Ed itors: S. Chen, D. Buser, D.

Wismeijer International Team

for lmplantology

Volume 5

Authors:
Sinus Floor Elevation H. Katsuyama
Procedures S.S. Jensen
 Editors:
ITI Treatment Guide S. Chen, D. Buser, D. Wismeijer
Vo lume 5
 Authors:
H. Katsuyama, S. S. Jensen German National Library CJP Data l he materials offered in the fTI Treatment Guide are
for educational purposes only and intended as a step·
The German National Library has listed this publication by-step guide to treatment of a panicular case and
in the German National Bibliogr.aphy. Detailed biblio- patient situation. These recommendations are based on
graphical data are available on the Internet at hnp:// conclusions of the lTl Consensus Conferences and, as
dnb.ddb.de. such, in line with the ITI treatment philosophy. These
recommendatjons, nevertheless, repres.ent the opinions
of the authors. Neither the ITI nor the authors. editors
and publishers make any representation or warranty for
Volume 5 the completeness or accuracy of the published materi·
al.s and as a consequence do not accept any liability for
damages [Including, without limitation, direct, indirect,
special, consequential or incidental damages or loss of
profits) c.aused by the use of t he information contained
in the ITI Treatment Guide. The information contained
Sinus Floor Elevation in the Ill Treatment Guide cannot replace an individual
assessment by a clinician, and its use for the trea.tment
of patients is therefore in the sole responsibility of the

Procedures clinician.

The inclusion of or reference to a ~rtic ular product,

method, technique or material relating to such prod·
ucts, methods, or techniques in the ITJ Treatment Guide
does not represent a recommendation or an endorse·
IC 2011 Quintessence Publishing Co, Ltd ment of the values, featu res, or claims made by its
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All rights reserved. In particular. the materials published
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written consent of the respective intellectual property
Illustrati ons: Ute Drewes, CH-Basel, right owner.
www.drewes.ch
Copyediting: Triacom Dental, 0 -Sarendorf, Some of the manufacturer and product names refe rred
www.denral.triacom.com to in this publication may be registered trademarks or
Graphic Concept Wirz Corporate AG. CH-Zurich proprietary names, even though specific reference to
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iv m Treatment Guide. Volume S

The ITI Mission is ...

"... to promote and disseminate

knowledge on all aspects of implant
dentistry and related tissue
regeneration through education and
research to the benefit of the patient."

ID Trearment Guide • Volume S v

Acknowledgment

We would like to thank Mr Thomas Kiss of the Ill Center Additionally, w• would lik• to •cknowltdee the enthusi·
for his invaluable assistance in the preparation of this astk: support and ~luable contributions received from
volume of the Treatment Guide series. We would also the followinc clinicians in the creation of the chapter
like to express our gratitude to Ms Juliane Richter (Quint· manuscripts 3, 4 and 1 for this Treatment Guide volume:
essenz Verlags-GmbH) for the typesetting and the coor- Or. Yoji Kamiura
dination of the productjon workflow, Mr Per N. OOhler Or. Toshifumi Kuroe
(Triacom Dental) for the editing support and Ms Ute Or. Shinichiro Kuroshima
Drewes for the exceUent illustrations. We als-o acknowl- Dr. Masaharu Miuuci
edge Straumann AG, the corporate partner of the tTI. for Dr. Kazutoshi Nakajima
their continuing support. Or. Yasushi Nakajima
Dr. Kotaro Nakata
Dr. Tsuneyuki Tsukioka
Or. Eiju Sen

V'li1 m Treatment Guide. Volume 5

Editors and Authors
Editors:
Stephen Chen, MDSc, PhD
223 Whitehorse Road
Balwyn, VIC 3123, Australia
f -mail: schen@balwynperio.com.au
Dani el Buser, ODS, Or med dent
Professor and Chairman
Oepanment of Oral Surgery and Stomatology
School of Dental Medicine
University of Bern
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail: daniel.buser(i!>zmk.unibe.ch
Daniel Wismeijer, DDS, PhD
Professor and Chairman Department
of Oral Function and Restorative Dent istry
Head Section Oral lmplantology and
Prosthetic Dentistry
Gustav Mahlerfaan 3004
1081 LA Amsterdam. Netherlands
E-mail: d.wismeijerGacta.nJ
Contributors
Authors: Simon Storgard Jensen, DDS
Department of Oral and Ma.xiUofacial Surgery
Hideaki Katsuyama, DDS. PhD Copenhagen University Hospital
MM Dental Clinic, Center of Implant Dentistry (CID) Blegdamsvej 9
3F, 3-3-1 Nishi-ku, Minato-mirai 2100 Kabenhavn 0 , Denmark
220-0012 Yokohama, Japan E-mail: simon.storgaardQijensen.mail.dk
E-mail: katsuyamah@aol.com
Bjarni Pjetursson
S"imon Storgird Jensen, DOS Professor and Chairman
Oepanme.nt of Oral and Maxillofacial Surgery Department of Reconstructive Dentistry
Copenhagen University Hospital Faculty of Odontology
Blegdamsvej 9 University of Iceland
2100 Kabenhavn 0 , Denmark Vatnsmyrarvegi 16
E-mail: simon.storgaard@jensen.mail.dk 101 Reykj avik, Iceland
E-mail: bel>Qlhi.is
Vivianne Chappuis, Dr med dent
Oep.artment of Oral Surgery and Stomatology
School of Dental Medicine
University of Bern
Freiburgstrasse 7
3010 Bern, Switzerland
E-mail: vivianne.chappui.sezmk.unibe.ch
ITI Treatment Guide •Volume S m Treatment Guide . Volume S
'
Ali Tahmaseb, DDS
Department of Oral Function and
Restorative Dentistry
Section of Oral lmplantology and
Prosthetic Dentistry
Academic Center for Dentistry Amsterdam (ACTA)
Gustav Mahlerla.nn 3004
1081 LA Amsterdam, Netherlands
E-Mail: ali@tahmaseb.eu
Christiaan ten Bruggenkate
Professor
The VU University Medical Center I ACTA
De Boelelaan 11 18
1081 HV Amsterdam, Netherlands
E-mail: chr.bruggenka.te.@vumc.nl
Daniel Buser, DDS, Dr med dent
Professor and Chairman
Department of Oral Surgery and Stomatology
School of OentaJ Medicine,
University of Bern
Freiburgstrasse 7
301O Bern, Switzerland
E·mail: daniel.buser@zmk.unibe.ch

Robert A. Levine. DDS
Pennsylvania Center for Dental Implants and
Periodontics, One Einstein Center, Suite 211·212
9880 Bustlet on Avenue
Philade lphia, PA 1911 S. USA
E-mail: rlevinee padentalimplants.com
Paolo Casentini, Or med dent
Narcodont
Piazza S. Ambrogio 16
201 23 Milano, Italy
E-mail: pao1ocasentini@nstwebnet.it
Luca Cordaro, MD. DDS. PhD
Head Department of Periodontics
and Prosthodontics, Eastman Dental Hospital
and Studio Associate Cordaro
00198 Roma. Italy
E-mail: lucacordaro@usa.net
Waldemar 0. Polido. DDS, MS, PhD
Oral and M.lxillofacial Surgery/Implant Dentistry
Contento - Odontologia Espec:iafizada
R. Marcelo Gama, 1148
Porto Alegre - RS - Brazil
E-mail: cirurgia.implante$0polido.com.br
Contributors
Table of Contents
1 lntrod uction .................................................................................................. 1
H. Karsuyam~ S. S. Jensen
2 Proceed ings of t he 4th ITI Consensus Conference and Literature Review:
Sinus Floor Elevat ion Procedures ................................................................. 3
Eduardo Marini, DDS, MS
Oral and Maxillofa.cia.1 Surgery/Implant Dentistry 2.1 Consensus Statements ....................................................................................................... 5
R. General Os6rio, 3291301
Bento Gonc;a.1ves - RS - Brazil 2.2 Proposed Clinical Approaches ............................................................................................ 6
E·mail: emarini@italnet.com.br
2.3 Literature Review ............................................................................................................... 7
Sanja Umanjec·Korac, ODS_,MSc S. S. k nsen
Department of Oral Function and 2.3.1 Maxillary Sinus Floor Elevation - Lateral Window Technique .... 7
Restorative De-ntistry, Section of Oral lmplantology 2.3.2 Maxillary Sinus Floor Elevation - Transcrestal Technique ..... .... 9
and Prosthetic Dentistry
Academic Center for Dentistry Amsterdam (ACTA)
Gustav Mahlerlann 3004 3 Preoperative Assessment and Planning for Sinus Floor Elevati on
1081 LA Amsterdam, Netherlands Procedures .................................................................................................. 11
E·mail: s.korac@acta.nl S. S. Jensen~ H. Katsuyama
Timothy Head, DDS 3.1 Anatomy........................................................................................................................... 13
Vend8me Surgical Services
Sl 22 Sherbrooke St. West, Suite 201 3.2 Medical History ................................................................................................................ 15
Montreal. QC, H4A 1 Ti , Canada 3.2.1 General Health Stat us .............................. ............... ............... .......................... .. 1 S
E·mail: thead0 maxillovendome.ca 3.2.2 Concomitant Medications................... ............... .......................... ............ 15
3.2.3 Allergies................................................... ............... ................ .. .......... 16
Matteo Chiapasco, MO 3.2.4 Tobacco and Alcohol..... ..................... .. ............. ............... .. .............. .. ..... 16
Professor. Head Unit of Oral Surgery 3.2.S Compliance ................... ............................... ............... ............... ............ 16
School of Dentistry a nd Stomatology
San Paolo Hospital, University of Milan 3.3 Clinical Exam inat ion ........................................................................................................ 17
Via Beldiletto 1/ 3 3.3.1 tndications and Contraindications for SFE................... . ..17
20142 Milano, Italy 3.3.2 l ocal Risk Factors.. ... .............................. . ..1 8
E·mail: matteo .ch i-apasc~u nim i.i t 3.3.3 Informed Consent ............................ ..................... ...... .. .. 19
3.4 Radiography, Cone-Beam CT, and Conventional CT for Implant Treat ment
Involving the Maxillary Sinus ........................................................................................... 20
3.4.1 Radiographic Techniques and Radiation Exposure....... .. ............. .. 20
3.4.2 Characteristics of Various Examination Techniques .. 21
3.4.3 Clinical Application of CT Images ......... ................... ............... .. 25
ITT Treatment Guide · Volume 5 xii m Treatment Guide . Volume 5
 Table of Contents Table of Contents

3.5 Non-Grafting Alternatives to SFE ..................................................................................... 27 6.5 SFE with BCP using a Staged Approach ........................................................................... 94
3.5.1 Short Implants ........... .......................................................................... ..... .......... ...... ..... ..... ..... ................ ..... .... 27 C. ten Bruggenkate
3.5.2 Angled/Tilted Implants ............................................................. .......................... ..................................... ......... 28
3.5.3 Zygomatic Implants .................................................................. ........................................................................ 29 6.6 SFE with a Composite Graft using a Combined Simultaneous and Staged Approach ... 100
D. Buser
3.6 Lateral Wi ndow Versus Transcrestal SFE.......................................................................... 30
6.7 Bilateral SFE with Transcrestal and Lateral Window Technique
3.7 Simultaneous Versus Staged SFE ..................................................................................... 31 using Various Composite Grafts ..................................................................................... 108
R. A. Levine

4 Treatment Options for Sinus Floor Elevation ............................................. 33 6.8 SFE with a Composite Graft using a Staged Approach ................................................... 119
H. Katsuyama,. S. S. Jensen P. Casentini

4.1 Diagnosis and Treatment Planning .................................................................................. 34 6.9 Combined SFE and Horizontal Ridge Augmentation with Autologous Block Grafts,
4.1 .1 Diagnosis ........................................................................ ..... ............................... ..................................... ......... 34 BCP, and GBR using a Staged Approach ........................................................................ 129
4.1 .2 Classification and Trecitment Options...................... ...... ..... ............................... .............................................. 36
L. Cordaro

4.2 Materials and Instrumentation ........................................................................................ 40 6.10 SFE with Particulated Autografts Combined with Vertical Ridge Augmentation
4.2.1 Instrumentation for SFE................................................. ..... .................. ............... ..................... ........... 40
using On lay Block Grafts and a Staged Approach .......................................................... 136
4.2.2 Biomaterials .... ..... ..... ..... ................................................ ..... ............................................................................. 45
W. D. Polido, E. Marin;
4.2.3 Implant Design .......... .......................................................................... ..... .......... ...... ..... ..... ..... ................ ..... .... 47

4.3 Surgical Techniques ......................................................................................................... 48 6.11 Bilateral SFE in the Edentulous Maxilla wit h DBBM using a Staged Approach ............. 147
4.3.1 Transcrestal Technique ............................................ ...... .. .. ....................... ....... ....... ...................................... 48 S. Un1anjec·Korac
4.3.2 Lateral Window Technique............................................. ..... ....................... ................................. 49
4.3.3 Timetable ........ ..... ..... ..................................................... ..... ....................... .. ............................... 53 6.12 SFE with Particulated Autografts Combined with Vertical Ridge Augmentation
4.3.4 Harvesting Site......................................................... .................................. .. ............................... 54 using Onlay Grafts and a Staged Approach .................................................................... 157
4.3.5 Managing Septa and Compromised Cases ..................... ..... ....................... ................................. 57 T. W. Head

