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Sinus presurgical evaluation: A literature review and a new classification

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DOI: 10.23736/S0026-4970.17.04027-4

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VOLUME 66 . N o. 3 . JUNE 2017

PUBBLICAZIONE PERIODICA BIMESTRALE - POSTE ITALIANE S.P.A. - SPED. IN A.P.D.L. 353/2003 (CONV. IN L. 27/02/2004 N° 46) ART. I, COMMA I, DCB/CN - ISSN 0026-4970 TAXE PERçUE
© 2017 EDIZIONI MINERVA MEDICA Minerva Stomatologica 2017 June;66(3):115-31
Online version at http://www.minervamedica.it DOI: 10.23736/S0026-4970.17.04027-4

REVIEW

Sinus presurgical evaluation:

a literature review and a new classification proposal
Lorenzo TAVELLI 1 *, Andrea E. BORGONOVO 1, 2, Dino RE 1, Carlo MAIORANA 3

1Department of Oral Rehabilitation, Istituto Stomatologico Italiano, University of Milan, Milan, Italy; 2Ludes
Fondation, University of Malta, Malta; 3Department of Implant Dentistry, Ca’ Granda Ospedale Maggiore Policlinico
Milano IRCCS Foundation, University of Milan, Milan, Italy
*Corresponding author: Lorenzo Tavelli, Department of Oral Rehabilitation, Istituto Stomatologico Italiano, University of Milan, Via
Pace 21, 20122 Milan, Italy. E-mail: lorenzotavelli92@gmail.com

A B S TRACT
INTRODUCTION: Presurgical evaluation with cone beam computed tomography (CBCT) or computed tomography
(CT) has become an essential tool for diagnosis and surgical planning, including maxillary sinus floor elevation. Before
performing a sinus lift, the clinician’s attention should not be only directed to the patency of the ostium through CBCT
or CT, because many anatomical features could influence the surgical approach of sinus floor elevation. The goal of this
article was to facilitate the communication between clinicians regarding the type of maxillary sinus, encourage in-depth
analysis prior to surgery and reduce the risk of complications due to possible underestimation of important parameters.
EVIDENCE ACQUISITION: An electronic search was conducted in Pubmed, Embase, Medline and Scopus, matching
the following keywords: “sinus lift”, “CBCT”, “CT”, “presurgical” and “evaluation”. Clinical Oral Implant Research,
Implant Dentistry, International Journal of Periodontics and Restorative Dentistry and Journal of Oral Implantology were
hand-searched. The bibliographies of review articles were checked and personal references were also searched.
EVIDENCE SYNTHESIS: Eleven parameters, that clinicians must check every time through CBCT or CT, were evalu-
ated from different studies. At the end of the literature review for every single feature, the Authors established a favorable,
a normal and an unfavorable situation, in order to provide a new classification.
CONCLUSIONS: The grade of the described classification may be useful for clinicians to understand what probably the
risk level of the sinus lift surgery could be and it may encourage the surgeon to have a careful pre-operative evaluation
through CBCT or CT.
(Cite this article as: Tavelli L, Borgonovo AE, Re D, Maiorana C. Sinus presurgical evaluation: a literature review and a new
classification proposal. Minerva Stomatol 2017;66:115-31. DOI: 10.23736/S0026-4970.17.04027-4)
Key words: Cone-beam computed tomography - Maxillary sinus - Diagnosis.

Introduction maxillary sinus pneumatization.4, 5 Maxillary

sinus evaluation cannot refer only to anatomi-

D ifferent classifications of the maxillary

sinus have been proposed, but none of
them have focused on the pre-surgical evalu-
ation with cone beam computed tomography
(CBCT) prior to sinus floor elevation (SFE).
Maxillo-facial and ear-nose-throat (ENT)
surgeons proposed “anatomical” classifica-
tions that can be applied in surgical proce-
dures,1 TNM staging system 2, 3 or to analyze
cal landmarks, presence or absence of lesions
or the volumetric sinus expansion. Param-
eters such as membrane thickness, presence
of sinus septa, alveolar antral artery course,
residual bone height, must be investigated
and examined preliminarily by CBCT or CT
scans. In a recent review by Rahpeyma and
Khajehahmadi,6 the importance of CBCT
is strongly underlined and it is suggested to

