oss30. All patients were 100%26,27,31. The 5-year implant survival
rehabilitated with fixed bridges. One fixed after bilateral MSFA in 11 patients with
bridge was lost due to loss of implants. either Bio-Oss or BoneCeramic and the
New implants were inserted and a new delayed placement of 23 and 24 implants
fixed bridge was fabricated; these were in was 91% (Bio-Oss) and 92% (BoneCera-
function at the 10-year follow-up exami- mic)31. The 8-year implant survival rate
nation30.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

after MSFA with Bio-Oss alone and the

The 5-year survival of the suprastruc-
ture was 100% after MSFA with two
different bone substitutes alone31. All
patients were rehabilitated with a fixed
prosthetic construction, and all were in
function at the 5-year follow-up examina-
tion31.
In summary, the long-term (5 years)
survival of suprastructures after MSFA
Yes
delayed installation of 24 implants in 10
patients was 100%28.
In summary, there was no statistically
significant difference in the long-term
(5 years) survival of implants after
MSFA with autogenous bone graft com-
pared to Bio-Oss, as evaluated in a retro-
spective study. The non-comparative
studies showed high long-term implant

Yes

Yes
Yes
Yes
Yes
Yes
No

No

with autogenous bone graft, a mixture of
autogenous bone graft and bone substi-
tutes, and bone substitutes alone has never
been compared within the same study.
Non-comparative studies have demon-
strated high long-term survival of supras-
tructures after MSFA with the different
treatment modalities.
survival rates after MSFA with autoge-
nous bone graft, with different mixtures
of autogenous bone graft and various
bone substitutes, and with bone substi-
tutes alone.
Secondary outcome measures

Survival of implants Implant stability quotient (ISQ)

In the comparative study, the 5-year im-
plant survival after MSFA with autoge-
nous bone graft from the chin was 97.1%,
compared to 94.9% for Bio-Oss24. There
Yes
No comparative studies reporting the im-
plant stability quotient were identified.
In the non-comparative studies, the 10-
year ISQ value after MSFA with a mixture

Yes

Yes
Yes
No

No
No

No

No

was no statistically significant difference
between the two treatment modalities.
MSFA was performed in 23 patients with
autogenous bone graft and in 24 patients
Table 8. Quality assessment of the included studies.
of 20% autogenous bone graft from the
chin and 80% Bio-Oss was 70.230. There
was no statistically significant difference
in ISQ between implants placed in grafted
bone and implants placed in host bone30.

with Bio-Oss alone. After 4 to 6 months of

healing, 70 implants were inserted in the
sinuses augmented with autogenous bone
and 98 implants in the sinuses augmented
with Bio-Oss. Prosthetic rehabilitation
was performed 4 months later24. All
patients participated in the 5-year fol-
low-up examination.
Cannizzaro et?al. 2013 Yes
The 5-year ISQ value after MSFA with a
mixture of 50% autogenous bone graft
from the tuberosity and 50% Bio-Oss
was 71.729. The ISQ value increased from
68.9 at abutment connection to 71.5 after 1
year of loading29.
In summary, the ISQ value after MSFA

Mordenfeld et?al. 201531 Yes

Bornstein et?al. 200825 No
No
No
No

Mordenfeld et?al. 201430 No

No
No

In the non-comparative studies, the 10- with autogenous bone graft, a mixture of
year implant survival after MSFA with autogenous bone graft and bone substi-
29

autogenous bone graft from the ascending tutes, and bone substitutes alone has never
Oliveira et?al. 201228
Scarano et?al. 201026

Nissen et?al. 201632

Özkan et?al. 201127

mandibular ramus was 100%32. The study been compared within the same study.
Lutz et?al. 201524

included 24 patients and 37 implants (si- Non-comparative studies demonstrated

multaneous/delayed implant placement: no significant difference in the ISQ value
13/24) inserted in 34 augmented sinuses32. between implants inserted in sinuses aug-
Reference