6.13 SFE with a Composite Graft Combined with Vertical Ridge Augmentation
5 Guidelines for Choosing the Surgical Technique and Grafting Protocol using On lay Grafts and a Staged Approach .................................................................... 164
M. Chiapasco
for Sinus Floor Elevation ............................................................................ 59
S. S. Jensen
7 Complications with Sinus Floor Elevation Procedures ............................. 173
H. Katsuyan1a
6 Clinical Case Presentation s......................................................................... 63
7.1 lntraoperat ive Complications ......................................................................................... 175
Transcrestal Protocols
7.2 Postoperative Complications ......................................................................................... 177
6.1 Implant Placement with Simultaneous SFE: Transcrestal Technique with DBBM........... 64
S.S. Jensen 7.3 Case Presentations of Failures and Complicat ions ........................................................ 181
7 .3.1 Membrane Perforation..... ................................. ................ ..... ...................................... .................. ..... 181
6.2 Implant Placement with Simultaneous SFE: Transcrestal Technique with DBBM ........... 69 E. Lems
8. E. Pjewrsson 7.3.2 Soft Tissue Oehiscence and Correction after SFE with Vertical and Horizontal Bone Grafting..... .. ... 187
H. Katsuyama
Lateral Window Protocols 7.3. 3 Sinusitis after Undetected Membrane Perforation during Surgery............................................. ........ ... .. 191
H. Katsuyama
6.3 Implant Placement with Simultaneous SFE: Lateral Window Technique 7.3.4 Bilatefdl Sinus Infection after Perforation due to Residual Non·resorbable Barrier Fragments .. .. ............... 194
with a Composite Graft .................................................................................................... 79 H. Katsuyama
V. Chappius 7.3. 5 lmplant Loss due to Unsuccessful Osseointegration .............. ..................................... ................... ............... 197
H. Karsuyama
6.4 Bilateral Implant Placement with Simultaneous SFE: Lateral Window Technique
with a Composite Graft .................................................................................................... 86 7.4 Conclusions .................................................................................................................... 200
A. Tahmaseb

ITI TceatmentGuide •Volume 5 xiii xiv ITI Treatment Guide . Volume S

 Table of Contents

8 References ................................................................................................ 201

8.1 References for Literat ure Review (Chapter 2.3) ............................................................. 202

8.2 Literature/References ..................................................................................................... 204

mTreatment Guide • Vohme s IY

1 Introduction
H. Katsuyama, S. S. Jensen
Continuous adv41inces 1n the fiekl of implant dentistry
have provided cfinicians with various treatment options
to facilitate the placement of den ml 1mpl.ant.s in patients
with vertical bone deficin 1n the Posterior maxdla.
Today. one of the most common ways to compcnQte
for inadequate vertical bone heicht is 10 elevate the
.sinus floor Often employed in combinauon with bone
grafts .ind bone subsdtute$, sinus floor elevation pro·
cedures are of moderate to hiah complexity, entailing a
signific.ant risk of complications
In August of 2008, the ITI held the 4th !Tl Consensus
Confetence to di5Cuss a number of current issues in
impbnt dentistry_One focus was on bone aucmtntatton
procedures in localized defecu and on lhe chn1col off•
cacy of the different protocols employe<l woth lhe many
grafting materials ;and techniques available today The
results of !his conferM!Ce we<e published 1n • supple-
ment to the International .Journa1 of Oral & Mu1llobcial
Implants in 2009.
The present frftb volume in the rn Treatment Guide
senes summarizes the findings and consensus state-
ments of the 4th ITI Consensus Conference and provides
.an up-to-date overview of the literature on sinus noor
elevation published jn the past four years. Reinforced
by this scientific evidence, emphasis is placed on clini-
cal recommendations and guidelines for evaluating pas·
sible p.ltients for sinus floor elevation and for choosing
the .1ppropriate treatment approach ..and augmentation
protocol All clinical procedures are illustrated and sup-
ported by detailed c•se reports.
As with the prec-eding four volumes of them Treatment
Guide, lhe authors hope 1hat this fifth volume win prove
a v~uable resource md reference for dinicians placing
implants in patients requiring sinus floor elev.titian to
minimize the rislc. of complic.ations iltld to ensure pre-
dic1<1ble and stable long-term resu~
mTreatment Guide •Volume S
 2 Proceedings of the 4th m Consensus Conference and literature Relliew: Sinus Floor Elevation Procedures

The International Team for lmplantology (ITI) is an inde-

2 Proceedings of the 4th ITI Consensus
Conference and Literature Review:
pendent academic organization that brings together
professionals from the various fields in implant den-
tistry and related tissue regeneration.The ITI regularly
publishes treatment guidelines based on evidence-based
clinical studies supported by long-term clinical results.
The Il l Treatment Guides have proven to be an invalu-
able resource for the clinician active in the field of
implant dentistry.

Sinus Floor Elevation Procedures
The ITt regularly organizes Consensus Conferences to
review the current literat ure on oral implantology and to
evaluate the scientific evidence suppon-ing a wide range
of clinical procedures. techniques. and biomaterials. The
proceedings are published in peer·reviewed journals.
The 4th ITI Consensus Conference was held in St uttgan,
Germany in August 2008. For this conference, the ITI
Education Committee focused on four topics:

Risk factors fo r implant therapy

Emerging techniques and technologies in implant
dentistry
Implant loading protocols,
Surgical techniques in implant dentistry

(Proceedings of the 4th ITI Consensus Conference,

lnternat;onal Journal of Oral and Maxi/Jofacial Implants
2009. Vol. 24, Supplement.)

A working group was elected for the exploration of each

topic. Working Group 4, under the leadership of Stephen
Chen, reviewed t he literature on surgical techniques.
Sinus floor elevation procedures were one of the topics
in focus of this group.

The participants of Working Group 4 were:

Mauricio Ara.Ujo Alessandro Louren~o Januario Anthony Sclar

Jay Beagle Simon Storgard Jensen Hendrik Terheyden
Daniel Buser Lars Ake Johansson
4
Alex Yi Min Tsai
4

Paolo Casentini John 0. Jones Gerhard Wah l

Maneo Chiapasco Dehua Li Dieter Weingart
Ivan Darby Thomas Oates Gerrit Wyma
Javier F<lbre-ga Bjami E. Pjetursson Alvin B. K. Yeo
Paul Fugazzon o Waldemar Daudt Polido
Timot hy W. Head Paul Rousseau

The following section presents the consensus stat'4

ments and recommended clinical procedures fo r sinus
augmentation.

m Treatmef'lt Guide •Volume 5 l • m Treatment Guide . Volume 5

 Proceedings of the 4th ITI Consenst5 Conference and literature Reo.·iew: Sinus Floof Elevation Procedures 2
2.1 Consensus Statements
Group 4 was asked to prepare evidence-based review
papers on surgical techniques in implant dentistry. Two
revie\V papers contained information related to the tech·
niques and biomaterials used in sinus floor elevation:
Simon Storg.lrd Jensen. Hendrik Terheyden: Bone
augmentation procedures in localized defects in
the alveolar ridge: clinical re-suits with different
bone grafts and bone substitute materials (Jensen
and Terheyden 2009)
Matteo Chiapasco, Paolo Casentini, Marco Zani·
boni: Bone augmentation procedures in implant
dentistry (Chiapasco et al. 2009)
Definition of terms
The following definitions were adopted from the Glossary
of Oral and Maxillofacial Implants (Laney 2007):
Maxillary sinus floor elevation: An augmenta.·
tion procedure for the placement of implants in
the posterior maxilla where pneumatization of the
maxillary sinus and/or venical loss of alveolar bone
has occurred.
Autograft (synonymous with autologous/autog·
enous graft): Tissue transferred from one location
to another within the same individual.
Allograft: A graft between genetically dissimilar
members of the same species.
Xenograft: A graft taken from a donor of another
species.
Allopfast: Inorganic, synthetic.. or inert foreign
materi.al implanted into tissue.
Maxillary sinus floor elevation using
the t ranscrestal technique
Maxillary sinus -floor elevation using a transcrestal
technique is a predictable procedure for augmenting
the bone in the posterior maxilla. A variety of graf-
ting materials can be employed safely and predicta·
bly, either alone or in combin.ation . These grafting
materials include autografts, allografts. xenografts,
and alloplastic materials-. At present, it is not clear
whether the introduction of a grafting material
improves the prognosis.
Maxillary sinus floor elevation using
the lateral window technique
Maxillary sinus floor elevation using the lateral win·
dow technique is predictable for augmentation of
bone in the posterior maxilla. A variety of grafting
materials can be used s,afely and predimbty.. either
alone or in combination. These materials inclu·
de autografts, allografts, xenog-raft:s, and alloplastic
materials. The use of autografts does not influence
survival rates of rough-surfaced implants .but may
reduce healing times.
Bone quantity and density in the residua) maxilla
influence implant sorvivaJ rates, independently of the
type of grafting procedure used.
The survival rates for implants with rough surfaces
placed in the aug_mented maxillary sinus are similar
to those of impf.a nts inserted in native bone.
ITI Treatment Guide •Volume 5
2 Proc:eediAgS" oft.he 4th m Consensus Conference and literature Review: Sinus Floor Elevation Procedures
2.2 Proposed Clinical Approacl1es
Maxillary sinus floor elevation using
the transc restal technique
Sinus floor elevation using the transcre-stal tech-
nique can be recommended in sites where the al·
veolar ere.st is sufficiently wide. initial bone height
is 5 mm or more~ and the anatomy of the sinus
floo r is relatively flat.
The main disadvantage of this technique is a risk
of sinus membrane perforation. which is difficult
to manage. Transcrestal procedures shook:I only be
user by clinicians experienced in performing sinus
floo r elevation using the lateral v1indow techn ique.
Pri mary in1plant stability is a prerequisite for this
technique.
s 6 rn Treatment Guide • Volume 5
Maxillary sinus floor elevation using
the lateral window technique
In sites where initial bone height is limited and
does not allow implants of the desired length to
be placed, sinus floor elevation using the lateral
window technique can increase bone height.
Atrophy of the maxilla occurs three-dimensionally.
The edentulous posterior maxilla should not only
be evaluated in terms of initial bone height below
the maxillary sinus but .al.s o in terms of vertical and
horizontal deficiencies of the ridge. If a relevant
venical or horizontal intermaxillary discrepancy is
present, onlay bone augmentation may be consid·
ered to create- sufficient bone volume and a proper
intermaxillary relationship in order to optimize im·
plant placement and related prosthetic restoration.
Data related to the initial clinical situation should
be reported and defects classified according to
well-defined criteria .
If the initial bone height allows primary implant
stability, simultaneous implant placement (one·
stage) can be recommended. Where primary
stability cannot be achieved, the sinus floor should
be elevated in a separate procedure. followed by
delayed implant insertion {staged approach).
Implants should have rough surfaces. Covering the
access window with a membrane may be considered.