Vol. 66 - No. 3 Minerva Stomatologica 115

TAVELLI SINUS PRESURGICAL EVALUATION
consider more than 10 parameters when plan-
ning a SFE through CBCT. Only with CBCT
based pre-operative planning, the clinician
could understand if SFE is possible or a risk
for complications is occurring, in order to as-
sess the level of difficulty and plan a different
approach (sinus augmentation through lateral
approach, transcrestal sinus augmentation, im-
plant insertion at the same time of the SFE,
etc.). As reported by some authors,5-9 a preop-
erative CBCT is mandatory for maxillary si-
nus augmentation.
Therefore, the proposed presurgical classifi-
cation, based on radiographic analysis, had the
following three objectives:
—— to facilitate the communication between
clinicians regarding the type of maxillary si-
nus, the surgical approach, risk level, sinus
pneumatization and the relationship between
sinus floor and teeth and many other signifi-
cant parameters;
—— to encourage clinicians to evaluate ev-
ery maxillary sinus before starting a surgery.
To make this evaluation more feasible, the
authors provided some guidelines and param-
eters that must be considered according to the
literature and their clinical experience;
—— to reduce the risk of an intra- and/or
postsurgical complications caused either by a
failed CBCT evaluation or by an underestima-
tion of certain parameters.
Data sources
The authors performed an extensive search
of the literature to identify articles published
between 1975 to November 2015, dealing with
patients who underwent preoperative CBCT or
CT prior to sinus floor elevation. An electronic
search was conducted in PubMed, Embase,
Medline and Scopus, matching the follow-
ing keywords: “sinus lift,” “CBCT,” “CT,”
“presurgical” and “evaluation”. Clinical Oral
Implant Research, Implant Dentistry, Interna-
tional Journal of Periodontics and Restorative
Dentistry and Journal of Oral Implantology
were hand-searched. The bibliographies of re-
view articles were checked and personal refer-
ences were also searched.
116 Minerva Stomatologica June 2017
Evidence acquisition
Sources selection
Studies were considered as appropriate for
inclusion if they met the following criteria: 1)
prospective or retrospective studies including
preoperative CBCT or CT scans; 2) studies
focusing on maxillary sinus features related
to the success of sinus floor elevation proce-
dure; and 3) sample size of 10 or more patients
who had undergone sinus floor elevation. The
exclusion criteria were as follows: 1) nonhu-
man studies; and 2) articles not in English.
Therefore, according to this criteria, fifty-four
articles were utilized to develop this new max-
illary sinus classification.
The authors decided to focus on certain pa-
rameters, such as anatomic variants, Schneide-
rian membrane thickness, bone condition, etc.,
that could be presurgically detected through
CBCT or CT and could influence the clini-
cian approach to the maxillary sinus surgery.
For each feature, all the selected articles were
carefully analyzed in order to establish a fa-
vorable situation, a normal situation and an un-
favorable situation, that means values or con-
ditions more or less easier to handle. Features
included in this literature review and then in
this new classification proposal are: membrane
thickness, sinus septa, angle of the buccolin-
gual maxillary sinus, teeth presence, implants
or teeth roots adjacent to sinus, buccal bone
thickness, residual alveolar ridge height, resid-
ual alveolar ridge width, sinus width, alveolar-
antral artery and visibility/oral opening.
Evidence synthesis
Is surgery possible?
A careful CBCT evaluation before sinus
floor elevation reduces the chances of intra-and
postsurgical complications, such as sinusitis,
which represents 15% of total complications
according to Timmenga et al.10 A study by
Torretta et al.7 demonstrated that a reduction
of complications is possible if the surgery was
planned in absence of ENT contraindications.
Through a CBCT or CT imaging, it is funda-
SINUS PRESURGICAL EVALUATION TAVELLI

mental to observe the appearance of maxillary membrane, absence of polypoid lesions, ab-
sinus, especially its radiolucency and the pa- sence of antral pseudocysts, mucous retention
tency of the maxillary sinus ostium which al- cysts or mucoceles (although mucous retention
lows a correct muco-ciliary clearance.11, 12 cyst or mucocele could be remove during the
According to Mantovani et al.,13 a maxillary sinus floor elevation surgery), absence of acute
sinus is considered healthy when: or chronic sinusitis with their appearance of
—— mucous compositions are regular; hydro-aerial level or complete sinus radiopac-
—— mucociliary clearance is efficient; ity, absence of suspicious lesions the could re-
—— sinus ostium is patent. flect the presence of a tumor. It must be taken
Also in case of minimal perforation or other into consideration that, in all the above men-
small procedural errors, a maxillary sinus with tioned, SFE is still allowed, after consultation
all of these features has higher chances of not with the ENT physician prior to surgery.
developing postsurgical pathologies.13 Dur- The importance of the role ENT physician
ing the presurgical analysis, the Schneiderian plays, regarding SFE procedures, is widely un-
membrane plays a major role: according to derlined in literature.7, 13, 18 A scheme regard-
some authors,14, 15 a membrane thickness of up ing the importance of case referrals to the ENT
to 2 mm is considered as physiological. How- physician is published by Shanbhag et al.11
ever, a thickness surpassing value might indi- In the present classification, a sinus is ranked
cate a higher correlation with sinusitis. Car- as grade 0 (that means not operable, unless a
meli et al.16 reported a significant correlation different referral from the ENT) when at least
between the thickness of Schneiderian mem- one of these following conditions are evident
brane of more than 5 mm and the risk of sinus (Figure 1):
ostium obstruction. Also Shanbhag et al.11 de- —— sinus ostium is not completely patent;
scribed a correlation between membrane thick- —— Schneiderian membrane has a thickness
ness and the risk of ostium obstruction: thick- >5 mm (discussed later on);
ness of up to 5 mm, 5-10 mm and more 10 mm
are correlated with a risk of ostium obstruction
of 6.7%, 24% and 35.3% respectively. In this
study, all sinuses with acute sinusitis showed
an obstruction of the ostium.
According to these authors, a flat Schneide-
rian membrane is frequently associated with a
higher thickness. Sinus floor elevation, in pa-
tients without sinus pathologies, does not af-
fect sinus physiology and its functions.10 Sinus
healing after surgery mostly depends on the ad-
equate drainage of the nasal cavity that could
be achieved only with a sinus ostium patent.
On the other hand, if the ostium is obstructed,
the drainage would be compromised result-
ing in different complications such as sinus-
itis or even a failed surgery.10 A retrospective
study 17 evaluated patients pre-surgically with
membrane thickening and history of sinusitis:
the risk of sinusitis development almost 12-80
months after SFE was very high.
For these reasons, it is mandatory to in- Figure 1.—Ostium analysis. The surgeon must examine the
patency of the ostium to evaluate if the sinus is operable or
vestigate the following through CBCT scans: not. A sinus with an ostium obstruction must not be operated.
ostium patency, thickness of the Schneiderian In this case, CBCT shows the ostium patency.