The 10-year implant survival after mented with a mixture of autogenous bone
MSFA with a mixture of 20% autogenous graft and bone substitute and implants
bone graft from the chin and 80% Bio-Oss inserted in host bone, after 10 years.
110 Starch-Jensen et al.
Peri-implant marginal bone loss
No comparative studies reporting peri-im-
plant marginal bone loss were identified.
In the non-comparative studies, the ra-
diographic peri-implant marginal bone
loss after MSFA with autogenous bone
graft from the ascending mandibular ra-
mus was 0.5 mm after 1 year and
0.6 mm after 10 years32. Panoramic
radiographs obtained after implant instal-
lation were compared to radiographs taken
after 1 year and 10 years. The marginal
bone level was measured mesial and distal
to the implant from the implant/abutment
connection to the bone level32.
The 10-year radiographic peri-implant
marginal bone loss after MSFA with 20%
autogenous bone graft from the chin and
80% Bio-Oss was 1.5 mm30. Intraoral
radiographs obtained at abutment connec-
tion were compared to radiographs taken
after 1 year, 3 years, 5 years, and 10 years.
The marginal bone level was measured
mesial and distal to the implant from a
defined reference point (0.8 mm apical to
the implant/abutment connection) to
the bone level. The 5-year radiographic
peri-implant marginal bone loss after
MSFA with 50% autogenous bone graft
from the tuberosity and 50% Bio-Oss was
0.72 mm compared to 0.26 mm at the
initial loading and 0.44 mm after 1
year29. The peri-implant marginal bone
level was assessed by intraoral radio-
graphs obtained with the paralleling tech-
nique at implant placement, at delivery of
the provisional prosthesis, and at 1 and 5
years after loading. The marginal bone
level was measured mesial and distal to
the implant from the coronal margin of
the implant collar and the most coronal
point of bone-to-implant contact. There
was a statistically significant gradual peri-
-implant marginal bone loss for all time
periods29.
The 5-year radiographic peri-implant
marginal bone loss after MSFA with
bone substitutes alone varied between
0.34 mm and 2.6 mm26,27,31. The 5-
year radiographic peri-implant marginal
bone level differences after MSFA with
BoneCeramic and Bio-Oss were 1.4 mm
and 1.0 mm, respectively31. There were
no statistically significant differences in
the peri-implant marginal bone level be-
tween the two bone substitutes. The mar-
ginal bone level was measured mesial and
distal to the implant from a defined refer-
ence point to the bone level at baseline
(delivery of the prosthetic reconstruction),
1 year, 3 years, and 5 years. The 5-year
marginal bone level change was 0.7 mm
with BoneCeramic and 0.5 mm with
Bio-Oss31. In another study, the radio-
graphic peri-implant marginal bone loss
after MSFA with Bio-Oss was 0.15 mm
after 1 year and 0.34 mm after 5 years27.
Panoramic radiographs obtained after im-
plant installation were compared to radio-
graphs taken after 1 year and 5 years. The
peri-implant marginal bone loss was mea-
sured mesial and distal to the implant from
the implant/abutment connection to the
bone level27. The 5-year radiographic pe-
ri-implant marginal bone loss after MSFA
with Apatos was 2.6 mm26. Postopera-
tive panoramic radiograph and/or peri-api-
cal radiographs were compared with
radiographs taken after 5 years26.
In summary, the peri-implant marginal
bone loss after MSFA with autogenous
bone graft, a mixture of autogenous bone
graft and bone substitutes, and bone sub-
stitutes alone has never been compared
within the same study. The majority of
non-comparative studies demonstrated
limited long-term (5 years) peri-implant
marginal bone loss after MSFA with the
three treatment modalities. However, a