2.3 I.iterature Review
Simon Storg~rd Jensen
Maxillary sinus floor elevation was comprehensively
reviewed as a major topic at the 4th ITI Consensus
Conference in August 2008. The folJowing is a summary
of the literature that was reviewed during that confer-
ence and of additional papers of significance published
subsequently.
2.3.1 Maxillary Sinus Floor Elevation
- Lateral Window Technique
Nore: To improve readability, extensive lists ofreferences
(referred to by superscript 11un1bers ;n brackets) are pre-
sented separately in Chapter 8.1.
Implant survival
Maxillary sinus floor elevation using the lateral window
technique is a well-documented and reliable proce-
dure to increase bone height in the posterior maxilla
to allow the placement of dental implants of optimal
length. Follow-tip data for one year or more after pros·
thetic loading were included in 85 studies. These stud·
ies reponed on 4.807 patients with 14,944 implants
inserted in augmented s inuse-s.lll
Survival rate.s were 61.2% to 100% (mean: 94.2%; medi·
an: 95%) after 12 to 107 months (mean: 31.2 months;
median: 29 months) of prosthetic loading. Survival rates
of rough·surface implants (plasma-sprayed, acid-etched
and/or sandblasted titan ium, or HA-coated) were 88.6%
to 100% (mean: 97. 7%; median: 98.8%). compared to
implants with machined implant surfaces, whose sur-
vival rates were 61.2% to 100% (mean: 87.9%; median:
89%). Rough-surface implant survival rates are compa·
rable to those of implants in non-augmented maxill-ary
bone. However. success rates determined by established
and well-defined succes.s criteria are rarely reported
(Chiapasco et al. 2009).
5ubantral bone height
The venical distance bet\veen the floor of the ma.xii·
lary sinus and the crest of the posterior maxillary
alveolar process constirutes the subantraf bone height
(also called initial bone heighr or residual bone height).
The subantral bone height is often used to determine
S.S. Jensen
whether implants can be placed simultaneously ·,vith
sinus floor elevation or whether a st<lged approach
should be preferred. Judging from the data in the lit-
erature, the mean subantral bone height before grafting
was calculated to be 3.8 mm. For simultaneous and two-
stage implant placements, it was 4.4 mm and 2.9 mm,
respectively. In tw ~stage procedures, the mean healing
time between grafting and implant placement was 6.0
months. The mean healing time between implant place-
ment and loading was 6.3 months.
Grafting protocols
A bone substitute n1ateriaf only was used in 19 studies
(740 patients. 2,481 implants).121
Autograft n1aterial only or a combination of aurografr.
n1ateria/ and a bone substitute was used in 36 studies
(1,21 O patients, 4,128 implants).13l
The mean subantral bone heights for the two groups
were 3.3 mm and 4.0 mm. respectively. For two-stage
procedures, the mean healing times before implant
placement were 6.6 months and 5.6 months, respec-
tively. In the bone substitute only group, survival rates
after 12 to 107 mont hs of loading were 82% t o 100%
(mean: 96.3%; median: 97.5%). By comparison, the
survival rates in the .autograft group were 61.2% to
100% (mean: 92.0%; median: 94.4%) after up to 60
months of lo<lding. Exclud ing studies using smooth-
surface implants, survival rates were 88.6% to 100%
(mean: 96.6%; median: 96.8%) with a bone substitute
alone after up to 42 months of loading, compared to
96% to 100% (mean: 99.4%; median: 100%) when par-
ticulated autograft material was included after up to 60
months of load ing.
Eight grafting protocols for sinus floor elevation were
documented in three or more studies.
Deproteinized bovine bone mineral (DBBM} only was
used for sinus floor elevation in 11 studies (565 patients,
1.771 implants).t•l
The initial bone height was reported in 4 of these studies
with an average of 2.8 mm (70 patients, 215 implants).
ITI Treatment Guide •Volume 5
2 Proceedings of the 4th m Consensus Conferenc.e and Literature Review: Sinus Floor Elevation Procedures
Survival rates after 12 to 68 months in function were
85% to 100% (mean: 96.2%; median: 97%).
DBBM and parricu/ated autografr material were used in
another 11 studies.I~
However. 4 studies reported on the same pool of
patients at different times {Hallman et al. 2001, 2002a.
2-004, 2005). Therefore, only clinical data from the lat-
est follow· up were included (Hallman et al. 2005). There
were 411 patients receiving 1,061 implants. Initial ridge
height was presented as an average of 4.4 mm for 5
patient pools. Survival rates were 89% to 100% (mean:
95.6%; median: 94.9%) with a follow-up of 1 2 to 60
months after loading.
Auto/ogous block grafts were used for augmenting the
maxillary sinus in 1O studies, all harvested from the iliac
crestJ61
In 5 studies (1 55 patients), 560 implants were placed
simultaneously with the grafting procedure, v1hereas 4
studies (85 patients, 351 implants) documented a staged
approach (1 study did not differentiate between staged
and simultaneous implant placement). The overall sur-
vival rates after up to 58 months in function were 61.2%
to 94.4% (mean: 83.5%; median: 84.9%). For simultane-
ous and staged implant placements in autologous bone
blocks, the corresponding surviva l rates were 61.2% to
92.2% (mean: 78.7%; median: 79%) and 76.9% to 94.4%
(mean: 87.4%; median: 89.1%), respectively.
Data on sinus floor elevations using part.icu/ated
autografts from different donor sitesW<lS presented in 7
studies (205 patients, 850 implants).m
The survival rates after 12 to 54 months of loading were
82.4% to 100% (mean: 95.1%: median: 99.5%).
A con1posite graft consisting ofparticulated autograft and
a/lograft was presented in 4 studies on 94 patients with
338 implants (2 studies did not report the number of
patients; Peleg et al. 1998; Mazor et al. 1999; Peleg et
al. 1999; Kan et al. 2002). All 4 srudies reported 100%
survival rates after loading for up to 42 months.181
Allop/astic particulate in the form of hydroxyapatite was
used as grafting materia l for sinus floo r elevation in 3
studies by the same group (56 patients, 135 implants;
Mangano et al. 2003, 2006, 2007). After up to 36
months in function, survival rates were 96% to 100%
(mean: 98.7%; median: 100%).191
7 8 ITI Treatment Guide . Volume 5
A combination of DFDBA and DBBM was used in 3
studies (Valentini and Abensur 1997; Kan et al. 2002:
Valentini and Abensur 2003) reporting on the augmen·
tation of 113 maxillary sinuses (the numbEr of patients
was not reponed by Kan et al.) and the placement of
283 implants. After up to 107 months in function, sur-
vival rates v1ere 82.1% to 96.8% (mean: 90.1%; median:
90.7%),110]
Three case series (63 patients, 110 impl<lnts) presented
delta on sinus floor elevation without grafting n1aterial.
Instead, the simultaneously placed implants acted as
tent poles for the elevated Schneiderian membrane,
allowing a coagutum to occupy the space created
(Lundgren et al. 2004; Chen et al. 2007; Thor et al.
2007). After 12 to 27.5 months of loading, survival rates
were 97.7% to 100% (mean: 99.2%; median: 100%).1111
Membrane over lateral window
A barrier men1brane was used to cover the lateral win·
dow in 16 studies (660 patients, 1975 implants).1121
No membrane was used in 28 studies {1,020 patients,
3,1 85 implants).1131
Survival rates with and without the use of a membrane
were 92% to 100% (mean: 97.8%; median: 99.1 %) and
61.2% to 100% (mean: 92 .9%; median: 94.9%) after
loading periods of up to 60 and 107 months, respec-
tively. Excluding studies using smooth surface implants.
survival rates were 92% to 100% (mean: 98.5%; median:
100%) with a barrier membrane after up to 60 months
of loading compared to 93% to 100% (mean: 98.5%;
median: 100%) without a membrane after up to 36
months of loading.
Complications
Perfof<ltion of the Schneiderian membrane was the
most common intraoperative complication and was
reported in 10% to 20% of the cases (range: 0% to 58%;
Pjetursson et al. 2008; Chiapasco et al. 2009). The proce-
dure had to be aborted due to the size of the perforation
in less than 1% of the cases. A few studies demonstrated
a correl<ltion between the size of the perforation and
subsequent implant loss, while others failed to observe
this link. Other intraoperative complications, including
excessive bleeding, displacement of implant or graft·
ing material into the sinus cavity, ;and damage to the
infra.orbital nerve were re-ported in only a few cases.
Postoperative infectious complications were reported
in 3% of the cases, with partial or complete loss of the
grafting material in less than 1% of the cases. Wound
dehiscence is another, less commonly reported postop·
erative complication.

2.3.2 Maxillary Sinus Floor Elevation
- Transcrestal Technique
Implant survival
The transcrestal elevation of the sinus floor (also referred
to as the osteotome technique) was documented in 18
studiesJt4 J
The number of implants placed was 1.744, in 1,096
patients. The survival r.ates were 83% to 100% (mean:
95.9%; median: 97.3%) after 12 to 64 mont hs of pros·
thet ic loading (mean: 27.1 months; median: 24 months).
Subantral bone height
The mean initial subantral bone height was reported in
14 studies with a mean of 6.4 mm. All studies but one
(Stavropoulos et al. 2007) placed t he implants simulta-
neously with transcrestal sinus floor elevation.HSI
Grafting protocol
Results after elevating the sinus floo r without grafting
nJaterial in 249 patients (443 implants) with a mean ini·
rial bone height of 5.8 mm were reported in 8 studies.f16J
S.S. Jensen
Survival rates were 91.4% to 100% (mean: 95.6%; medi-
an: 96.5%) after 12 to 36 months of loading (mean: 23.3
months; median: 23 months).
DBBM only was used as grafting material in 4 stud-
ies (Zitzmann and Scharer 1998; Deporter et al. 2005;
Rodoni et al. 2005; Krennmair et al. 2007) on 122
patients with a mean initial bone height of 7 .5 mm, in
whom 195 implants were placed. Survival rates were
95% to 100% (median: 99%) after a follow-up period of
12 to 45 months after Joading.11n
The highest number of patients (489) was grafted with
autologous bone in which 771 implants were placed in
subantral bone with a mean initial height of 6.6 mm and
followed for 20 to 54 months after loading (Fugazzotto
and De Paoli 2002; Ferrigno et al. 2006). Survival rates
were 93.8% to 97.8% (median: 94.8%).1181
ITI Treatment Guide •Volume 5 9
 ) Prt-opcrative Assessment and PlaM..ing for Sinus Floor Elevation Procedlxes

Careful patient selection is critic.al to the long·term sue·

cess of implant treatment in cases requiring sinus floor
eJevation {SFE). For proper evalt.1ation, clinicians need
in-<lepth knowled,ge of the anatomy both of the maxi~
3 Preoperative Assessment b.ry sinus with its adjacent structures and of the p.anern
of bone modeling that takes place after tooth extraction.
Relevant ;ospeas of each medical history need to be as·
and Planning for Sinus Floor s.esscd to determine the patient's suitability for SFE.
There is a need for clinicians to underst3:nd in detail the
indic.i.tions and contraindiations.. the various treatment
Elevation Procedures options av01ilable. and the implications of different r.i-
diopaphk techniques. Only with this information can
they select appropriate GtSes for treatment and consider
non-gr.ifting ~ermrives to SFE.

S. S. Jensen, H. Katsuyama

ITI Treatment Guide •Volume 5 11 12 m Tre<11tment Guide . Volume 5


3.1 Anatom~
Fig 1c lateral \.ieW of the maxif/ory sinus llrith lhe sinus floor extending
around the apkes ofthe maxilk11y molars and second prernoku.
The maxillary sinus is a pyramid-shaped cavity within the
maxillary bone (Figs la·c)
The base of this pyramid is formed by the lateral nasal
\valJ and the tip within the maxillary zygomatic buttress.
The roof {i.e. the cranial wall) of the maxillary sinus is
also the floor of the orbit and accommodates the infraor-
bital canal. A communication with the nasal cavity (the
semilunar hiatus) is located in the posterosuperior area
of the sinus cavity just below the concha nasa.lis media.
To minimize the risk of postoperative infective compli-
cations, t his communication should be kept intact and
clear of any grafting material. Ante riorl y~ the maxillary
sinus will normally extend to the canine or premolar re·
gion, although this may vary considerably (Fig 2).
S. S. Jensen, H. Katsuyama
Fig lb laurol' Wew of the maxillary sinus wirtl limit.ed extension of the
sinus floor ;nan anterior and inkrior direction.
Fig 1 Panoramic rodiograph showing the maxillary sinus bilaterally ex·
tendirw to the regions ofthe cenrral mdsot-s.
The sinus floor will usually take a downward convex
route with t he dee.pest point in the first-molar region.
The cavity does not occupy any significant space before
the permanent teeth erupt and becomes increasingly
larger throughout life. Ongoing pneumatization is s.een
throughout adolescence, and secondary pneumatization
may follow the loss of posterior maxillary teeth. ConicaJ
elevations projecting into the cavity, reflect ing the roots
of the maxillary molars and premolars, are frequently ob·
served. Bony walls or septa may project into the cavity
from t he sinus floor and lateral wall (Figs 3a-b).
ITI Treatment Guide •Volume 5 13
3 Preoperative Assessment and Planning fa Sinus Floor Elevation Procedures
Fig 3a Panoramk radiceraph of an edentulous patient with bilaterol
tlle posterior third ofthe marillOI)' s;nus.
Septa in
Jn fact, septa may divide the entire sinus into two or
more almost completely separat ed entities. Their inci·
de-nee varies between 16% and 58%, most commonly
taking the form of a single unilateral septum (Koymen
et al. 2009). Septa are classified as pri mary or secondary,
the forme r being developmental in nature, while the lat ·
ter are caused by irregular pneumatization fo llowing the
loss of posterior teeth . ft is essential that any irregulari·
ties of the maxillary sinus floor be identified pre-opera·
rively, as such irregularities will increase the risk of sinus
membrane perforation during surgery.
The mucosa.I lining of the maxillary sinus (also known as
the sinus or Schneiderian membrane) consists of normal
ciliated respiratory epithelium coveri ng a t hin layer of
connective t issue. It ranges in thickness between 0.45
and 1.40 mm. As a thin membrane increases the risk
of intraoperative perforation, any preoperative findings
that can help predict membrane thickness are poten·
tially useful when preparing for the surgical procedure.
A number of factors are commonly associated with in·
creased membrane thickness: thick gingival biotype and
a history of chronic sinus inflammation. In contrast,
smokers tend to have reduced membrane thickness
(Aimetti et al. 2008; Hadar et al. 2009). SFE procedures
are contraindicated if membrane thickness is increased
due to existing sinus pathology (e.g. sinusitis or mucos.al
cysts). Conditions of this type should be treated in a sep--
arate session before the procedure.
14 m Treatment Guide . Volume 5
Fit 3b Coronal section of a CT scan ofthe same patient confirming the
presence ofsepta. At this level, the sepwe completely diride the sinus into
two compartments in the orofacio/ dfmensk>n.
The lateral bony wall of the maxillary sinus may also vary
considerably in thickness. The normal range is between
0.5 and 2.5 mm, with values generally being somewhat
higher in men than women (Neiva et al. 2004; Yang et
al. 2009). Preoperatively, this information can only be
obtained from coronal sections of a cone-beam or tradi·
t ional CT scan.
The blood supply for the maxillary sinus comes from t he
infraorbital an:ery, the greater palatine artery, and the
posterior superior a lveolar artery. This latter vessel is
a particular concern for 5FE procedures, as it may pass
through the area where preparation of the lateral win·
dow is planned. The distance of the intraosseous poste-
rior superior alveolar artery to the alveolar crest is 16 to
19 mm on average (Elian et al 2005). Cases of extensive
intraoperative bleeding will usually originate at the later·
aJ sinus wall or at a tear in the Schneiderian membrane.
The sinus floo r itself will rarely contain any vessels of
clinical significance. However, when SFE procedures are
conduct ed through a t ranscrestal technique, orofacial
narrowness of the sinus may cause the osteotome to en·
gage the lateral wall, thus inducing significant bleeding
from the posterior superior alveolar artery.
 S.S. Jensen. H. Kat:suyama 3 Preoperative Ass~sment and Planning for Sinus Floor Elevation Procedur~

3.2.3 Allergies 3.2.5 Compliance

3.2 Medical Hifil:ory
While allergies per se are rarely an issue for SFE, some
patients may be allergic to any of the perioperative med-
ications prescribed, notably including antibiotics and
analgesics.
Patients unable to comply with postoperative instruc-
tions or presenting with inadequate oral hygiene should
not be considered for SFE procedures.