Vol. 66 - No. 3 Minerva Stomatologica 117

TAVELLI SINUS PRESURGICAL EVALUATION
—— presence of polypoid lesions in the sinus
or other lesions that could be suggestive of tu-
mors;
—— presence of acute or chronic sinusitis;
—— signs of systemic granulomatous pathol-
ogies: e.g. Wegener granulomatosis, sarcoid-
osis, etc.;
—— stenosis of the sinus drainage systems.
Despite the fact that membrane thickening
and obstruction of the ostium are considered as
transitory mucosal inflammation phase and not
a true pathology, the authors decided to con-
sider membrane thickening, associated with an
ostium obstruction, as a surgical contraindica-
tion. The Authors suggest that, in such situa-
tions, it might be better to postpone the surgery
and request an ENT referral (grade 0 according
to our classification). In case of the presence
of antral pseudocyst or mucous retention cyst,
there is not an unanimous opinion in literature:
according to Mantovani,13 these situations as
well as sinus septa or concha bullosa, should
not contradict sinus floor elevation surgery.
To make sure that maxillary sinus floor el-
evation becomes an “effective procedure,” as
stated during Sinus Consensus Conference of
1996, it is mandatory to carefully examine the
pre-surgical sinus conditions and request an
ENT referral, if needed.
Risk of perforation:
—— membrane thickness;
—— sinus septa;
—— angle between buccal and palatal wall;
—— teeth presence;
—— implants or teeth roots adjacent to sinus.
Von Arx et al.19 carried out a retrospective
study to analyze the frequency of Schneide-
rian membrane perforation during the sinus
floor elevation surgery with a lateral approach.
The aim of this study was to investigate if risk
factors like age, smoking habits, surgical tech-
nique, osteotomy technique, presence of sinus
septa, residual bone crest height, vestibular
wall thickness of the sinus and membrane con-
ditions could influence the frequency of per-
forations.
Differences were found between smokers
and non-smokers (46.2% vs. 23.4%), presence
and absence of sinus septa (42.9% vs. 23.8%),
118 Minerva Stomatologica June 2017
residual bone crest height less than 4 mm and
more than 4 mm (34.2% vs. 20.5%). Neverthe-
less, the results were not statistically significant.
Current literature has focused on the intact-
ness of the sinus membrane during the SFE:
according to many authors,20, 21, 57, 58 maxillary
sinus floor elevation is a predictable surgery
only in absence of schneiderian membrane
perforations. As highlighted by Nolan et al.,57
infections, graft failures and antibiotic use for
postoperative sinusitis are statistically higher
in case of sinuses with perforated membranes
during sinus lift surgery. Moreover, also the
implant survival rate seems to be negatively
affected by membrane perforations.58 Among
all the possible complications, membrane
perforations are considered the most frequent
and therefore, a lot of studies investigated the
presence of predisposing factors that could in-
crease the risk of membrane lacerations. Ac-
cording to the authors’ experience, parameters
like Schneiderian membrane thickness, pos-
sible presence of sinus septa, angle between
sinus vestibular and palatal wall, sinus shape,
dental roots or implants with a close relation-
ship with sinus floor, could easily influence the
perforation of the membrane, thus necessitat-
ing an accurate CBCT presurgical evaluation,
to evaluate all these risk factors.
Membrane thickness
Different values of average schneiderian
membrane thickness are reported in literature,
depending on both high inter-individual vari-
ability and different measurement methods, ini-
tially on corpse and lately through CBCT. Lots
of studies 9, 22 consider 1 mm of thickness as a
physiological value. However, since a mem-
brane thickening is often seen also in asymp-
tomatic patients, some Authors recommend to
consider pathological membrane thickness over
4 mm.9, 23 Many studies 24-26 based on CBCT re-
ported an average value of membrane thickness
within the range from 0.8 to 1.99 mm. Accord-
ing to some authors, an average and physiologi-
cal value is up to 2 mm,27 while it was reported
to be up to 6 mm by others.28
Nevertheless, Soikkonen and Ainamo 29
SINUS PRESURGICAL EVALUATION TAVELLI

suggested that measuring the membrane is not
a correct way to evaluate a physiological or
pathological condition; on the contrary, radi-
opacity of the sinus walls should be examined
to understand health. Rak et al.14 noticed an
increased risk of sinusitis when membrane
thickness surpassed 2 mm; nonetheless, Car-
meli et al.16 and Shanbhag et al.11 stated that
a value over 5 mm was gradually correlated
to an increased risk of ostium obstruction and
eventually the development of sinusitis. Cho
et al.30 demonstrated a correlation between
Schneiderian membrane thickness and perfo-
rations rate: perforations were most common if
the membrane thickness was less than 1.5 mm.
On the contrary, others 25 believed that there
is a risk for perforation only if thickness is
less than 1 mm. According to a recent study 31
with the aim of evaluating the perforation rate
in correlation with sinus membrane thickness
during sinus floor elevation with trans-crestal
approach surgery, membranes with a thickness
less than 0.5 mm or thickness over 3 mm were
found to be more prone to perforations. On the
other hand, the perforation rate is lower if the
membrane thickness falls within the range be-
tween 1.5 and 2 mm (Figure 2).
Based on the data from these studies, the au-
thors decided to evaluate and subdivide the op-
timal dimensions of Schneiderian membrane,
in order to have concrete indications regarding
SFE, as the following (Figure 3):

Figure 2.—Diagram correlating the membrane thickness to the risk of perforation or ostium obstruction. According to differ-
ent studies, it is possible to figure out a range of average membrane thickness in physiological conditions, a range of mem-
brane thickness correlated with an increased risk of perforation, a range of membrane thickness correlated with a decreased
risk of perforation and a range of membrane thickness linked to the risk of maxillary sinus ostium obstruction.

Figure 3.—Diagram that demonstrating favorable, unfavorable and normal range of membrane thickness. Based on the previ-
ous diagram, starting from the thickness of the Schneiderian membrane, it is possible to recognize a range defined as “normal
thickness,” a range related with higher risk of perforation or higher risk of ostium obstruction (“unfavorable thickness”), and
a range linked to lower risk of perforations (“favorable thickness”).