significant gradual peri-implant marginal
bone loss was observed from baseline to
the 5-year follow-up examination.
Bone regeneration
In the comparative study, the 5-year re-
duction in the augmented sinus height
after MSFA was compared between au-
togenous chin bone graft and Bio-Oss
using two-dimensional panoramic radio-
graphs24. This study demonstrated a com-
parable long-term reduction in the
augmented sinus height for the two treat-
ment modalities24. However, no statistical
test was used. No vertical height reduction
was found in 43.5% of the augmented
areas with autogenous bone graft com-
pared to 50% with Bio-Oss. An augment-
ed sinus height reduction up to 50% was
reported in 8.7% with an autogenous bone
graft and 4.2% with Bio-Oss24.
In the non-comparative studies, the
change in grafted sinus height after MSFA
with autogenous bone graft from the as-
cending mandibular ramus was 6.9% after
1 year and 14.9% after 10 years32. Pan-
oramic radiographs obtained before and
after MSFA and at 1 year and 10 years
after loading were used for two-dimen-
sional linear measurements from the mar-
ginal crest to the inferior border of the
maxillary sinus to estimate the changes in
the graft material.
The grafted sinus height after MSFA
with 20% autogenous bone graft from the
chin and 80% Bio-Oss was 13.3 mm at 10
years, compared to 15.8 mm after 3
months, 14.7 mm after 1 year, and
14.0 mm after 2 years30. There was a
statistically significant reduction in
grafted sinus height between 3 months
and 2 years, and between 3 months and
10 years. However, there was no statisti-
cally significant reduction in sinus height
between 2 years and 10 years after graft-
ing. Two-dimensional radiographic linear
measurements of the augmented sinus
were performed on panoramic radio-
graphs, cross-sectional tomograms, and
cone beam computed tomography
images30.
The reduction in grafted sinus height
after MSFA with Bio-Oss was 5.8% at 6
years31. There were no statistically signif-
icant differences in grafted sinus height at
different time points. The grafted sinus
height decreased from 14.8 mm at base-
line to 14.2 mm after 2 years, 14.1 mm
after 4 years, and 14.0 mm after 6 years.
Two-dimensional linear measurements on
panoramic radiographs were used to esti-
mate the changes in the augmented sinus
height from baseline to 6 years after graft-
ing31. In another study, the 5-year grafted
sinus height after MSFA with Bio-Oss was
5.32 mm compared to 6.80 mm immedi-
ately after surgery and 5.54 mm at 1 year
after implant placement27. Two-dimen-
sional linear measurements on panoramic
radiographs were used to estimate the
changes in the augmented sinus height,
disclosing a statistically significant gradu-
al reduction in grafted sinus height27.
In summary, long-term changes in the
augmented sinus height after MSFA with
autogenous bone graft compared to Bio-
Oss seem to be minimal and equivalent
based on two-dimensional panoramic ra-
diograph measurements. The different
treatment modalities demonstrated a grad-
ual reduction in the original augmented
sinus height over time; this reduction
appears to be more pronounced during
the first years after MSFA.
Patient-reported outcome measures
No comparative studies describing
patient-reported outcome measures were
identified.
One non-comparative study reported
the patients’ appreciation of the final im-
plant treatment outcome after MSFA with
autogenous bone graft from the ascending
mandibular ramus32. This was assessed
at 10 years using a questionnaire that
covered the overall aesthetic outcome,
appearance of the implant crown and pe-
ri-implant soft tissue, implant function,
and satisfaction with the total implant
treatment in general using a visual