3.2.4 Tobacco and Alcohol

Before implant treatment and bone augmentation can
be performed, it is mandatory to thoroughly review the
patient's medical history. Special attentjon should be
devoted to patient·relate-d factors that may affect bone
healing prior to determining the suitability of a patient
for SFE.
A systematic approach includes:
1. General health status
2. Concomitant medication
3. Allergies
4. Tobacco and alcohol
5. Compliance
3.2.1 General Health Status
Candidates for SFE should not present with any condi-
tions that would affect bone healing, either locally or sys-
temically. Patients who have undergone head-and-neck
radiotherapy where the field of irradiation included the
maxilla should not be considered for SFE. Poor glycemic
control in diabetic patients (i.e. uncontrolled diabetes)
has been associated with increased susceptibility to
postoperative infections; these patients should be treat-
ed with great caution. SFE procedures are not, however,
contraindicated in patients with well-controlled diabetes
(Tawil et al. 2008). Transplant patients may be undergo-
ing long-term immunosuppressive therapy. Wh ile several
experimental studies have shown that immunosuppres-
sive agents like cyclosporine reduce normal bone heal-
ing around dental implants, no clinical data regarding
implant placement or SFE procedures are available for
patients -of this type. It has been recommended that
alternatives to implant treatment and bone augment.1-
tion be preferred until c linical data are available to sup-
pon these procedures (Bornstein et al. 2009a). \Vhether
osteoporosis is a risk factor for implant failure is open
to debate. \Vhile it is believed that osteoporosis does
Smoking is a risk factor for implants placed both in na-
tive bone and in the augmented posterior maxilla (Mc-
Dermon et al. 2006; Huynh·B• et al. 2008; Heitz·May·
field and Huynh·Ba 2009). Although tobacco use should
not be considered an absolute contraindication for SFE
not per se contraindicate implant placement or SFE, t he procedures, it is mandatory to inform these patients
risk may be increased by long-term treatment with oral about the increased risk of implant loss and peri-implant
bisphosphonates (Bornstein et al. 2009a). Studies deal· bone infection. They should be motivated to quit or at
ing with implant placement or bone augmentation pro- least reduce their smoking.
cedures in patients with neuropsychiau-ic disorders are
vinually non-.existent. Disorders of this type are not con- Alcohol is known to affect bone grafting. However, the
traindications in themselves, but may affect compliance. main issue with alcoholism in implant patients are pre-
It is extremely imponant to make sure that these pa· sumably compounding facto rs such as malnutrition,
tients \viii be able to comply with postoperative instruc- poor oral hygiene and compliance (Li and Wang 2008).
tions and to maintain an adequate level of oral hygiene. Therefore, patients with any kind of abuse issue should
be evaluated with utmost care. In many situations, al-
ternatives to implant therapy including SFE procedures
3.2.2 Concomitant Medications should be preferred.
A complete list of medications should be obtained well
ahead of the surgical procedure, allowing the surgeon
to evaluate whether any of the drugs would pose an
absolute contraindic.a tion t o the planned treatment.
Absolute contrajndicat ions would include i.v. bisphos-
phonates, chemotherapy, or indeed any drug known to
suppress bone healing or immune response. Ot her types
of medication, such as antithrombotic drugs, indicate
that extra caution should be exercised during surgery.
Antithrombotic treatment should generalty not be dis-
continued, as the risk of severe bleeding is usually much
lower than the risk of thromboembolic events (Madrid
and Sanz 2009). Discontinuation or a dose reduction
from therapeutic to prophylactic levels may be indicated
if a complex procedure involving an increased risk of
bleeding is expected (e.g. extensive bone augmentation,
extraoral bone harvesting). Any adjustments of concomi-
tant medication should only be made in agreement with
the patient's physician.
In addition, surgeons need to make sure that regular
medications wi ll not interact with drugs pre-scribed in re-
lat ion to surgery. A number of known interactions with
antibiotics and analgesics dictate that the treatment of
patients on antithrombotic vitamin·K antagonists should
be considered very carefully.

ITI Treatment Guide•Volume 5 15 16 rTI Treatment Guide • Volume S


3.3 Clinical F..xamination
3.3.1 Indications and
Contraindications for SFE
Careful and appropriate selectjon of patients based on
well-defined clinical indications is critical to the long·
term success of impJant treatment with SFE. Proper case
selection requires a thorough (clinical and radiographic)
examination and careful treatment planning. In addition
to the general examination requirements for implant
treatment, specific aspects of the maxillary sinus need
to be examined on a separate basis. Ridge morphology
and interarch relations need to be assessed specifically
from a restorative viewpoint. A detailed radiographic
examination, usually by computed tomography, is indis·
pens.able. Following this detailed examination. the final
treatment plan is developed based on the best scientific
evidence available.
It is recommended to pursue the following treatment
objectives in the edentulous posterior maxilla requiring
SFE:
1. Occlusion extending at least to the first molar.
2. Surgery on an outpatient basis under local
anesthesia.
3. Bone harvesting from intraoraJ donor sites.
4. Simultaneous implant placement {only if primary
implant stability is ens.ured).
S. S. Jensen, H. Katsuya:ma
Two basic types of SFE procedures can l>e distinguished:
the tra.nscre-stal technique and the lateral window tech-
nique. A transcrestaJ technique is selected when condi-
tions in the surgical site are ide.al (i.e. adequate orofacial
bone width, sufficient subantral bone to achieve implant
stability, acceptable interarch relation). Creating a lat-
eral window for access is preferred when a transcrestal
technique is rendered impossible by advanced resorp-
tion (lack of bone volume) or complex sinus anatomy
(i.e. secondary cavity). Furthermore, it may be necessary
to revert to the lateral window technique when the sinus
membrane has been perforated on anempting a trans-
crestal technique.
ITI Treauneot Guide• Volume 5 17
3 Preoperative ksessment and Planning for Sinus floor Elevation Pfocedwes
Fig 4 Narrow sirrus.
3.3.2 Local Risk Factors
Contraindications
SFE procedures are contraindicated in irradiated pa-
tients.full-dose radiotherapy, and i.v. administration of
bisphosphona.tes.
Factors involving a high risk
Chronic periodontitis is a risk factor for SFE and im-
plant therapy. Individuals with untreated periodontitis
should not receive dental implant treatment or SFE until
periodontitis has been managed successfully. Even after
periodontitis has been treated, there is still a trend for
lower survival and/or success rates than in pa.tjents with
no history of periodontitis {Heitz-Mayfield and Hyunh·Ba
2009). Consequently, patients who have a. history of peri-
odontitis need to be counseled on the increased risk of
pe-ri-implantitis and of implant failure.
Acute sinusitis is a. high-risk factor for SFE. Dental fac-
tors have been reported to be the cause of sinusitis in
10% to 12% of ca.ses (Brook 2006). Teeth with periapi·
cal lesions or cysts have been implicated. In patients
with periapical disease, the odds ratio for sinusitis was
3.6 (p < 0.0001) compared to controls (Abrahams et al.
1996). AJso, in cases with a suspected communication
between a sinus and apical tooth segment, an adequate
healing period should be considered between tooth ex-
traction and SFE to minimize the risk of perforating the
Schneiderian membrane.
Significant diffic ulties a.re likely to arise in the wake of
tess-than-ideal postsurgical healing of soft and hard tis-
sues. A c.ammunica.tion between the extraction socket
18 m Treatment Guide . Volume 5
and maxillary sinus would increase the risk of mem·
brane perforation and hence the surgical risk at large.
This possibility needs to be carefully evaluated. Numer·
ous cases of tooth loss due to periodontitis are followed
by extensive destruction of local bone. In this situation,
the resultant bone defects and their relationship with
the sinus floor become complex. It should also be noted
that extensive {three-dimensional) bone augmentation
will be required in the presence of extreme bone resorp·
tion. Situations of th is type often require bone harvest·
ing from extraoral sources such as the iliac crest.
Factors involving a moderate risk
Severa.I studies have reported higher failu re rates for im·
plants in smokers than non"'Smokers follow ing SFE{Keller
et a l. 1999; Olsen et al. 2000; Mayfield et al. 2001: Kan
et a.I. 2002). ln a. recent systematic review, the rate of
implant fa ilures in grafted sites was shown to be almost
twice as high in smokers as in non-smokers (Pjetursson
et al. 2008). Even though the difference was not sta.tisti·
c.a.lly significant, caution should be exercised when con·
sidering smokers for SFE. It should be noted that smok·
ing combined with a history of treated periodontitis has
clearly been demonstrated to be a risk factor both for
implant survival and for biological complications in gen·
eral (Heitz-Mayfield and Hyunh-Ba 2009).
Abnormalities of the sinus membrane (e .g. hypertrophy)
are not a contraindication to SFE but should be consid·
ered a relative risk.
Hypertrophy of the Schneideria.n membrane may be
c.aused by chronic sinus infection, radicular cysts, al-
lergies, benign tumors, development.al cysts-, or fibrous
dysplasia.
Infective causes of membrane thickening are diagnosed
based on an examination that will include dental symp·
toms {e .g. dull pain, periradicular pneuma.tization) and
the patient's medical history (Brook 2006).
Inflammatory polyp formation is a common finding in
the nasal cavity.
SFE can generally be safely conducted in the presence of
mild membrane thickening or where the hypertrophy is
not caused by infection . Situations of aberrant site heal·
ing following extraction will involve an increased risk
of sinus perforation. It is necessary to allow sufficient
time for healing and restitution of the sinus membrane
(van den Bergh et al. 2000a). Any abnormalities of the
alveolar mucosa caused by infection, bullous disease.
or aberrant healing will increase the risk of soft tissue
dehiscences follow ing surgery. Any of these conditions
need to be treated and resolved prior to conducting SFE.

Any secondary cavity identified in the presurgical CT
study will need to be assessed for its complexity. Non·
complex secondary cavities can usually be managed at
a moderate risk of perforation. The maxi11ary sinus is a
pyramide-shaped cavity; it is believed that the narrow
form is often foun d in the anterior region of the sinus
(Fig 4) (van den Bergh et al. 2000a; Velloso et a l. 2006).
Obtaining adequate access to this region. which is fre-
quently the site of perforation, is difficult and may re·
quire a larger window than initially thought. In the pres-
ence of an artery, any osteotomy created in the lateral
wall will increase the risk of hemorrhage during and after
surgery (Greenstein et al. 2008). A detailed presurgical
analysis, including a CT scan. is mandatory to identify
any of these fdre blood vessels in the lateral wall (van
den Bergh et a l. 2000>).
Bone density is usually poor in maxi llary posterior seg·
ments. Compared to the other major jaw segments (an·
terior maxilla, anterior mandible. posterior mandible),
the posterior maxilla has the lowest bone density in
terms of Hounsfield units (de Oliveira et al. 2008; Turk·
yilmaz et al. 2007). One srudy found this difference to be
statistically significant {Fuh et a l. 2010). In the presence
of a minima l conical layer, primary implant stability will
be difficult to obtain. In situations when can cello us bone
is non-existent, bone regeneration with bone substitute
alone is very difficult, making the use of autogenous
bone alone or in combination with bone substitute in·
dispensable (Jensen and Terheyden 2009).
There is also a higher likelihood of encountering unfavo·
rable interarch relations in the posterior maxilla due to
the specific three-dimensional pattern of bone resorp-
tion in the molar areas. Both vertical a.ugmentation of
the s inus floor and horizont.al bone augmentation may
be needed to optimize the restor~ujve outcome. These
cases require the use of autogenous block grafts. When
bone height is inadequate for impl.ant placement due to
a combination of vertical resorption of the alveolar bone
and sinus pneumatization, it is necessary to explore the
need for vertical bone augmentation at the crest.
Although evidence for a relationship between bruxism
and implant failure is lacking (Lobbezoo et al. 2006). rel·
evant precautions should be taken for implants placed
in the posterior maxilla following SFE. All biomechanical
aspects relating to the span a.nd design of the prosthesis
should be carefully considered.
S. S. Jensen, H. Katsuyama 3 Preoperati...e Assessment and Planning fa Sinus Floor Elevation Procedut('$
Depending on the clinic.al situation, the recommenda·
tion is usually to select as many implants as possible and 3.4 Ra_diQgiaphy, Con~Beam CI~and
of the greatest length possible. An extended healing pe-
riod before loading the implants helps to minimize the Co11ventional (,"T for Implant Treatment
risk. If bone height is inadequate and not enough im·
plants can be placed, it is preferable to use an implant· [11volving_ tl1e Maxillary Sinus
supported removable overdenture, such that the mucosa
will be able to dissipate some of the load. A night guard
(occlusal splint) is recommended (Zinner et al. 2008).
The condition of the teeth (e.g. remaining tooth struc·
ture or pulp status) adjacent to the proposed SFE needs
to be considered prior to treatment planning for SFE, so
as to minimize any unexpected tooth-related complica·-
tions that m ight otherwise persist and eventually affect
the long-term outcome.
3.4.1 Radiographic Techniques Radiation exposure
Patients will be exposed to radiation in a.ny kind of radio-
3.3.3 Informed Consent and Radiation Exposure graphic examination. It is therefore necessary to know
SFE for implant tre.a tment is a complex surgical proce· Radiographic techniques for sinus imaging the dose level and the anatomical structures likely to be
dure. Clinicians need to explain its advantages a.nd dis· Radiographic imaging is indispensable to determine ana- included in the field of radiation. Structures panicularly
advantages for patients to give their informed consent. tomical complexity and the most appropriate treatment sensitive to radiation that will normally be exposed to
The following points should be considered in these dis· approach in any type of implant treatment. C.omputed radiation during imaging of the maxillary sinus include
cussions: tomography (CT) is panicularly effective when implants the corneas and salivary glands (Ekestubbe et al. 1993).
a.re planned in the atrophic posterior maxilla, offering
1. Alternative restorative options with their strengths diagnostic insight into the form of the maxillary bone l he International Comm ission on Radiological Protec-
and we.aknesses, including fixed dental prostheses that is not attainable by panoramic radiography alone tion (ICRP) supports the use of radiographic imaging in
with a distal cantilever and re.movable dental pros· (Dufa et al. 1996). EU guidelines (Radiation in impfanto l- 1he planning phase of implant treatment (2007). The
theses. ogy 2004) recommended that plain dental radiography disadvantage of radiation exposure is exceeded by the
2. Alternative implant options, including shortening of and panoramic radiography should be combined with large body of detailed information offered by CT, such as
the dental arch. distal cantilever implants supported conventional CT or cone-beam CT {CBCT). Table 1 il- the form of the sinus and posterior maxilla or the pres-
fixed dental prosthesis, and angled implants to lustrates the scheduling of these various recommended ence of any septa or vascular structures (Dula et al. 1996;
increase the distal reach of the implant-supported techniques. Ganz 2009).
prosthesis (see Chapter 3.5).
3. Selection of biomateriaJs and source (intraoral.
extraoral) and volume of autogenous bone (Chen et
a l. 2009).
4. Shon-term and long·term surgical risks (e.g. s inusi-
tis) and long-term prognosis (survival and success
rates, complication rates when SFE is performed). Table 1 Radiographic imaging ofthe maxillary smus and posterior moxitlo: dmil1£ and recommended techniques.
S. Esthetic risk, especially in patients with broad smiles
diS<losing the posterior maxillary teeth (Fradean1 Periapical radiograph Panoramic radiograph CT or CBCT
2004).
6. Cost of treatment, as implant procedures involving
SFE are invariabfy more expensive than standard
Initial visit
• •
implant treatment. Before surgery 0 0 • (Maxilla/Mandible)
'
7. Duration of tre.a tment, as st.aged SFE in particular
will involve protracted treatment periods.
8. Esthetic demands, patient cooperation, and consent
After surgery (after SFf )
• 0 O (Maxilla)
to treatment.
After surgery (after placement)
• 0 I. 0 (Maxilla)
Long-term monitoring
• 0 l!.
Emergency fJ. 0
I •
• recommended, <>justified, A optional
ITI Treatment Guide• Volume S t9 20 m Treatment Guide .Volume 5