Vol. 66 - No. 3 Minerva Stomatologica 119

TAVELLI SINUS PRESURGICAL EVALUATION
—— favorable thickness: 1.5-2.0 mm;
—— normal thickness: 0.8-1.49 mm, 2.01-
2.99 mm;
—— unfavorable thickness: <0.79 mm, >3
mm.
According to this subdivision, suitable for
the classification, the authors considered the
range from 0.8 mm to 1.99 mm like aver-
age value of sinus membrane in the absence
of pathology, as suggested by Pommer et al.,
Yilmaz et al. and Anduze-Acher et al.24-26 In
order to identify an “unfavorable thickness,”
the Authors referred to the studies by Cho
et al.30 and Wen et al.:31 in the former study,
perforation risk increased in membranes with
a thickness lower than 1.5 mm, while in the
latter, the risk was associated with a thickness
less than 0.5 mm. Consequently, membrane
thickness lower than 0.79 mm are considered
unfavorable because this value represents the
lower bound of the average membrane thick-
ness in physiological condition. Furthermore,
unfavorable thickness will be defined by val-
ues over 3 mm, as such values are associated
with increased perforations rate according to
Wen et al.31 Some authors21 stated that Schnei-
derian membrane characterized by a thickness
over 4 mm could be elevated without an in-
creased risk of complications. The authors of
this study decided to fix the limit of thickness
up to 5 mm: membrane thickness over 5 mm
must be deemed as grade 0 according to our
classification. As a matter of fact, this means
that the sinus is inoperable, unless stated other-
wise by the ENT physician. As confirmed in
literature,14, 16 membrane thickness of more
than 5 mm is highly correlated with the risk of
inflammatory pathologies, such as sinusitis or
obstruction of sinus ostium.
To decide how to distinguish between “nor-
mal thickness” and “favorable thickness,”
the authors have been working on the article
of Wen et al.,31 in which a membrane thick-
ness from 1.5 mm to 2 mm is associated with
a lower risk of perforations. Consequently, the
authors fixed values ranging between 0.8 mm
to 1.49 mm and between 2.01 mm to 2.99 mm
as normal thickness, because of the ordinary
risk of perforation.
120 Minerva Stomatologica June 2017
As a conclusion, there are many studies 8, 32, 33
showing that sinus membrane thickness is as-
sociated with endodontic lesions and that it is
possible to have a reduction of pathological
membrane thickness in case of lesion resolu-
tion or in case of problematic teeth extractions.
Therefore, for this classification, in the pa-
rameter “Membrane thickness,” the following
values should be considered:
—— favorable thickness: 1.5-2.0 mm;
—— normal thickness: 0.8-1.49 mm, 2.01-
2.99 mm;
—— unfavorable thickness: <0.79 mm, >3
mm.
Sinus septa
Sinus septa (or Underwood’s septa) can
be found inside the maxillary sinus with a
frequency close to 38% of all cases (9) and,
according to their shape, position and devel-
opment, they could compromise membrane in-
tegrity during the sinus floor elevation. All the
authors 9, 34-37 agree that the presence of these
anatomical variations increases perforation
risk. According to a study 9 conducted at the
University of Milan, there is a statistically sig-
nificant difference between membrane thick-
ness in presence or absence of sinus septa: in
the presence of septa, the membrane is double
the thickness. However, there is a lack of cor-
relation between the height of sinus septa and
membrane thickening. The results showed that
higher Underwood’s septa are more frequently
spotted in that anterior-medium area of the si-
nus. Secondary septa (also called incomplete
septa, which are septa derived from loss of
teeth and following abnormal sinus pneumati-
zation) are 2.1 mm lower in average than pri-
mary septa (congenital septa) and more com-
mon in the posterior area of the sinus. Similar
results, in terms of septa positions, were found
also by Selcuk et al.38
In order to understand the difficulty of
sinus floor elevation during the surgery, at-
tention should be paid to the development
of Underwood’s septa: whenever the sinus
septum is running transversely, surgery is not
complicated; on the other hand, if the sinus
SINUS PRESURGICAL EVALUATION TAVELLI
septum is longitudinal or incomplete (sec-
ondary), the operation could become more
complicated during the membrane elevation
(Figures 4-6).
Figure 4.—CBCT detection of a transverse sinus septum. It
is important to notice the presence of sinus septa and their
shape before the surgery. According to the Authors’ experi-
ence, a sinus septum running transversely (like in this case)
is easier to manage than a longitudinal sinus septum.
Figure 5.—Intrasurgical picture of a transverse sinus sep-
tum. Maxillary septa are walls of cortical bone within the
maxillary sinus. The presence of Underwood’s septa could
compromise the Schneiderian membrane integrity during
the sinus floor elevation. In this case, the sinus is divided
in two cavities by a transverse sinus septum. The surgeon
performed two separate lateral windows antrostomies in or-
der to avoid sinus septum and elevate the membrane without
increasing risk of laceration.
Vol. 66 - No. 3 Minerva Stomatologica 121
Therefore, for this classification, in the pa-
rameter “Sinus septa,” the following should be
considered:
—— favorable: absence of sinus septa;
—— normal: presence of one complete and
transverse sinus septum;
—— unfavorable: presence of one or more in-
complete or longitudinal sinus septum.
Angle of the buccolingual maxillary sinus wall
The angle of the buccolingual maxillary si-
nus wall can be defined as the angle consisting
of vestibular and palatal (medial) sinus wall. A
study 30 conducted at the New York University
demonstrated an increased number of perfora-
tions when this angle was lower than 30°, cal-
culated on a perpendicular tomographic sec-
tion. When the angle is lower than 30°, the risk
of membrane perforations becomes maximum,
while the most common situations (angle be-
tween 30° and 60°) is correlated with a normal
perforation rate (28.5%). Best values, in terms
of lower membrane perforations risk, are when
the angle of the buccolingual maxillary sinus
is greater than 60°: in this case, membrane lac-
erations risk is almost 0% (Figure 7).
In the case of sharp angle, it is recommend-
ed, during surgery, to bring the mesial margin
of the bony window osteotomy more anteri-
Figure 6.—Intrasurgical picture of a longitudinal sinus sep-
tum. Presurgical evaluation with CBCT is very important to
assess the presence and the development of Underwood’s
septa. In this case, the sinus septum is running longitudinally
and this means more difficulties in sinus floor elevation than
situations without septa or with a transverse septum.
TAVELLI SINUS PRESURGICAL EVALUATION
Figure 7.—Angle of the buccolingual sinus wall. There are a
lot of software that allows the clinician to measure distances
and angles starting from the CBCT exam. Here, the angle
formed between the buccal and the palatal sinus wall is very
wide and this should be considered a favorable factor related
to the lower perforation rate.
orly to avoid Schneiderian membrane perfora-
tion and to easily elevate the sinus floor.
A study by Velloso et al.37 revealed that
acute angles are more common in second pre-
molar area with average values of 36.3°, while
in first molar and second molar areas, the me-
dium values were 47.7° and 58.2° respectively.
Therefore, it is believed that the risk for perfo-
ration during SFE is higher in the proximity of
second premolar area and hence in the anterior
part of the sinus.
Therefore, for this classification, for the pa-