analogue scale (VAS)32. A VAS score
higher than 90 was reported for all mea-
surements. Professional evaluation of the
long-term implant treatment outcome was
evaluated using the pink and white aes-
thetic scores, demonstrating a pink aes-
thetic score of 9 (maximum 14) and white
aesthetic score of 8 (maximum 10)32.
In summary, patient-reported outcome
measures have never been reported in
comparative studies. A non-comparative
study revealed high long-term patient sat-
isfaction with the final implant treatment
outcome after MSFA with autogenous
bone graft from the ascending mandibular
ramus.
Complications
No intra- or postoperative complications
were reported after MSFA with autoge-
nous bone graft compared to Bio-Oss after
5 years in the comparative study included
in this review24. The surgical procedure
and postoperative wound healing were
uneventful, but an unspecified number
of sinus membrane perforations were
reported.
In the non-comparative studies, perfo-
ration of the sinus membrane was the most
frequent intraoperative complication,
varying from 0% to 32%24–26,28–30,32.
Smaller perforations were left untreated,
while larger perforations were sealed with
fibrin, collagen fleece, or a resorbable
membrane24–26,29,32. One study reported
that the long-term implant treatment
outcome was not influenced by the intra-
operative perforation of the sinus mem-
brane25. Postoperative infection, swelling,
mild postoperative oedema, pain, and nose
bleeds were reported infrequently26,30,32,
but four implants in two patients were
removed due to an abscess and severe
sinusitis, while most of the graft material
was lost in another case due to acute
infection after MSFA with a mixture of
autogenous bone graft and bone substi-
tute25,29.
Long-term prosthetic complications
were reported and consisted of ceramic
fracture, cementation failure, and fracture
of the connecting screw27,29,32.
In summary, the frequency and severity
of complications with the different treat-
ment modalities seem to be comparable.
Intra- and postoperative complications af-
ter MSFA were not reported in all includ-
ed studies, but when reported, they were
generally infrequent and not severe. Per-
foration of the sinus membrane was the
most frequent intraoperative complica-
tion, but this does not seem to influence
the final implant treatment outcome.
Long-term studies on sinus floor augmentation 111
Meta-analysis outcomes after MSFA with autogenous
bone graft compared to a mixture of au-
Since the majority of the studies were non-
togenous bone graft and bone substitutes
comparative, a meta-analysis of propor-
or bone substitutes alone. Primary out-
tions was used to draw the forest plots.
come measures were the survival of
Patient-based implant survival was used
suprastructures and survival of implants.
rather than implant-level survival, to avoid
Secondary outcome measures included the
introducing dependence between observa-
ISQ, peri-implant marginal bone loss,
tions. Hence, the outcome variable is bi-
bone regeneration, patient-reported out-
nary: whether the patient has lost any
come measures, and complications.
implants or not.
A total of one comparative long-term
For the analysis of data at the patient-
study and eight non-comparative long-
based implant level, the comparative study
term studies using the lateral window
was regarded as two independent stud-
technique were included24–32. High sur-
ies24. Also, for the study by Mordenfeld
vival rates were found for the suprastruc-
et al. 201531, no distinction was made
tures and implants, regardless of the graft
between the two bone substitutes; the
material used. Moreover, a high ISQ, high
results were combined, and it was instead
patient satisfaction, and limited peri-im-
considered a study of 11 patients with 22
plant marginal bone loss were reported
MSFA procedures and 47 delayed inserted
with the different treatment modalities.
implants with implant loss in three
However, no long-term randomized con-
patients. The mean implant survival value
trolled clinical trial comparing the differ-
for the two treatment modalities was cal-
ent treatment modalities was identified.
culated to be 91.5%31.
Hence, the conclusions drawn from the
The Freeman–Tukey algorithm was
results of this systematic review should
used to deal with the points near the end
be interpreted with caution.
of the range, especially in the studies with
The primary outcome measures are the
a 100% implant survival rate27,28,32. In
most important measures for the assess-
addition, a test of heterogeneity was per-
ment of long-term implant treatment out-
formed, which showed no reason to use a
comes. However, secondary outcome
fixed-effects method: none of the studies
measures were also included in this sys-
dominated the analysis by having a weight
tematic review as surrogate measures, as
of 50% or more, and the test for heteroge-
well as non-comparative studies involving
neity demonstrated a significant amount of
solely MSFA with the different treatment
heterogeneity (P = 0.01 and I2 = 56.27%).
modalities due to the lack of comparative
Hence, a random-effects method was
studies.
used. The summary patient-based implant
As stated previously, the survival of the
survival was calculated as a weighted
suprastructures after MSFA with the dif-