Table 1 Stochastic effect by radiation exposure giwn as carcinogenesis rote and risk offat.al cancer.
Radiographic technique
lntr1oral dental radiograph
Panoramic radiograph
Cone-beam CT (CBCT)
Multi-slice CT (MCT)
A preoperative CT scan to evaluate the anatomy of the
maxillary sinus is therefore strongly recommended.
CBCT will involve a significantly lower effective dose of
radiation than conventional multi-slice CT (MCT) in the
majority of cases and is therefore usually preferred, es-
pecially because in some cases several examinations are
required. Considering the risk of inducing malignancies,
however, the indication for CBCT needs to be carefully
assessed in each case. Table 2 summarizes the effective
doses of various radiographic techniques against the risk
of developing fatal cancer (EU guidelines 2004, Koong
2010).
Effective doses of MCT and CBCT examinations cover a
wide range. Doses delivered by MCT will vary with im-
aging protocols. which can be customized by the radi-
ologist. tow-dose MCT protocols have been reponed to
yield diagnostic images of sufficient quality for numer-
ous purposes in dentislJY (Koong 2010). CBCT offers less
control over imaging protocols than MCT. Effective dos-
es delivered by CBCT will largely depend on the equip·
ment used. Paradoxically, some small field-of-view units
may deliver higher doses than larger field-of-view units.
Various units and studies available on the subject have
been found difficult to compare (De Vos et al. 2009).
S.S. Jensen, H. Katsuyama 3 Preoperative Assessment and Pbnfljns for Sinus Floor Elevation Procedures
lntraoral radiography
lntraoral radiography using the paralleling technique
Effective dose Risk of fatal cancer
can provide information on available bone height and
trabeculation. However, as the technique does not shed
1 - 8 µSv 0.02 - 0.6 x lo-6
light on orofacial bone width the majority of proposed
3.85-30 µSv 0.21-1.9x 1 ~
implant sites cannot be properly evaluated on this basis
alone. Care must be taken to account for image distor-
27-1073 µSv - tion if the fi lm is not placed p.arallel to the long a.xis of
t:he ridge and/or if the x-ray beam is not perpendicular to
Maxilla 8 - 242x10-6 the film. Figs Sa-b give an example of the potential mag-
474-1410 µSv
Mandible 18.2-88x 10-6 nitude of distonion. Intra.oral radiography may suggest a
bone height sufficient to place an implant without bone
augmentation (Fig Sa) while CBCT may demonstrate
that bone height is actually reduced to a much larger
degree (Fig Sb). Diagnostic errors of this magnitude c.an
have significant clinical consequences.
3.4.2 Characteristics of Various
After treatment, intraoral radiography is recommended
Examination Techniques to verify the outcome of implant placement and for long-
Examination by intraoral and panoramic radiography term monitoring of peri-implant bone conditions (Fig 6).
Intra.oral radiography using a film retainer and a paral-
leling technique is a good imaging technique to obtain
preliminary information and to evaluate the degree of
vertical alveolar bone resorption following tooth extrac-
tion. Panoramic r.;:diographs will also yield a good over-
Figs »b Presurpj,col examination of the subonrral bone
view, but with varying degrees of vertial and horizontal wiN Olten requite more than convenDonaJ petjQpical rCNJio..
distortion along the image. Varying magnification fac- graphs. In this case, the introoral rodiogoph suggested a
tors along the film (1 5% to 30%) may be present that bone height of 12.1 mm (aJ. but rhe true height~
strated by CBCT was acruatly 6. Smm (b). Three-dimensional
affect the positional relationships between anatomical
diagnqsi.s by CT is reaxnmended wheneverpossibk, even if
structures. These overview techniques will provide a ba- few implants ore planned.
sis to assess the need for SFE and to perform a CT -scan
with the patient's consent.
F1g 6 lnuaorot radklgraphy has the tmmrr.we cf offering relatively k1W
radiation aposure and convenient handfine- h i'S therefote effeaive for inJ.
rial eYllfuation d"the subanual bone and Iongirudinal obsmution after Nn-
plant insto/kl!ion. This~ reveals pen.implant. bone conditions 3 ~
ofter a mixed simultaneous and staged approach. Starting from the meWJ
aspect. die first implant ""1S pkxed into an extraaioo soctet the second
was placed ;,, a simultaneous approach. and me thitdlfourth implants in
a staged approach. Gfvt>n its radiation IM>l.s. CT imaging is aurmtJy not
considered appropriare for routine Jongkudinal examination.
Ill Treatml?flt Guide • Volume 5 21 22 ITI Treatment Guide • Volume S

Figs 11Ja.b CBCT scans o«afrred aft.er implant place-
ment us;ng a transaestal uchn;que. 1his image is highly
occurate thanks to rhe rtaflow acquisition range (o). Fol--
foft·ing implont pl«emerR.. the sinus flooris elevated and
the grafting material compressed into the elevated space
by the implant (b).
3.4.3 Clinical Application
of CT Images
CT images a.re reconsuucted from the original digital data
captured by the scanning unit. They are stored, handled,
printed, and transmitted in standard DICOM (Digital Im·
aging and Communications in Medicine) format.
Analysis using simulation software
DICOM da.ta provide the basis to reproduce the ana-
tomical features under study. The vinual environment
thus created can be used to plan implant locations us-
ing simulation software and to share this plan with other
members of the dental team.
Figs 11a-b SNnukrtion sottwwe d'fe.rs significant advantQgeS for implant planning. Once rhe form of the maxiltary sinus and wbantral bone has been
dewminetl (a.), implants con be placed in o virtual erwironmem (b}. This wiH funher the dinkian's understanding ofthe amount ofbone ~ration
required and ofideal irnplontparameters (location and length). The cwerall technical a«urocy ofthe Sl.ltgical procedure will be imprcwed. Several surgical
techniques are frequently combined. and simuJodon software aOows conveying m;s information to the patients for C'OJ'lserlt-
S. S. Jensen, H. Katsuyama. 3 Preoperative Assessment and Planning for Sinus Floor Elev.rtioo Procedures
,,
. .
-
Simulation software will readily disclose the need for
.
SF-E or any other bone augmentation procedures. ft will
Fies 1la< In this simulated phn. SFE can be ovoKled by pladne an im-
also supply information about the augmentation volume
plartt in the pre.molar area in on indined position (a). In cases such as
required for an ideal outcome and about implant pa- these.. the. simufotion software ron be used to analyze the superimposed
ra.meters such as ideal length, number, and positioning. il'f'IQge of rhe final superstructl..lfe. thus rendering the treatment plan more
This approach offers significant advantages especially in accurate and faa1itaring comtruaioo ofa surgk/JI tempkrte {band c).
anatomically complex posterior segments of the maxilla
(Figs 1h ·b).
Simulation software will also yield vital information to
consider alternatives to SFE. A case is presented in which
implants placed in the premolar areas were inclined to
a.void SFE (Figs 12a-c). The sequence of procedures in·
vofving the use of simulation software includes:
1. Initial diagnosis
2. Fabrication of a scanning stent
3. CT scanning
4. Treatment planning
5. Construction of a jaw model
6. Surgery
Software·based simulation based on CT dat:a can be
readily implemented and is an effective tool for man·
aging the posterior maxilla. However, given the rapid
developments in software applications and fabrication
technologies for surgical templates, any new processes
and systems should always be carefully verified.
ITI Treatment Guide• Volume 5 25 26 m Treatment Guide • Volume 5

Figs 11Ja.b CBCT scans o«afrred aft.er implant place-
ment us;ng a transaestal uchn;que. 1his image is highly
occurate thanks to rhe rtaflow acquisition range (o). Fol--
foft·ing implont pl«emerR.. the sinus flooris elevated and
the grafting material compressed into the elevated space
by the implant (b).
3.4.3 Clinical Application
of CT Images
CT images a.re reconsuucted from the original digital data
captured by the scanning unit. They are stored, handled,
printed, and transmitted in standard DICOM (Digital Im·
aging and Communications in Medicine) format.
Analysis using simulation software
DICOM da.ta provide the basis to reproduce the ana-
tomical features under study. The vinual environment
thus created can be used to plan implant locations us-
ing simulation software and to share this plan with other
members of the dental team.
Figs 11a-b SNnukrtion sottwwe d'fe.rs significant advantQgeS for implant planning. Once rhe form of the maxiltary sinus and wbantral bone has been
dewminetl (a.), implants con be placed in o virtual erwironmem (b}. This wiH funher the dinkian's understanding ofthe amount ofbone ~ration
required and ofideal irnplontparameters (location and length). The cwerall technical a«urocy ofthe Sl.ltgical procedure will be imprcwed. Several surgical
techniques are frequently combined. and simuJodon software aOows conveying m;s information to the patients for C'OJ'lserlt-
S. S. Jensen, H. Katsuyama. 3 Preoperative Assessment and Planning for Sinus Floor Elev.rtioo Procedures
,,
. .
-
Simulation software will readily disclose the need for
.
SF-E or any other bone augmentation procedures. ft will
Fies 1la< In this simulated phn. SFE can be ovoKled by pladne an im-
also supply information about the augmentation volume
plartt in the pre.molar area in on indined position (a). In cases such as
required for an ideal outcome and about implant pa- these.. the. simufotion software ron be used to analyze the superimposed
ra.meters such as ideal length, number, and positioning. il'f'IQge of rhe final superstructl..lfe. thus rendering the treatment plan more
This approach offers significant advantages especially in accurate and faa1itaring comtruaioo ofa surgk/JI tempkrte {band c).
anatomically complex posterior segments of the maxilla
(Figs 1h ·b).
Simulation software will also yield vital information to
consider alternatives to SFE. A case is presented in which
implants placed in the premolar areas were inclined to
a.void SFE (Figs 12a-c). The sequence of procedures in·
vofving the use of simulation software includes:
1. Initial diagnosis
2. Fabrication of a scanning stent
3. CT scanning
4. Treatment planning
5. Construction of a jaw model
6. Surgery
Software·based simulation based on CT dat:a can be
readily implemented and is an effective tool for man·
aging the posterior maxilla. However, given the rapid
developments in software applications and fabrication
technologies for surgical templates, any new processes
and systems should always be carefully verified.
ITI Treatment Guide• Volume 5 25 26 m Treatment Guide • Volume 5
 S. S. Jensen, H. Katsuyama. 3 Preoperative Assessment and Planning for Sinus Floor Elev.rtioo Procedures

3 5 No11-GraftingAlternativesJQ...SFE

Fig 14 Plaamem of4 implants for the SUppolt ofa rlXed bridge estoblisfl..
irig second premolar occfusion in an atrophic posterior maxilla. The two
posttriot im/41rtlS are afl8uloted 45 degrees distaJ1y to avoid an SFE and to
emerge in the area of the s.econd pumo/ars. These ore rigidly fixed to the
3.5.1 Short Implants two anwi<x implants, which, importantly, are loaded axialfy.
Fit JS Pfacemenr of6 implants for the support ofa fiml bridge establish-
ing first molar ocdusion in an atrophic posre.riol maxitla. The two posterior
implants are anchored in the madl/aty wborositylptetygaid plate to avokl
an SFE They ate rigjdfy fiud to the anterior implants. which are loaded
axially.

While the survival rates of single-tooth replace·ments

were found to be reduced ff supponed by implants
< 10 mm in length (Renouard and Nisand 2006) (Fig 13),
interest In these short designs has been growing with
the introduction of rough surfaced implants. SurvivaJ
rates of rough-surfaced short impl.ants for single-tooth
replacement have been reported to approach those of
implants~ 10 mm (Deporter et al. 2008; Corrente et at.
2009).
Fig 13 Trrotmem options m the case ofa pneumatilld maxillatysinus in
However, this find ing was predominantly obtained in the seccmJ premolar region: Placement ofshort implant l'S. placement of
the posterior mandible, where the bone is usualty of an implant:: 10 mm in combination with an SF£
higher density. Therefore, it should be expected that
an implant <10 mm placed in the posterior maxilla car-
ries an increased risk of failure (Hagi et al. 2004). The
survival rates of short implants in the posterior maxilJa
have never been compared to those of longer implants
in combination with SFE for the same indications, nor
in randomized controlled studies. Due to crestal bone
loss and/or sinus pneumatization, vertical bone height
will often fa.II short of 10 mm in the posterior maxilla . 3.5.2 Angled/Tilted Implants That being said, any tilted implants will need to be rig·
Until more data regarding the long-term survival of im- idly connected to axially loaded implants in the anterior
plants< 10 mm are available, it is still recommended to To a.void sinus grafting, angled implants may be anchored segment. This need limits the spectrum of indications al·
augment sufficient bone to accommodate an implant in the anterior or posterior sinus wall or in the pterygoid most exclusively to completely edentutous patients and
O?" 10 mm in length . Implants < 10 mm may be consid- plate (Figs 14 and 1 S). This approach will potentially re- requires sufficient native bone in the anterior segment
ered when two or more implants are a.bout to be placed, duce the overall duration of trea.tment and enable the use to accommodate two or more axiaJly loaded implants.
and provided that the implant-supported crowns a.re rig· of longer implants, thus adding to the primaiy stability of There are also high demands on restorative pJa.nning
idly splinted. implants placed in the posterior maxilla. and coordination. Angled posterior implants combined
with at lea.st two anterior implants in native bone by way
of cross· arch stabilization have been demonstrated to of·
fe r short-term success rates on a par with rough-surfaced
implants placed in bone augmented by SFE procedures
(Block et a l. 2009; Jensen and Terheyden 2009; Chiapas-
co et al. 2009).