rameter “Angle of buccolingual maxillary si-
nus wall,” the following should be considered:
—— favorable: angles >60°;
—— normal: angles from 30° to 60°;
—— unfavorable: angles <30°.
Presence of teeth
The loss of posterior teeth is strongly in-
volved in the alveolar ridge resorption and
in the maxillary sinus pneumatization. Using
CBCT data, Velasco-Torres et al.60 showed
that tooth loss can determine a vertical col-
lapse of the maxillary sinus with a concomitant
122 Minerva Stomatologica June 2017
increase of its mediolateral width. This article
also reported that the dentition status can also
influence the location of the posterior superior
alveolar artery with regard to the sinus floor,
the alveolar crest and the sinus volume. The
loss of posterior teeth has also an impact on the
schneiderian membrane elevation. When an
intimate contact between sinus membrane and
teeth roots occurs, especially in case of single
posterior missing tooth, the perforation risk in-
creases during SFE.41 According to Von Arx et
al.,19 totally missing teeth in molars area are
associated with a higher perforation risk than
in premolar area (26.2% vs. 16.7% respective-
ly). Shanbhag et al.11 reported that, sometimes,
when first and second molars are missing, si-
nus membrane could have a thickness of more
than 5 mm, which is a critical value associated
with a higher risk of ostium obstruction. In the
clinical practice, favorable situations are mul-
tiple edentulous areas, namely the lack of all
posterior teeth or the lack of second premolar
and first molar (Figure 8).
On the other hand, more difficult situations
arise from all cases with single missing tooth
(one single missing tooth that could be second
premolar or first molar or second molar); in
these conditions, the membrane elevation is
more challenging due to the presence of sinus
pneumatization only in a small area with an ir-
regular sinus floor shape (Figure 9).
Figure 8.—Intrasurgical picture of the edentulous posterior
maxilla. In this situations, there is a totally posterior eden-
tulous area and the sinus lift with lateral approach should
be less challenging than other situations. Indeed, in case of
only one or two posterior teeth with an intimate contact be-
tween their roots and sinus membrane, the perforation risk
is increased.
SINUS PRESURGICAL EVALUATION TAVELLI
Figure 9.—Intrasurgical picture of sinus lift in case of one
missing tooth. The surgical approach in situations character-
ized by only one missing tooth is highly influenced by the
residual alveolar ridge height. If the height of the alveolar
ridge is not less than 4 mm, also a sinus lift with transcrestal
approach should be considered. In this case, the alveolar
ridge height was not enough for the transcrestal approach
and, for this reason, a sinus lift with a lateral approach was
performed. An antrostomy with a complete removal of the
bone window was completed and then the Schneiderian
membrane was elevated.
When the patient has two adjacent miss-
ing teeth, SFE with perforation would be less
probable than when a single tooth is missing
(Figure 10).
Therefore, for this classification, in the pa-
rameter “Presence of teeth,” the following
must be taken into consideration:
—— favorable: totally missing teeth (from
second premolar to second molar);
—— normal: two adjacent missing teeth
(from second premolar to second molar);
—— unfavorable: single missing tooth situa-
tion (from second premolar to second molar).
Implants or roots adjacent to sinus
It is important to evaluate cases with sinus
floor adjacent to implants, where the apex of
implants have an intimate contact with sinus
floor or even into the sinus, and also when si-
nus floor is adjacent to teeth, with their roots
penetrating the sinus. Abnormal sinus pneuma-
tization can lead to this particular relationship
between sinus floor and implant apex or roots.
In such cases, there is a high possibility of sch-
neiderian membrane perforation, because the
membrane is more fragile in the areas where it
envelops the implant apex or root. On the con-
Vol. 66 - No. 3 Minerva Stomatologica 123
Figure 10.—Intrasurgical picture of sinus lift in case of two
missing teeth. In presence of two missing teeth, depending
on the residual alveolar ridge height, it is also possible to opt
for a sinus lift with transcrestal approach. In this case, a mu-
coperiosteal flap was elevated in order to perform the bone
window in the area corresponding to the second premolar
and first molar.
trary, when sinus membrane is attached to the
bone, it is less prone to perforation. Moreover,
in presence of multiple-rooted teeth, like first
or second molars, when CBCT shows an intra-
sinus position of their roots, it could further
complicate the elevation of sinus floor.
Therefore, for this classification, in the pa-
rameter “Implants or roots adjacent to sinus,”
the following should be considered:
—— favorable: no implant apex or teeth roots
contiguous or into sinus floor (intra-sinus posi-
tion);
—— unfavorable: implant apex or teeth roots
contiguous or into sinus floor (intra-sinus posi-
tion).
Bone condition:
—— buccal bone thickness;
—— residual alveolar ridge height;
—— residual alveolar ridge width.
Buccal bone thickness
Many factors related to an increased risk of
maxillary sinus membrane perforation have
been studied so far, however only few papers
focused on maxillary buccal bone thickness
and its involvement in Schneiderian mem-
brane perforations. Yang et al.,61 using CT in
TAVELLI SINUS PRESURGICAL EVALUATION
edentulous patients, reported a mean maxillary
buccal bone thickness from the first premolar
to the second molar respectively of 1.69±0.71,
1.50±0.72, 1.77±0.78 and 1.89±0.85 mm.
Monje et al.62 analyzed CBCT scans and a
mean sinus lateral wall of 1.71±0.12 mm and
1.57±0.07 mm was found in partially and in
totally edentulous patients, respectively. This
study also highlighted that buccal bone thick-
ness tends to increase from the second pre-
molar to the second molar. Moreover, teeth
adjacent to the edentulous area, residual ridge
height and age were found to be able to influ-
ence the maxillary sinus lateral wall thickness.
The buccal bone thickness is an important
feature which should not be underestimated
since it has a significant impact on the correct
membrane detachment from the bone (Figure
11). Indeed, during the lateral antrostomy, the
clinician can decide whether to perform the
so called “trap door” technique, which means
partial conservation of bone window with
Figure 11.—CBCT analysis and calculation of the buccal
bone thickness. If the buccal bone wall thickness is minimal,
like in this case, the use of piezoelectric cutting inserts is
suggested. The buccal bone thickness could influence also
the antrostomy technique with the partial conservation of
bone window or its complete removal. In this CBCT it is
also possible to observe the presence of the infraosseous
course of the alveolar-antral artery.
124 Minerva Stomatologica June 2017
its overturning inside the sinus, or to totally
consume the cortical plate until exposing the
Schneiderian membrane. In case of thick buc-
cal bone, van den Bergh et al.63 recommended
to completely remove the lateral bone wall of
the antrostomy since a central bony window
would make the membrane detachment from
the inner bony sinus more difficult and more
prone to perforate the membrane. Stacchi et
al.64 demonstrated that the window erosion is
the safest technique in terms of perforations
especially when the buccal bone is very thick.
Therefore, thin buccal bone is considered