average of the implant survival in each
ferent treatment modalities has never been
study. The weight was the proportion of
compared within the same study. The
patients in each study relative to the total
survival of suprastructures was reported
number of patients in the studies.
in some of the non-comparative studies,
The meta-analysis showed an overall
and all suprastructures were in function
estimated patient-based implant survival
at the 5-year and 10-year follow-up
of 94% (95% CI 0.88–0.98) (Fig. 2). The
examinations30–32.
timing of implant placement demonstrated
The placement of oral implants in par-
that the overall estimated patient-based
tially or totally edentulous patients with-
implant survival for delayed implant
out bone augmentation has demonstrated
placement was 94% (95% CI 0.91–0.97)
high long-term implant survival rates, as
compared to 98% (95% CI 0.91–1.00) for
documented in several reviews and long-
simultaneously inserted implants (Fig. 3).
term studies34–37. A systematic review has
The overall estimated patient-based im-
indicated that implant loss before func-
plant survival according to the graft mate-
tional loading is expected to occur in about
rial used was 98% (95% CI 0.89–1.00) for
2.5% of all inserted implants and in about
autogenous bone graft, 95% (95% CI
2–3% of implants supporting fixed recon-
0.88–0.99) for autogenous bone graft
structions during functional loading, while
mixed with bone substitutes, and 95%
in overdenture therapy more than 5% of
(95% CI 0.90–0.98) for bone substitute
the implants can be expected to be lost
alone (Fig. 4).
during a 5-year period38. Another system-
atic review and meta-analysis assessing
Discussion
implant survival after MSFA, estimated
The objective of this systematic review that the annual implant failure rate was
was to test the hypothesis of no difference 3.48%, which was translated into a 3-year
in long-term (5 years) implant treatment implant survival of 90.1%39.
112 Starch-Jensen et al.
Fig. 2. Overall estimated patient-based implant survival with no implant loss. Abbreviations: ES, estimated survival; CI, confidence interval.
In the present systematic review, the
long-term (5 years) implant survival
varied between 89% and 100% after
MSFA with autogenous bone graft, differ-
ent mixtures of autogenous bone graft and
bone substitutes, and bone substitutes
alone24–32. No statistically significant dif-
ference in implant survival was found after
MSFA with autogenous bone graft com-
pared to Bio-Oss in a non-randomized
retrospective study24. Moreover, the
meta-analysis showed no statistically sig-
nificant differences in the summary pa-
tient-based implant survival rates
regardless of the graft material used and
the timing of implant placement. A previ-
ously published systematic review
revealed that the available evidence on
implant survival neither supported nor
refuted the superiority of autogenous bone
graft over other graft materials for
MSFA12. Thus, MSFA appears to be a
predictable surgical procedure with high
long-term implant survival regardless of
the graft material used. However, the
number of studies focusing on long-term
(5 years) implant survival after MSFA
with the different treatment modalities
was found to be limited, and only one
non-randomized long-term comparative
study was identified24.
The bone quantity and quality is
regarded as an important factor for obtain-
ing osseointegration and determining the
timing of prosthetic loading, but the heal-
ing period following grafting and implant
placement before loading differed consid-
erably among the studies included in the
present systematic review24–32. Very re-
cently published systematic reviews asses-
sing histomorphometric variables
concluded that the autogenous bone graft
results in the highest amount of newly
formed bone in comparison to various
bone substitutes, although allografts, allo-
plastic materials, and xenografts appear to
be good alternatives to autogenous bone
grafts for MSFA20,21. Moreover, a meta-
analysis assessing the total bone volume
after MSFA based on histomorphometric
analysis demonstrated a significantly
higher proportion of mineralized bone
during the early healing phase when au-
togenous bone was used as graft material
as compared with various bone substitutes
used alone or in combination with autog-
enous bone40. However, following a heal-
ing period of more than 9 months, no
statistically significant differences were
found between the different treatment mo-
dalities40.
The studies included in the present sys-
tematic review used different graft healing
periods and time frames between surgical
installation procedures and the start of
prosthetic loading24–32. A graft healing
time of 4 to 6 months before the installa-
tion of implants and an additional 4-month
healing period before implant loading
showed an equivalent implant survival
rate after MSFA with autogenous bone
graft and Bio-Oss alone24. A non-compar-
ative study revealed a 100% implant sur-
vival rate after MSFA with Bio-Oss alone,
in which the mean graft healing period
was 13.8 months before implant installa-
tion, with a further 8.7 months of healing
before loading28. However, MSFA with
50% tuberosity bone graft mixed with
50% Bio-Oss and simultaneous installa-
tion of implants demonstrated an implant