ITI Treatment Guide • Volume 5 27 28 m Treatment Guide • Volume 5


Fjg 16a Placement of6 implants for rtie support of o fixed bridge~
lishHtg first molar occlusion in an atrophk postetiot marilla. As an oftet~
rive to on SFE. the two posterior implants «e anchored in die zygomatic
bodies andgo t/Jtouaf't the maxiYory sinus bilareraily to emetge in the area
of the first molars. These are tigidfy fittd to rhe fol.N anterior implants.
•·hkh ate loaded oxiaPy.
Fig 16c MooMace proj«tion of
the same patient. Courtesy of Dr.
N. W.orsaae.
3.5.3 Zygomatic Implants
Another alternative to SFE in completely edentulous pa 4
tie-nts would be- to place zygomatic implants. One or two
implants can be anchored bilaterally in the zygomatic
bodies (Figs 16a-d).
With regard to splinting, the same requirement applies
a.s for posterior titted implants: enough bone needs to be
pre-sent to anchor two to four conventional implants in
the anterior segment, thus obtaining cross·arch stabiliza·
tion through rigid splinting of all implants. Unlike tilted
implants, zygomatic implants need to be placed under
general anesthesia, although lhese patients can usually
be discharged on the day of surgery, which is rarely pos·
S. S. Jensen, H. Katsuyama.
Fig 16b J'afl(J(amic HOY ofa fidl)' edemulous patient wM substantial or·
rophy ofthe marl/a and mandible. Two zygomatk implants ore connected
rigidly wrrh a bat constrtfCtion to the three imp/onrs placed Kl the anterior
moxitla. CoortesyofDr. N. Worsaoe
Fig 16d Anteroposterior projec·
rion cf the same pav·eJ11 prior to
ptC'ISlheric rehablitation. Counesy
ofDr. N. WOISOae.
sible after majof bone grafting procedures with extraoraJ
donor sites. Another advantage of zygomatic implants
over staged grafting procedures is that they reduce the
overall treatment time. A final prosthesis can normally
be delivered within 6 months. Disadvantages of zygo·
matic implants include their highty operator sensitive 4
placement, palatal bulkiness of the final prosthesis due
to their palatal emergence platform, and more serious
(although rare) complications than those reported after
SFE procedures. Combined with two or more anterior
implants, zygomatic implants offer a survival fdte simi·
lar to implants placed in grafted sites of the posterior
maxilla (Block et al. 2009; Jensen and Terheyden 2009;
Chiapasco et al. 2009).
ITI Treatment Guide• Volume 5 29
3 Preoperative Assessment and Planning for Sinus Floor Elev.rtioo Procedures
3.6 Lateral Wind.QF Vers.!!£ Tran~ resttl SFI~
SFE can be accomplished either through a lateral win-
dow or through a tra.nscrestal technique (also known as
the open and closed techniques, respectively).
Chapter 4 will discuss the surgical techniques in detail.
In brief, the lateral window technique involves a muco-
periosteal full thickness flap to gain access to the lateral
4
wall of the maxilla. The size of the window to be pre-
pared into the lateral sinus wall may vary with the de-
sired bone volume to be augmented or the number of
implants to be placed. The Schneiderian membrane is
carefully elevated, whereupon a grafting material can be
placed. The transcrestal technique includes elevation of
the sinus floor through the prepared implant be-d. After
preparing the implant bed to around 1 mm short of the
sinus floor, an osteotome is used to fracture the sinus
floor. A grafting material may be ge-ntlycompressed into
the space created beneath the sinus membrane; alter·
natively, the space may be left empty to fill with blood.
Finally, the implant is placed.
The lateral window technique is capable of augmenting
large volumes of bone and can be utilized irrespective
of sinus anatomy. The transcresta.1 technique is capable
of yielding only 2 to 3 mm of additional bone height
(Pjetursson et al. 2009a). Considering that implants
O? 10 mm in length are usually preferred, this approach is
therefore limited to cases with an initial subantral bone
height of~ 7 mm. A systematic review concluded that
implant survival is dramatically reduced after transcres-
tal SFE procedures if initial bone height was s 5 mm (Tan
et al. 2008). As an additional limitation, the transcrestal
30 m Treatment Guide • Volume 5
technique should remain confined to situations where
the sinus floor runs approximately horizontally. Using
an osteotome to fractu re an oblique sinus floor will
considerably increase the risk of perforating the Schnei-
derian membrane. tf perforalion does indeed occur, it
is recommended to revert to the lateral window tech 4
nique~ as this will allow the perforation to be repaired
through the window created (see Chapter 7). Few stud 4
ies have evaluated the integrity of the membrane during
transcrestal SFE in a consistent fashion, using a depth
gauge to check membrane resilience and the Valsalva
maneuver {nose-blowing test). Whi1e membrane perfora 4
tion has been claimed to be a rare complication during
transcrestal SFE. it has also been reported to occur in
10% to 26% of cases (Pjetursson et al. 2009b; Gabbert
et al. 2009). For the lateral window technique, perfora 4
tion rates of 10% to 20% have been documented (Jensen
and Terheyden 2009; Chiapasco et al. 2009). The main
advantage of transcrestal SFE is its lower morbidity in
terms of postoperative swelling and pain compared to
the lateral window technique.
It is a common misconception that less trained surgeons
should prefer the transcrestal technique. Although the
surgical technique a.s such may be less demanding, there
is always a risk of complications like membrane perfo 4
ration or (less frequently) severe bleeding. As complica4
tions of this type will can for appropriate management
such as opening the lateral sinus wall to repair the per4
foration or identifying the source of bleeding, surgeons
need to master the lateral window technique even as
they conduct the transcrestal technique.

3.7 Simultaneous Versus Staged SFE
Simultaneous SFE refers to elevation of the sinus floor
during the same session as implant placement. An ap-
proach of this type may be considered if primary stabil-
ity of the implant is attainable in the residual sub.antral
bone. It used to be a general rule that simultaneous SFE
was appropriate at sites offering a residual bone height
of'?: S mm. Primary stability is. however, influenced by
several other factors as well. Bone density, for example,
has a significant role. The quality of loosely structured
trabecular bone in the maxilla may be enhanced by bone
condensing. Th is is achieve<I by using only the small-<ti-
ameter spiral drills to prepare the implant bed, followed
by application of osteotome-s or the implant itself, thus
condensing the bone in a lateral direction to enhance
primary stability (Figs 17a-b).
Another technique to increase primary stability in
trabecular maxillary bone involves the use of tapered
implants. Yet another way to improve primary stability
would be to use an implant with a shoulder wider than
its body, such that the implant shoulder engages the cor-
tical crestal bone.
Staged SFE is recommended whenever adequate pri-
mary stabi lity cannot be obtained. Depending on aug-
mentation volume, sinus anatomy, and grafting pro-
Fig17o Theimplantb&:lispre-
pared by only using die narrow
diameter dtitl.
S. S. Jensen, H. Katsuyama 3 Preoperative Assessment and Planning fer Sinus Floot Elevation Procedure$
Acknowledgments
Research Suppon
Or. Yoji Kamiura - Center of Implant Dentistry,
Yokohama, Japan
Or. Tsuneyuki Tsukioka - Center of Implant Dentistry,
Yokohama, Japan
tocol, the healing period may vary between 3 and 12
months until implant p lacement. A waiting period of 3
t o 4 months may be appropriate in single-tooth gaps if
the sinus anatomy is narrow and an autograft {alone or
in combination \Vith a bone substitute} is used for aug-
mentation. A total of 1O to 12 months of graft consoli-
dation are needed before implants can be predictably
insened if an .. eggshell" sinus floor is augmented with
a bone substitute alone.
Previously it was recommended to place autogenous
bone block inlays in the maxillary sinus when the resid-
ual bone volume was insufficient to achieve primary sta-
bility, and to immobilize these blocks with the implants.
Today this technique is no longer preferred, as it has
been shown to involve a high rate of implant fa ilure and
technical difficulties in obtaining appropriate implant
positions driven by restorative consideratjons (Jensen
and Terheyden 2009).
No randomized controlled clinical trials have been per-
formed to compare the simultaneous and staged SFE ap-
proaches in identical clinical situations. A review of the
literature has, however, suggested that both approaches
may involve similar rates of implant survival (Del Fabbro
et al. 2008).
Fig 1711 The final diame!FI of
the implant bed is 1e:xhed by
usinf osteoromes of incteasine
diametet, ttfikh are calibrated to
the impkrm system that is used.
ITI Treatment Guide •Volume S 31 32 m Treatment Guide • Volume S
 4 Treatment Options for Sinus Floor Elevation
4.1 Di~is and Tre_atm •nt Plannin.g
4 Treatment Options
for Sinus Floor Elevation
H. Katsuyama, S. S. Jensen
4.1.1 Diagnosis
To provide a functional and predictable implant-sup-
ported restoration, the position and number of implants
should be determined in accordance with a prosthetic.al-
ly driven treatment plan, which should take into account
the specific clinical challenges of the posterior maxilla.
When implant therapy is planned in the a.trophic poste-
rior maxilla. bone height is a diagnostic factor of primary
importance. Inadequate height for standard-sized im-
plants may be caused by sinus pneumatiz.ltion or resorp-
tion of the alveolar ridge (Chiapasco et al. 2008, 2009).
Resorption of the posterior maxilla will often proceed
in all three dimensions, such that limited bone volume
must be expected not only in the vertical but also in the
horizontal plane.
As bone resorption progresses, the vertical and horizon-
tal deficiencies become more pronounced. In m ild to
moderate resorption. the interarch relationship may be
acceptable and SFE may be chosen as the only adjunc-
tive procedure. However, it should be noted that sinus
grafting by itself ma.y not ere.a te ideal tissue contours. In
severe cases of resorption. as the extent of the resorption
increases, a combined approach with three-dimensional
site development should be considered (Chiapasco et al.
2008) (Figs 1>-b and 2a-b). For this reason, not only the
available bone volume but also the three-dimensional
interarch relations should be evaluated when implant
therapy is considered in the atrophic posterior maxilla .
m Treatment Guido? • Volume .5 34 m Treatment Guide • Volume 5
To select the most suitable treatment option for patients
with severe horizontal and/or vertical resorption of the
alveolar crest. a diagnostic wax· up involving appropriate
interarch relations is mandatory. Both the (vertical and
horizontal) interarch relations and the crown length can
be evaluated (Figs 3a·b).
Not only can the final image be visualized, but the de--
ficiency of tissue volume is also clarified. Subsequently,
a radiographic template should be fabricated based on
the diagnostic wax-up. tt is recommended to perform
an MCT or CBCT scan with the radiographic template
in place to evaluate the relation between the desired
crown position and the available bone in all three dimen-
sions. The decision concerning implant size and number
should rest not solely on the available bone volume but
should also take into consideration prosthetic and bio·
mechanic.al aspects. Virtual implant planning with simu-
lation software may often enhance the flexibility of the
diagnosis and treatment planning (Nikzad et a1. 2010).
As discussed in Chapter 3.5, augmentation sufficient
lo accommodate an implant ~ 1O mm in length is rec·
ommended for single implants until more data on the
long-term survival of non-splinted implants< 10 mm are
available.
 H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation

4.1.2 Classification and Treatment

Options
The auophic posterior maxilla can be categorized into
four groups {see Table 1 and Figs 4 to 7). Each situation
requires a different surgjca.J approach to achieve ideal
bone volume and three-dimensional interarch relations.

Figs 1a.b Thtee-dimensional evaluation ofrheattophic moxilkl r,,, bone volume and interorch telation is a maf'lda.
tOI)' diagnasric st.ep. This iU'IJStration displays tmwable condirions for SFE. The inodeqoote bane he.igfft due to sinus
expansion cm be managed wfth SFEas the only adj/Jl1Ctive procedute.
Table 1 CJassification afrhe atrophic pasteJiot maxilla 011d 1mted ttearmenr options.

Classificatjon Clinical characteristics ISurgical approach

Insufficient subanual bone height
Group 1 (figs 4a-c) Adequate widih of alveolar ridge SFE procedure with bone substitute and/or
Acceptable (vertical and horizontal) autogenous bone from intraoraJ donor site
interarch relations

SFE procedure and horizontal ridge

Insufficient subantral bone height
Group 2 (Figs Sa-c) Inadequate width of alveolar ridge
Acceptable vertical interarch relations
Figs 1a-b This situation is less favorable for SFE os the onty acfunct/K> proadure. Due re rhe verric.a/ cteslal resorp-
tion, fan.get implant crowns are necessary. In addition, the horizontoljaw relations/Vp ;s not ideal. If this teJticat
and horizontal discrepancy is too sew.re, a combined approach with rhtee-dimensional site development should be
considered..
lnsuffi.cient subantral bone height
Adequate width of alveolar ridge
Group 3 (Figs 6a-c) Acceptable horizontal interarch relations
Unfavorable vertical intera.rch relations
due to advanced crestal resorption
augmentation
Autogenous (horizontal) block graft (may be
combined with a bone substitute and barrier
membrane)
lntraofdl or extraoral donor site depending on
the extent of atrophy
SFE procedure and vertical ridge augmentation
Autogenous (vertical) block graft (may be
combined with a bone substit ute and barrier
membrane}
lnrraoraJ or exrraoral donor site depending on
the extent of atrophy

SFE procedure and horizontal/vertical ridge

Insufficient subantral bone height
u nra.vorable interarch relations due to augmentation
Group 4 (Figs 7a-c) Autogenous {vertical and horizontal) block
advanced horizontal and vertical crestal
resorption graft (may be combined with a bone substitute I
and barrier membrane)

Fig 3a Set-up performed on a study cast. toe'Mluare the rh.fee.dimensiof>. Frg 3b Diognes!k set--OP indkaring Um cons.ideroble 'l'MicaJ ridge re-
al jaw relations. The diQpflostic setup in this example does nOl indicatt any Sl'Xption has oc.ruaed. This probkm cannot be soA'ed by SFE alone.
major sigfJs ofvenico/ ridge resrxptjon.