a favorable condition because it allows the
clinician to perform both the techniques of
lateral antrostomy. Furthermore, thin buccal
bone usually makes it possible to see the typi-
cal blue color of the maxillary sinus under the
lateral cortical wall, which undoubtedly helps
the surgeon to outline the bony window. In
presence of a minimal vestibular wall thick-
ness, it is suggested to directly use ultrasonic
or piezoelectric cutting inserts to perform the
antrostomy, since they are related to lower per-
foration’s rate.21, 64, 65 On the other side, thick
buccal bone requires more time to expose the
schneiderian membrane and overturning the
bone window inside the sinus without perfo-
rate the membrane is considered challenging.66
Therefore, for this classification, in the pa-
rameter “Buccal bone thickness,” the follow-
ing should be considered:
—— favorable: thickness <1 mm;
—— normal: thickness from 1 to 2.5 mm;
—— unfavorable: thickness >2.5 mm.
Residual alveolar ridge height
Some authors confirm that residual alveolar
ridge height is an important factor related to
membrane thickness 25 and to implant therapy
success over time.39 In particular, Testori et
al.39 observed that implants failure rate after
sinus lift was higher in the presence of resid-
ual alveolar ridge height lower than 4 mm. A
group from the University of Michigan, during
a study 5 on sinus pneumatization, introduced
a classification regarding the residual alveolar
ridge height as the following: 4 mm, from 4 to
SINUS PRESURGICAL EVALUATION TAVELLI
Figure 12.—CBCT showing alveolar ridge high and its di-
mension. In this case, in presence of a residual alveolar ridge
height of 5 mm, the clinician should also opt for a sinus lift
with transcrestal approach. According to different authors,
sinus lift with transcrestal approach should be limited and
considered only in case of alveolar ridge height not less than
4 mm.
7 mm and from 7 to 10 mm are termed severe-
ly deficient, moderately deficient and slightly
deficient alveolar, respectively.
It is a view shared by many authors 11, 43-45
that a residual alveolar ridge height lower than
Figure 13.—CT scan of alveolar ridge width. The occlusal
view shows the residual alveolar ridge width in the edentu-
lous area and, on the basis of this dimension, the clinician
chooses the implant diameter. If the alveolar ridge width is
very narrow, bone augmentation is recommended prior to
implant insertion.
Vol. 66 - No. 3 Minerva Stomatologica 125
4 mm needs a sinus lift with a lateral approach
(Figure 12).
A correlation between a reduced residual al-
veolar ridge height and a thinner Schneiderian
membrane is reported: this could lead to an in-
creased perforation rate during SFE.39, 40-45
Chiapasco et al.46 introduced a pre-surgical
classification regarding maxillary atrophy and
4 mm value was used as a cut-off between dif-
ferent classes. A similar classification of upper
jaw atrophy, in order to have more indications
for implant therapy, was proposed by Wang
and Katranji.47 According to the authors’ clini-
cal experience, a sinus lift in case of an alveo-
lar ridge lower than 2 mm could be easily con-
sidered challenging.
Therefore, for this classification, for the pa-
rameter “Residual alveolar ridge height,” the
following should be considered:
—— favorable: height >4 mm;
—— normal: height from 2 to 4 mm;
—— unfavorable: height <2 mm.
Residual alveolar ridge width
This parameter concerns implant diameter
and not really a possible intrasurgical compli-
cation, but, according to the authors, it is im-
portant to evaluate the alveolar ridge width in
order to plan the surgery, which very often dic-
tates the insertion of implants simultaneously
with the SFE (Figures 13, 14).
Figure 14.—Alveolar ridge width. This dimension influenc-
es the implant insertion, especially the choice of the implant
diameter and the necessity of bone expansion or not. In this
case, the alveolar ridge width was wide enough to insert a
standard diameter implant without bone augmentation.
TAVELLI SINUS PRESURGICAL EVALUATION
A study by Spray et al.67 investigated the
influence of the facial bone thickness on mar-
ginal bone response. The facial bone thickness
measured with a caliper following preparation
of the osteotomy site was found to be 1.7±1.13
mm on the average. This study showed that the
facial bone thickness is related to bone loss
and that all the failed implants had 0.1 mm
less bone thickness on average than the sur-
viving implants. Moreover, the largest amount
of vertical bone loss occurred when the facial
bone thickness was less than 1.4 mm, while
in the case of facial bone thickness between
1.8 and 2.0 mm, the study reported a favorable
response in terms of lower bone loss or even
bone gain. This led Spray et al. to define 2.0
mm of facial bone thickness as “critical thick-
ness” since below this value the chance for
vertical bone loss is increased, whereas above
this value the chance for bone loss is reduced
and the chance for no change or even bone
gain is increased.
Accordingly, the authors consider a re-
sidual alveolar ridge width of at least 7.75
mm as favorable, because there is no need
to expand the alveolar ridge to insert tradi-
tional implants, with a diameter of 3.75 mm,
totally surrounded by 2 mm of peri-implant
bone. Given the fact that at least 1.5 mm
of bone around the implant is necessary for
crestal bone stability and for minimizing the
bone loss, an alveolar ridge wide at least 6.75
mm is required to place a traditional implant.
Therefore, alveolar ridges width between 6.75
and 7.75 mm are considered normal since
they allow the clinician to place a traditional
diameter implant. On the other hand, a re-
sidual alveolar ridge width of less than 6.75
mm obliges the clinician for a surgical bone
expansion, utilizing different techniques such
as bone blocks of guided bone regeneration
(GBR), or alternatively use small-diameter
implants.
Therefore, for this classification, for the
parameter “Residual alveolar ridge width,” it
should be considered:
—— favorable: ≥7.75 mm;
—— normal: 6.75-7.75 mm;
—— unfavorable: <6.75 mm.
126 Minerva Stomatologica June 2017
Other parameters:
—— sinus width;
—— alveolar-antral artery;
—— visibility/oral opening.
Sinus width
When maxillary sinus is pneumatized, its
shape becomes pyramidal with the nasal wall
like base and with the apex spreading into zy-
gomatic process of maxillary bone. Accord-
ing to Karmody et al.,48 the average volume
of maxillary sinus is 15 mL, with the average
height of 33 mm, 23-25 mm of width and 34
mm for antero-posterior dimension. Trimar-
chi et al.49 analyzed and discussed different
pneumatizations, calling them “hypersinus,”
“pneumosinus dilatans,” “pneumocele” and
“pneumatocele.” Maxillary sinus is considered
flexible since its walls can expand and com-
press in response to internal or external patho-
logical processes. Some pathological lesions
produce sinus pneumatization and consequent
bony wall erosion, other lesions can gradually
provoke sinus obstruction.50
Chan et al.5 proposed a classification (nar-
row, average and wide) based on sinus width
at the lower and upper boundary of lateral
window osteotomy. According to the Au-
thors, in case of narrow sinus it is better to
avoid trap door technique and to utilize a
complete removal of bony window. Tolstu-
nov et al.4 proposed a classification of sinus
pneumatization in order to correlate the sinus
expansion to the average bone volume of the
upper jaw and then the possibility of insertion
of dental implants with or without bone aug-
mentation or sinus lift. According to Kutkut