Fig. 3. Overall estimated patient-based implant survival with no implant loss according to the time of implant placement. Abbreviations: DIP,
delayed implant placement; SIP, simultaneous implant placement; ES; CI, confidence interval.
survival of 89%; the implants were loaded
after 45 days29. Consequently, the optimal
healing time for the graft material and
implants before loading after MSFA with
autogenous bone graft, a mixture of au-
togenous bone graft and bone substitutes,
or bone substitutes alone is presently un-
known. Nevertheless, a prolonged healing
period for the graft material after MSFA
with bone substitutes alone seems to be
rational.
A higher ISQ value can be regarded as
an indication of improved implant stabili-
ty41. Non-comparative studies revealed
that the long-term ISQ value after MSFA
with different mixtures of autogenous
bone graft and Bio-Oss was higher than
7029,30. Moreover, no statistically signifi-
cant difference in the ISQ level was found
between implants placed in grafted bone
and implants placed in host bone30. Previ-
ous studies focusing on the ISQ have
revealed a significant association between
ISQ values below 40 and failed implants,
while others have concluded that ISQ
values below 50 are critical for implant
survival42,43. It has also been reported that
Long-term studies on sinus floor augmentation
implants with ISQ values higher than 50
show an implant survival of 100% after 12
months44. Nevertheless, an implant sur-
vival rate of 89% was reported after im-
mediate implant installation and MSFA
using 50% tuberosity bone and 50%
Bio-Oss, with an average ISQ value of
69 after an implant healing period of 45
days, increasing to 72 at the 5-year follow-
up examination29. Consequently, MSFA
with the different treatment modalities
seems to facilitate acceptable long-term
ISQ values.
Several factors may influence peri-im-
plant marginal bone loss, including smok-
ing, poor hygiene practices, systemic
medical conditions, parafunctional habits,
different connections between the implant
and suprastructure, implant neck design,
and implant surface45–47. According to
Albrektsson et al., a criterion of successful
implant treatment is marginal bone loss of
less than 1–1.5 mm during the first year
after implant loading and less than 0.2 mm
annually, which in turn corresponds to a
maximum of 2.3 mm over 5 years and
3.3 mm after 10 years46,47.
113
Most of the studies included in this
systematic review disclosed a gradual pe-
ri-implant marginal bone loss; only one
did not meet these long-term success cri-
teria26. A total of 246 Bone System
implants were inserted 4 to 6 months after
MSFA with sterilized porcine mixed bone
particles (Apatos). The mean peri-implant
marginal bone loss was 2.1 mm after
1 year and 2.6 mm after 5 years26. It has
been stated that only Astra Tech, Nobel
Biocare, and Straumann dental implant
systems have scientific documentation
on peri-implant marginal bone loss in
terms of two or more 5-year prospective
clinical studies, showing a mean marginal
bone loss over 5 years well below the
previously accepted recommendations47.
Therefore, a mean marginal bone loss of
2.6 mm after 5 years may be considered
remarkable26.
In all of the studies included in this
systematic review, the major part of the
peri-implant marginal bone loss occurred
during the first year after prosthetic load-
ing, which is in accordance with previous-
ly published studies assessing long-term
114 Starch-Jensen et al.
Fig. 4. Overall estimated patient-based implant survival with no implant loss according to the graft material used. Abbreviations: ES; CI,
confidence interval.
marginal bone level changes with different
implant systems47,48. Moreover, no sta-
tistically significant differences in margin-
al bone level from 3 to 10 years have been
documented between implants placed in
residual bone and implants placed in
grafted bone30. Therefore, the results of
the present systematic review indicate ac-
ceptable long-term peri-implant marginal
bone loss after MSFA with the different
treatment modalities.
A recently published systematic review
assessing volume changes after MSFA
reported that some loss of augmentation
volume always occurs during the early
healing phase19. Autogenous bone graft
revealed a greater reduction in the aug-
mented volume compared to composite
grafts or bone substitutes alone. However,
the augmentation volume loss did not
seem to compromise implant placement
or implant survival19. Long-term changes
in the augmented sinus height after MSFA
with autogenous bone graft compared to
Bio-Oss appeared to be minimal and
equivalent based on measurements made
on two-dimensional panoramic radio-
graphs24. Moreover, the different treat-
ment modalities presented in this
systematic review revealed a gradual re-
duction of the original augmented sinus
height over time, but the reduction seemed
to be more pronounced during the first
years after MSFA27,30–32. The results of
the studies described above were all based
on two-dimensional quantification. The
graft within the maxillary sinus is an
inhomogeneous and three-dimensional
anisotropic structure, which is why
three-dimensional methods should be ap-
plied in studies assessing the reduction of
the graft. Thus, more long-term studies
using three-dimensional methods are
needed to assess the volumetric stability
of the graft material after MSFA with the
different treatment modalities.
Patient-reported outcome measures are
essentially subjective reports of patient
perceptions of their oral health status
and its impact on their daily life or quality
of life. Understanding the influence of
different prosthodontic rehabilitation
options on orofacial aesthetics, chewing
function, and oral health-related quality of
life is an important prerequisite for the
selection of the best rehabilitation proce-
dure with the highest treatment effect and
lowest morbidity for the patient. The Oral
Health Impact Profile Questionnaire, Oro-
facial Esthetic Scale, and Chewing Func-
tion Questionnaire are methods commonly
used for the assessment of patient-reported
outcome measures. A few studies have
evaluated long-term patient-reported out-
come measures after the installation of
oral implants using questionnaires, reveal-
ing a high degree of patient satisfaction
with the treatment outcome49–51. These
results corroborate the findings of the
single non-comparative study reporting
such results in the present systematic re-
view32.
Intra- and postoperative complications,
including prosthetic complications, were
not reported in all studies, but when
reported, they were generally infrequent
and not severe24–30,32. Perforation of the
sinus membrane was the most frequent