ITI Treatment Guide • Volume 5 JS 36 m Treatment Guide • Volume 5

 H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation

Figs 4a< Expanded s.iiws cavity with limited bone he.igfR !Or implant Fws Sa< &ponded sinus cavfty with limited bone he.igfR.. ~nee bone Figs 6o< &ponded sinus call'hy Mich limited bone fleithr. In cases with Figs lo< &ponded sinus cavity with limited bone heilftL In addition,
plocemenr. Thanks to idt?ol interorch relations. there is no need fof proce- width is o1so inadequate for impiont plocement sinus augmentation in exueme v-ertkal atrophy, SFE may be combined with WJtical ridge oug. bone widrh is insufficient and Yeftiati intennaxilfary distance is large. SfE
dures «her than Sl'ilUS floor elevation. combination with horizootat ridge augmentation is indicated. me.ntation. in combination with horizontal and venicul ridge augmentation with block
grafts is indkat.ed.

ITI Treatment Guide• Volume 5 37 38 m Treatment Guide • Volume 5


lateral versus transcrestal techniques
Two substantially different approaches to SFf can be
distinguished, both having specific advantages and dis·
advantages. Clinicians therefore need to make a correct
decision, based on subantral bone height and sinus floor
anatomy, as to which technique should be adopted.
One major advantage of £he transcrest al cechnique is
ics reduced invasiveness and, consequently, its substan·
tially lower morbidity than the tateral window technique.
On the downside, transcrestal SFE can increase bone
height by only 2 to 4 mm and therefore requires a larger
volume of preexisting native bone than the lateral win·
dow technique (Jensen and Terhe-yden 2009). In other
words, transcrestaf SFE is not appropriate for severely
atrophic cases but should only be used when primary
implant stability can be achieved. More than 6 mm of
preexisting bone height are highly recommended to al-
low placement of an implant ~ 10 mm in length. The
anatomy of the sinus floor should also be included In
the presurgical assessment to decide which approach is
indicated in a given situation. An oblique sinus floor will
carry a significantly increased risk of membrane perfora-
tion. Regdrdless of which approach is being considered,
obtaining CBCT or MCT scans is highly recommended.
At sites exhibiting s 6 mm of bone height and/or an ob--
lique sinus floor, the lateral window technique should
be used.
Table Z Guidelines for selecting o trmscrestal versus Jarerol window technique..
Sinus floor Horizontal
anatomy Oblique
Table 3 Guidelines for the surgical approach Kith the latero/ window technique /COfltined to
lateral SFE when imerorch relations ore adeqtJOte).
Technique
Lateral window (simultaneous approach)
Lateral window (staged approach)
H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation
lateral window technique:
Simultaneous versus staged approach 4.2 Mate1igjs. d I.nfilrn.ment ti
Whenever the lateral window technique is considered,
the most important prerequisite for simultaneous im·
plant placement is the prospect: of attaining primary sta·
bility (Jensen and Terheyden 2009). Residual bone vo~
ume is therefore the main criterion in deciding whether
a simultaneous or staged procedure should be used (Ta·
ble 2). This decision, however, is a lso influenced by oth-
er fetctors such as bone density (Jensen and Terheyden
2009) and the need for vertical and/or horizontal veneer
grafts. Poor bone density may not allow for primary im·
plant stability even if bone quantity meets the criteria
for simultaneous placement outlined in Table 2. A con·
ventional MCT scan would offer valuable information
about bone density in terms of Hounsfield units (HU).
Conversely, good bone density may sometimes allow ad· 4.2.1 Instrumentation for SFE Round·shaped rotary instruments with a smaller di·
equately stable placement of a tapered implant in sites a.meter (1.4 or 2.3 mm) are suitable for marking the
with a subantral bone height of less than S mm. SFE procedures. whether through transcrestal or lateral outline of the lateral window. larger instruments are
window techniques. rely on the principle of preparing an more efficient for trimming the buccal bone plate
The need for a venical and/or horizontal veneer graft osteotomy to gain access to the maxillary sinus, followed when the ~wall-off' technique is selected. This tech·
would preclude simufta neous placement of an implant. by elevation of the Schneiderian membrane to create nique Involves complete removaJ of the buccal plate,
Comprehensive diagnosis is mandatory to decide on the space for the grafting material and implant. Numerous which may be advantageous in limited SFE procedures
appropriate timing of implant placement. instruments have been introduced for both osteotomy or in situations where infracture of the lateral win·
preparation and membrane elevation. dow is complicated by factors such as a narrow sinus
Several case series have recently presented favorable re· anatomy. A fine-grit large-diameter diamond bur with
suits for simultaneous implant placement in preexisting Rotary instruments. These instruments are most com· reverse rotation is recommended for this purpose, as
ridges 1 to 4 mm in height (Peleg et • I. 1998, 1999a; monty used to create the lateral or transcrestal osteo· chis type of instrument will carry a lower risk of perfo·
Cordioli et al. 2001; Mangano et al. 2007; Mardinger et tomy through which the sinus floor is access.ed (Fig 8). rating the sinus membrane than a smaller round bur.
a l. 2007). Given the low-level evidence of these study de- Ultrasonic or piezosurgical devices may be preferable
signs. the recommended criteria in Table 3 are upheld For the preparation of a lateral window, a round bur to reduce the risk of membrane perforation when the
until higher·level research becomes available. is normally used to outline the shape of the window. facial bone covering the sinus cavity is thin.
Subantral bone height
>6mm ~6mm
Transcrestal lateral window
lateral window
'-4teral window
Subantral bone height
~ S mm
< S mm
'
Fig 8 Rotary insuuments used for rhe ktw-al window rechnique. The sinus
cavity is accessed with round totational burs (left ro rir,hc round carbide
bur, ectfShaped bur, diamond bur).
ITI Treatment Guide• Volume 5 39 40 m Treatment Guide • Volume 5
 H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation

\I _,.-._r ,..
-
,... .. .,. .
-

-. '
flg 9a Surgkal instTVmenrs for window and membrane elrnrtion. Var,.. Fig 9b Surffeal insuument used to compress !he crafti.ng material A ffar Fig 11a lnstromMU usedlot uanscrestai SFE. Bone condensation devk.es Fig 11b lnstrumems used fix uansaer.ot SFE. An os:reocome wirh a con-
OIJS shapes. sizes and cutv0tures are needed dependi.ng on window she and surface ;s useful in shaping the mareriol. •ith a tJJpered tip and an (f)ptopriate diameter are empl"'ftd to widen the wve tip is empk1yed to froaute rhe bottom of the sinus cavity.
sinvs configuration. .implant bed.

Hand insrru1nenrs. These instruments are commonly

used to elevate the sinus membrane (Figs 9a-c). In most
situations, smaller instruments are used for initial lib-
era.tfon of the sinus membrane from the osseous wan,
while larger instruments are used to expand the elevated
space.

When the first window prepared is too small, a Srantze

will be used to increase the size of the opening (Figs 10a·
a b
b). This insuument could be used especially if the win-
rws 11a-b Examples ofbone mills.
dow needs to be enlarged while avoiding damage to the
sinus membrane. Fig 9c SU!gical instrument used to compress the f/"Olting material. A
tound shape is kleal to avoid damaging tile P.J1TOU11ding rissue.

Trans.<restal SFE. by contras.t. requires. special instru-
ments to match the implant type selected. Tapered
osteotomes are selected if an adjunctive procedure of
bone condensing or spreading is required (Fig 11a). If no
such procedure is required, a concave tip should be s.e-
lected to facilitate the tas.k of fracturing the sinus floor
(Fig 11b).
Instruments used for harvesring and processing autogen-
ous bone grafts. A bone mill is routinely used when
large autogenous bone grafts are harvested (Figs 12a-
b). While different versions of this instrument exist, a
sharp and efficient bone mill is indispensable to deal
with autogenous bone involving a high conical content
from the chin or ramus. Both of these areas offer good
quality bone with a cortical surface. It is recommended
to mill the harvested bone to an appropriate size, ex-
panding the osteogenic surface and accelerating osteo-
conduction.
When less autogenous bone is needed for the SFE proce-
dure, sufficient amounts can usuaUy be harvested from
the area where the lateral window is planned or from
the infrazygomatic ridge using a bone scraper. lastly,
while small amounts of bone dust can be collected with
a suction device during preparation of the implant bed
or lateral window, the quality and safety of this grafting
material is sti ll debated.
Ne•v approaches. Perforation of the sinus membrane oc-
curs in approximately 10% of cases, being the most com-
mon intraoperative complication in SFE procedures (Chi-
apasco et al. 2009). Perforation may occur during the
osteotomy or during elevation of the membrane. New
approaches have been proposed to minimize this risk.
Ultrasonic devices such as piezoelectric surgical instru-
ments, used either alone or in combination with rotary
instruments, have attracted attention as a new method
of creating the osteotomy (Figs 13 and 14).

Fig 10a A Sranrze used for bone scraping tD enlotge rhe window carries a
much smaller risk ofdamaging the membrone (J( surroonding tissue than
a chisel.

ITI Treatment Guide• Volume 5 41 •2 m Treatment Guide • Volume 5


C-
fig 13 Piezosingjco/ instromenrs.
1
It has been reported that the risk of membrane perfora:·
tion may be lower with piezosurgica.J than with rotary
instruments (Wallace et al. 2007). Another small-scale
clinical study with a randomized conuolled design,
however, failed to confirm this difference (Barone et al.
2008). On the whole, the superiority of piezosurgery over
conventional techniques has not been validated. One
inherent disadvantage of piezosurgery is its lower cut-
ting performance than the one offered by conventionaJ
rotary instruments. As more time is usually required to
prepare the buccal window, piezosurgery may be suit·
able for delicate areas.
H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation
Surgical setup for SFE
Being a complex surgical procedure, SFE requires an iso·
lated and aseptic surgical environment with comprehen·
sive surgical instrumentation as in routine oral and max·
illofacial surgery(Figs 15and 16). As shown in Figure 17,
a surgical microscope and a piezosurgical device may be
helpfu l in managing particularly complex situations.
Fig 14 Oinical Wew ofa pkzosurpjcai instrument being used to open the F°'IBS 16 l.<i)OUf ofsurgical instrun>ents for SFE.
fateral sinus wdl.
As an alternative to hand instruments, the use of an in·
ftatable balloon to elevate the Schneideria.n membrane
has been advocated. A number of clinical reports have
described this technique in conjunction with transcres·
ul SFE (Kfir et al. 2006. 2007. 2009a, 2009b; Hu et al.
2009). According to these authors, the balloon tech·
nique was less invas ive and involved a lower complica.·
tion rate than conventional methods. Since these stud·
tes were case series with no control groups. the balloon Figs 17 A surgical microscope is befltfi:ial for optimd surgkal precision
approach should not be considered a. routine technique and meticulous tissue handliftl..
at this stige.
ITI Treatment Guide• Volume 5 43 m Treatment Guide • Volume 5

4.2.2 Biomaterials
Grafting materials
Different grafting materials for SFE procedures have
been studied extensively, and a wide range of graft-
ing protocols may be considered well documented (see
Chapter 2). The first decision to make is whether a graft-
ing mate rial should be used at all. or whether it may
suffice t o just elevate t he S.c:hneiderian membrane, us-
ing the implant as a tent pole. and leave t he space cre-
ated beneath t he membrane to be filled with coagulum.
There is sound evidence that 2 to 3 mm of bone height
can be g.ained in this way. Placement of a grafting mate-
rial is recommended, however. if more than 3 mm are
needed to anchor an implant of adequate l.ength or if
bone fo rmation au around the implant apex is desired.
There is substantial clinical evidence that equally high
implant survival rates can be obtained when SFE pro-
cedures are performed with particulated autografts or
bone substitutes alone or in combination (Jensen and
Terheyden 2009; Chiapasco et al. 2009). This does not
imply. however, that different grafting materiaJs will trig-
ger the s.ame biological response.
CLASSIFICATION OF BONE GRAFTING MATERIALS
Allogenic bone
Bone fro.m same species
but from another
individual
Block graft Free frozen bone
Particulate Freeze-dried bone
Bone mill allograft
Bone scraper
Suction device (dust)
Demineralized freeze-
dried bone allograft
Deproteinized bone
allograft
H. Katsuyama. S. S. Jensen
As autogenous bone is being transplanted, osteoinduc-
tive molecules such as bone morphogenetic protein
(BMP) and osteogenic cells will enter the augmented
site. Bone form ation is thus significantly accelerated as
comp.a.red to situations in which bone substitutes are
used alone (Buser et al. 1998; Jensen et al. 2006, 2007,
2009). Healing times can therefore be reduced by using
augmentation materials with a high autograft content.
Typically. when autografu are used alone or in combina-
tion with a bone substitute material, restorative proce-
dures can be staned 3 to 4 months after SFE procedures
with simultaneous implant placement, and implants can
be placed 4 to 6 months after two-stage SFE procedures
in this situation. Histomorphometric evidence from
human studies has revealed significantly greater bone
formation within the fi rst 9 months of healing whe-n
autografts we-re used. Later than 9 months, no signifi-
cant differences were observed (Handschel et al. 2009).
Therefore, whenever a bone substitute is used alone, ex-
tended healing times (by a facto r of 1.5 to 2) must be
allowed (see Chapter S).
Xenogenic bone Alloplastic bone
substitute substitute
Material of biologic origin Material of synthetic
but from another species origin
Materials derived fro m Calcium phosphates
bone of animal origin
Materials derived Glass ceramics
from corals
Materials derived from Polymers
calcifying algae
Metals
ITI Treatment Guide• Volume 5
4 Treatment Options for Sinus Floor Elevation
Jt is important to realize that the osteogenic potentiaJ of
autografts may vary considerably with age, the presence
or absence of systemic diseases, the donor site (man-
dible/iliac crest, corticaVcancellous bone). and the bone
harvesting technique resulting in various particle sizes
of bone (bone mill, scraper, or filter on suction device).
Bone harvested from elderly and osteoporotic patients
with a. suction device has a clearly lower osteogenic po-
tential than milled corticocancellous bone from the iliac
crest of healthy young individuals. It is highly recom-
mended to harvest intra.oral bone either locally within
the same flap to reduce morbidity for the patient, or
Fig 18b 6 months.
Fig 1&1 48months.
45 m Treatment Guide • Volume 5
from the mandibular body and ascending ramus instead
of the chin area, especiaUy when larger amounts of the
bone .are needed. Bone harvested from the chin area
will involve substantially more complications in terms
of comprom ising sensory function of the mental nerve
(Clavero and Lundgren 2003).
Autografts used alone in SFE procedures will often result
in long-term foUow-up radiog1aphs indicating re-pneu-
matization of the maxillary sinus in the augmented areas
(Figs 1Ba-e), as may be observed around naturaJ molars
and premolars.
fie 18a Petiopkal rod'iofraph obtained 3 months after in-
sertion ofon implant replacing a maxiltary riiflt first molar.
The implant was placed with simuftaneous lateral window
SFE. Primary stability was obtained by bone condensation.
Autogenous grafting material was hotvested from the right
inftozygomadc ridge wKb a bone scraper. The follow.up ro-
cJioeraphs showed gradual re-pneumatizabon of the sinus
<Ner the first 12 months. Thereafter, the situation rmiained
more rx less stable. (Courtesy of LX. L-A. Johansson.}
Fig 18c 12 months.
fig 18e 54 months.