et al.,51 the sinus width is an important factor
for bone regeneration and healing. This study
showed a better healing outcomes and bone
regeneration in narrow sinuses than in wide
sinuses.
Therefore, for this classification, in the pa-
rameter “Sinus width,” the following should
be considered:
—— favorable: narrow;
—— normal: average;
—— unfavorable: wide.
SINUS PRESURGICAL EVALUATION TAVELLI
Alveolar-antral artery
According to the literature, the infra-osseous
anastomosis (which is called alveolar-antral
artery) between the posterior-superior alveolar
artery (PSAA) and the infraorbital artery is al-
ways present, instead, the extraosseous anasto-
mosis exists only in 44% of all cases.51-53
Hemorrhage of the alveolar-antral artery
(AAA) is one of the most frequent complica-
tion that during sinus lift surgery. Even though
stopping this bleeding with electrocauter is
possible, it would be better to pre-surgically
diagnose the presence of the artery in the bone
vestibular area where the bony window oste-
otomy is usually performed (Figure 15).
Testori et al.21 proposed to caudally shift the
bone antrostomy, in order to avoid the AAA
which runs in an antero-posterior course. The
clinician must pre-surgically evaluate, through
CBCT exam, if the AAA course is infraosse-
ous and if it passes through the area usually
designed for the antrostomy: in this case the
surgeon can choose to ligate the vessel.30
Figure 15.—Detection of alveolar-antral artery through
CBCT. It is important for the surgeon to pre-surgically rec-
ognize the presence of the infraosseous course of the alveo-
lar-antral artery in the area designed for antrostomy.
The evaluation of the alveolar-antral artery diameter should
not be underestimated.
The clinician should opt to caudally shift the bone antros-
tomy or to perform a double window technique antrostomy
or to ligate the vessel.
Vol. 66 - No. 3 Minerva Stomatologica 127
A new technique allowing the AAA isolation
was described by Maridati et al.:20 this proce-
dure could be applied in cases where the artery
is clearly present inside the surgical area and
is detectable through CBCT. Once the AAA is
identified before the bone window osteotomy
is one, its course is transferred to the bone wall
by using a surgical pencil and then the clini-
cian could easily perform a double window
antrostomy, in order to avoid the vessel. If the
artery course is extraosseous (or partially in-
fraosseous), a condition that could be not al-
ways recognized through CBCT, the surgeon
will find the vessel adherent to the Schneide-
rian membrane and therefore the membrane
elevation will also include lifting of the vessel.
According to Testori et al.,54 this infraosse-
ous anastomosis is always present (100% of
the cases) from anatomical point of view, but
it is detectable on radiograph only in 47% of
cases. Some authors 55 studied the diameter of
the alveolar-antral artery within the infraosse-
ous course: it is lower than 1 mm in 55.3% of
cases, between 1 or 2 mm in 40% cases and
from 2 to 3 mm in 4.3% of cases. In case of
bleeding of small diameter vessels, the hemor-
rhage can be stopped easily with bone wax, but
in the of bigger vessels (2-3 mm of diameter),
it is suggested to bond the artery before ligat-
ing it.54
Valente 56 analyzed and summarized all the
studies in literature regarding the alveolar-an-
tral artery. According to his study, the vessel
course would be very often infraosseous with a
diameter frequently lower than 1 mm. Howev-
er, there are many cases in which the diameter
of this vessel is up to 2 mm. Valente 56 also re-
ported the mean distances of the vessel course
from the alveolar ridge (11.25-26.90 mm) and
from the sinus floor (5.8-10.4 mm).57, 58
Güncü et al.59 analyzed the course and the
location of the PSAA by using the CT scan.
CT scan was able to detected the vessel in
the 64.5% of all sinus examined and in most
of the cases the vessel’s course was infraos-
seous (AAA) with a diameter of 1.3±0.5
mm. To avoid sever intraoperatory bleeding,
Güncü et al.59 recommends to limit the supe-
rior border of the bony window up to 18 mm
TAVELLI SINUS PRESURGICAL EVALUATION
Figure 16.—Intrasurgical picture of alveolar-antral artery. It
is possible to see the vessel through the cortical bone. The
surgeon created the bony window with no resection of the
alveolar-antral artery.
from the ridge. Valente 56 and Güncü et al.59
strongly advise the use of CBCT or CT during
the pre-operative evaluation in order to reduce
risks of intra-surgical hemorrhage. According
to Rosano et al.,55 the sinus lift surgery with
lateral approach interferes with the course of
alveolar-antral artery only in 10% to 30% of
all considered cases (Figure 16).
Therefore, for this classification, in the pa-
rameter “Alveolar-antral artery,” the following
should be considered:
—— favorable: not detectable radiographi-
cally or of diameter <1 mm;
—— normal: diameter 1-2 mm;
—— unfavorable: diameter >2 mm.
Visibility/oral opening
Some patients have problematic intraoral
opening and a tissue distension unfavor-
able from a surgical point of view. In case of
brachytype subjects or in case of sphincterical
mouth, the more the surgeon pulls, the more
the mouth closes. Contrary to the others pa-
rameters, this is a subjective parameter and is
not detectable through CBCT. However, the
Authors decided to consider also this param-
eter for the presurgical evaluation because, in
their opinion, it should not be underestimated.
Therefore, for this classification, for the pa-
128 Minerva Stomatologica June 2017
rameter “Visibility/Oral opening,” the follow-
ing should be considered:
—— favorable: optimal opening that lets the
clinician work without any problems;
—— unfavorable: critical opening that cre-
ates difficulties to the clinician.
Discussion
Maxillary sinus presurgical evaluation: a
new classification proposal
The present classification shall consider
these 11 parameters/factors analyzed and for
each of them, a favorable condition, a normal/
average condition and an unfavorable con-
dition can be identified. In two parameters,
however, the authors chose not to consider a
normal/average condition and so the clinician
should choose only a favorable or unfavorable
condition. Regardless of the analyzed param-
eter, a favorable condition is equivalent to a
score of 1, a normal condition to a score of
2 and an unfavorable condition to a score of
3. The parameter score then has to be multi-
plied for the “significance” of the parameter.
The significance of each parameter was set by
the authors according to literature and to their
clinical experience. If the parameter does not
influence too much the difficulty of the maxil-
lary sinus lift surgery, they consider its signifi-
cance equal to 1. On the other hand, a parame-
ter which could influence enough the difficulty
of the surgery has got a significance equal to
2 and, finally, the significance of a parameter
fundamental for the surgery is considered as a
value of 3.
Below, the authors provide the value of sig-
nificance decided for each factor: membrane
thickness “3,” sinus septa “3,” angle of the
buccolingual maxillary sinus wall “3,” teeth
presence “3,” sinus floor contiguous to implant
or teeth roots “2,” vestibular bone thickness
“2,” residual alveolar ridge height “1,” residu-
al alveolar ridge width “1,” sinus width “2,” al-
veolar-antral artery “2,” visibility/oral opening
“3.” In this way every factor has got a score
of 1, 2 or 3 according to their favorable, nor-
mal or unfavorable situation: this value has to
SINUS PRESURGICAL EVALUATION TAVELLI