intraoperative complication, but this did
not seem to influence the final implant
treatment outcome25, which is in accor-
dance with previous publications52,53.
Nevertheless, a membrane perforation
has been reported to be strongly associated
with the appearance of postoperative com-
plications52. Hence, the frequency of sur-
gical and prosthetic complications within
the studies included in this systematic
review seem to be in accordance with
the frequency of complications after
MSFA when autogenous bone grafts and
bone substitutes are used6,8,12,54.
MSFA with bone substitutes alone is
associated with obvious advantages for the
patient, including reduced morbidity, a
less invasive procedure, and a reduced
operation time. Consequently, a compari-
son of different treatment modalities for
MSFA should contain an evaluation of
donor site morbidity after autogenous
bone harvesting, an economic perspective,
and patient-related outcome measures.
However, these aspects were only
addressed superficially in one of the in-
cluded studies32.
In conclusion, the hypothesis of no dif-
ferences in long-term (5 years) implant
treatment outcomes after MSFA with par-
ticulated autogenous bone graft compared
to a mixture of particulated autogenous
bone graft and bone substitutes or bone
substitutes alone, applying the lateral win-
dow technique, could neither be confirmed
nor rejected due to the absence of long-
term randomized controlled clinical trials.
However, a non-randomized comparative
study and eight non-comparative studies
have demonstrated high long-term surviv-
al rates for suprastructures and implants
regardless of the graft material used. Thus,
MSFA with autogenous bone graft, a mix-
ture of autogenous bone graft and bone
substitutes, or bone substitutes alone, ap-
plying the lateral window technique,
seems to be a highly predictable and suc-
cessful surgical procedure to enhance the
alveolar bone height of the posterior part
of the maxilla before or in conjunction
with implant placement, and has a high
long-term implant survival rate. However,
long-term randomized clinical trials fo-
cusing on the final implant treatment out-
come, comparing the different treatment
modalities with the inclusion of patient-
reported outcome measures and donor site
morbidity, are needed before any one
treatment modality can be considered
superior to another.
Funding
None.
Long-term studies on sinus floor augmentation
Competing interests
None.
Ethical approval
Not required.
Patient consent
Not required.
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Address:
Thomas Starch-Jensen
Department of Oral and Maxillofacial
Surgery
Aalborg University Hospital
18–22 Hobrovej
DK-9000 Aalborg
Denmark
Tel: +45 97 66 27 98
Fax: +45 97 66 28 25
E-mail: thomas.jensen@rn.dk