be multiplied for the significance established

for that parameter. After doing the same for all
parameters, the clinician has to add up all the
results and divide this sum by “25,” which is
the sum of all the significances.
The final result will be in the range of 1 to
3, in particular:
—— from 1 to 1.5 the situation is defined as
grade I (favorable sinus);
—— from 1.501 to 2.1 the situation is defined
as grade II (normal sinus);
—— from 2.101 to 2.6 the situation is defined
as grade III (problematic sinus);
—— from 2.601 to 3 the situation is defined
as grade IV (unfavorable and risky sinus);
—— grade 0 (inoperable sinus) it is a situ-
ation where there are one or more complica-
tions discussed before.
Therefore, based on different factors with
their different significance, from a surgical
point of view, a sinus can be pre-surgically
classified as inoperable (grade 0), favorable
(grade I), normal (grade II), problematic (grade
Figure 17.—Microsoft Excel worksheet of sinus presurgi-
III), unfavorable and risky (grade IV). cal evaluation and new sinus classification. The clinician
In order to make the final calculation more should only fill the table assigning scores to each parameter
feasible, to reduce the chance of errors by the and then, according to this new classification, a sinus grade
will be shown automatically through the Microsoft Excel
operator and to make a faster and standardized software.
the evaluation, the authors created a Microsoft
Excel worksheet with a simple table where the courages the surgeon to have a careful pre-
clinician has only to insert the value 1, 2 or 3 operative evaluation through CBCT, which is
(depending on favorable, normal or unfavor- believed to be highly essential.
able situation) and the final grade would ap- In order to validate its effectiveness, further
pear automatically. For the purpose of helping clinical studies based on the proposed classifi-
the clinician, the parameters were brought to- cation are therefore necessary.
gether into 3 categories: “Risk of perforation,”
“Bone condition” and “Other.” Therefore, the
operator should only evaluate these 11 factors References
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
discussed in the manuscript.
Article first published online: February 15, 2017. - Manuscript accepted: February 13, 2017. - Manuscript revised: February 6, 2017. -
Manuscript received: September 17, 2016.
Vol. 66 - No. 3 Minerva Stomatologica 131
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