Whether this phenomenon will have any clinical impli·
cations on long·term implant survival is debated but
not currently known. As seen in procedures of guided
bone regeneration (GBR), the resorption tendency of
autografts may be reduced or even eliminated by com·
bining the autograft with a bone substitute offering a
low substitution rate (Adeyemo et al. 2008).
Barrier membranes
Conflicting results concerning the benefit of placing a
membrane over the lateral window have been reported.
Some studies revealed a tendency for better bone forma·
t ion and less implant failu res when the lateral window
w~ covered with a resorbable membrane (Tawil and
M•wl• 2001; Pjetursson et •I. 2008; Choi et • I. 2009).
The beneficial effect of .:e membrane becomes less ap-
pdrent, however, when the.se results are cleared for
confounding factors like smooth-surfaced implants and
simultaneous implant placement in autogenous bone
blocks (see Ch•pter 2, Jensen •nd Terheyden 2009). A
recent review of clinical studies with histomorphometric
data following SFE with autografts alone did not confirm
any effect of a barrier membrane on bone formation
(Kli jn et •I. 201 OJ. overall, it •ppe•rs th•t covering the
lateral window with a resorbabte_membrane may have
a limited beneficial effect. It is recommended to use a
resorbable membrane over the lateral window in clinic.al
situations characterized by a limited osteogenic poten·
rial of the patient or the grafting material used. No data
are available to support the use of a non·resorbable in·
stead of a re-sorbable membrane for this indication.
H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation
4.2.3 Implant Design
4.3 S!!x.gical Tecl1n1 ues
Another consideration for implants to be placed in con·
junction with SFE is the fact that bone density is of·
ten suboptima.J in the posterior maxilla. It i.s therefore
highly recommended to select an implant design whose
geometry and surface <haracteristics can maxjmize pri·
mary stability. Although evidence is lacking to determine
which geometric features are essential for maximum pri-
mary stability~ a number of geometric designs have been
proposed. These include threads with a modified shape,
self·tapping threads, tapered profiles, and flared necks. 4.3.1 Transcrestal Technique tips are indicated for bone condensing (Fig 20). Once the
sinus floor has been fractured, autogenous bone and/or
On the other hand, there is strong evidence that the sur· Transcrestal SFE is indicated when implant stability can a bone substitute is delivered to the osteotomy and care·
vival rate of implants with a roughened surface (96.9%) be achieved despite the limited bone height (Summers fully packed into the prepared impl•nt bed with the oste·
is significantly higher than the survival rate of implan ts 1994, 1995) (see Table 2). Supported by accurate radio- otome. The pressure from the condensed graft material
with • machined surface (88%) (Chi•pasco et •I. 2009). graphic analysis, a crestal incision is performed and the elevates the S<hneiderian membrane. After repe.ating
However, since a ll implants with plasma·sprayed, HA· implant bed prepared 1 to 2 mm shorter than the avail· the s.ame procedure several times for adequate mem·
coated, and sandbl.asted/acid·etched surface types fall able bone height (Figs 19 ..d). Following prepar•tion of brane elevation. the selected implant is insened to ideal
into the category of "rough-surface" implants, it is not the implant bed, the osteotome (most of these devices depth. It is recommended to perform the Valsalva test
clear how different surface treatments may affect im· featu re a diameter of 4.0 to 5.0 mm) is utilized to frac· (nose-blowing test) prior to grafting and implant place·
plant survival and success. tu re the sinus floor by tapping action using a mallet. Ca.re ment to verify that the membrane has not been perfo·
should be taken that the osteotome does not enter the rated in the process of fracturing the sinus floor. Finally,
It has been suggested that healing periods before pros· sinus cavity, thus avoiding the risk of membrane perfo- the insertion torque should be measured to obtain addi-
thetic loading can be reduced with micro-tough implants ration. Genera.Hy, devices with concave tips .are suitable tional information about the appropriate healing period
compared to implants with more traditional surface fo r fracturing the sinus floor, while devices with tapered to be selected.
characteristics (Cochran et al. 2002; Ro<cuzzo et al.
2008). Recently, implants offering• chemically modified
and hydrophilic micro-rough surface have been devel-
oped {SLActive surface). In conjunction with SFE, there
is no evidence of superiority to conventional surfaces
at this time. although predinical and clinical srudies
have yielded promising results for this newly developed
surface type (Buser et •I. 2004; Ferguson et • I. 2006;
Schwarz et al. 2007; Ganeles et al. 2008; Roccuzzo and
Wilson 2009).
F1g 19a Preparing rhe implanr Fig 19b An osteotome IS used to
bed. fracture the sinus fJoor.
Fig 19c The membrone is eJ.
evated by inserting graft material. Rg 19d lmplam in situ.
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 H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation

A periapical or ot her radiographic examination should
be performed after surgery to verify the outcome of
SFE. If a perforation of the sinus membrane is con-
fi rmed intraoperatively, the surgeon should switch to
the lat eral window technique (Jensen and Terheyden
2009). The he•ling period will be sele<ted in •ccord-
ance with implant type, surface, length, and diameter.
Empirically. however, a 16--week healing period is rec-
ommended when t he insertion torque is lower than
15 Nern. A 12-week healing period is recommended In
most cases when the insertion torque is between 15 and
35 Nern . If the insertion torque is higher than 35 Nern,
the implant may be loaded afte r 6 weeks. Future stud-
ies will reveal whether resonance frequency analysis
using ISQ measurements, performed at the time of im-
plant placement and/or fo llow-up visits, a re clinically
helpful in determining the ideal time of prosthetic load-
ing. A non-submerged healing protocol may be used if
bone augmentation around the implant shoulder has
not been performed.
Only one clinic.a.I study has investjgated a staged ap-
proach to tr>nscrestal SFE (St>vropoulos et •I. 2007).
The justification for this approach should therefore be
considered limited at piesent. A staged lateral window
technique is recommended when sub.antral bone height
and bone density are not sufficient to achieve primary
implant stability at the time of sinus augmentation• .as
this approach is much better documented (20 studies;
Jensen and Terheyden 2009).
4.3.2 Lateral Window Technique
There is strong e-vidence for the lateral window tech-
nique as a predictable procedure for sinus floor elevation
using a simultaneous or staged approach (Jensen and
Terheyden 2009; Chiap•sco et •1. 2009) (Figs 21>-c, 22).
Depending upon the local conditions at the planned im-
plant sites, a simultaneous and staged approach proce-
dure is sometimes combined at t he same surgical sites.
Fig 22 Implants placed with simuftaneous lateral window SFE. Just before
bone grafting into sinus cw'ify. Implants are fixed within re;s;dual bone..
Also, the lateraJ window technique may be combined with
various augmentation techniques for horizontal .and/or
vertical bone deficiencies. The incision line is designed to
avoid the pl•nned location of the l>teral window (Fig 23).
Most commonly, a mid-crestal incision is selected.
An incision made too far palatally may result in soft tis-
sue dehiscence due to compromised blood supply (Klein-
heinz et al. 2005). When a staged approach is indicated,
the recommended approach may be to place t he inci-
sion line on the facial aspect of the crest, as this may
offer easier and quicker acces.s for window opening. Care
should be taken, however, that the incision line does not
cross the planned area of the lateral window. Wound
edges lacking bone support may give rise to soft tjssue
Fig 13 The ;ncision fine is designed ro avoid the window, as a safety mar-
gin is required to covet che ouone.nted site. Furthetmaie, adequate ltJod
supply should be provided to avoid ris:sue perforation. A sftght palataf inci-
sion and a sukus inc$on are ccmbined to fadlitote access. along with a
mesial releasing inciWn.
collapse or major dehiscences in the absence of blood
supply. A mucoperiosteal fla p is elevated and complete
soft tissue de-bride-ment performed.
The window size and position are determined in accord-
ance with anatomic conditions (Figs 24a-b). While rotary
instruments are commonly used for window prepara-
tion, the recent development of piezoelectric ultrasonic
devices may contribute to reducing intraoperative com-
plications such as membrane perforation {Wallace et al.
2007). Membrane perforation can be reduced by metic-
ulous soft tissue handling and utilization of a surgical
microscope. The Se<tuences for staged and simultaneous
5FE procedures are illustrated schematically in Figs 25a-f
•nd Figs 26>-g.

Fig 20 A tapered osteotome is

used for bone condensation. ~L

Figs Z4a-b Windowsile ond prn.ition ore delerrnin«J in acco.ntoncr with onatomiC 'ondiri<Nls. A l<llge win®w, whik fixiiftaring accas ro the sif'HIS carity,
ltoofd weaten the. lateral wall. It is rherefore recomn>ended to creote a window ju.st large enough to achieve compltte access to the sinus cavfty. tWndow
heighr from the residual bone is determinedbased on the length ofthe planned implant to whidl at least 2 mm «extra space are added. Some bone wal.ts
a.re ret'rlf:Wed ond utilized for bone gro:ftin£ (a}; othets ore left as is {bj. This dedsion wit/ be based on window size and configuration ofthe sinus cavity.

ITI Treatment Guide• Volume 5 49 so m Treatment Guide • Volume 5


Sequence illustrating a staged lateral SFE procedure
Fig 1Sa Flap etevution and
•indow pteparation for a staatd
lateral SFE procedure. Note the
limited bone height (UJdicated by
arrows.).
Fig 25c Graitin&
F~ 2Se Grafted site ofter healing.
H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation
Sequence illustrating a simultaneous lateral SFE
procedure
Fig 26o Ftop e/evobon 0J1d win-
dow preparation for a simuftane.
ous lateral window procedure.
Note the ode.qi.Kite bone heigflt
for simufraneous implant ~
ment (nJkaced by arrows).
Fig 1Sb Elevation d trap door Fie 16c Dritling procedure for
and sinus membrane._ implam bed. Note that die ITIE'm-
brone is elmtted and prot«r.ed
Fig 26b Ele'WJtiott of trap door by a paddle-shaped insttumenr to
and sinus membrane. avoidperforotion tt•ith tile drill.
Fig 25d Closed flap with barrier
membrane underneath.
Fig 26d Sinus caviry filled with Fte Z6e Implant inside the sinus
tfle graft motetial. aMty fi1Jed with graft material.
Fig 25f fmplont followin£ staged
placement.
Fig 16f Closed flap with barrier Fig 26g Groft.ed site and devot·
membrane underneath. ed sinus tJoor alter healirw,
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 H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation

4.3.3 Timetable
The timing of implant placement and loading will es-
sentially depend on the a.mount of native bone. The
technique and material selected enters the equation as
a modifying factor that may reduce or extend the heal-
ing period. Guidelines for the healing times involved in
various grafting procedures are summarized in Table 4.
As discussed earlier in this chapter (see Chapter 4 .2.2),
the exclusive or additional use of autogenous bone is
likely to allow a shorter healing period before implant
placement and loading than the exclusive use of a bone
substitute (Jensen and Terheyden 2009). Longer heal·
ing periods between grafting and implant placement
are required for highly atrophic ridges (subantral bone
height< 3 mm). The c1inician should modify placement
and loading protocols in accordance with clinical vari-
ables specific to each case, including radiographic find-
ings at the grafted site, insertion torque, number and
size of implants, the osteophylic properties of the uti-
lized implant surface. and absence or presence of sys-
temic diseases.
a
Fig 2la Exposed lateral bone surliJa of rhe planned window site. Hatves6ng alaurc.sroft c11;ps with a bone saopet.

Table .4 Trmerabk ofWJrious SFE opproadies.

•
Pre-
operative First-stage surgery Second-s1age surgery Prosthetic procedure
situation
SFE {tr.anscrestal or lateral window
technique)
Subantr.11 Simultaneous implant placement
bone
height Graft material Autograft a.lone
>6mm Autograft/bone No second-stage surgery 3 months after surgery 1
substitute (1: 1)
Bone subSlitute alone
SFE (lateral window technique) P1g 27c FoNowing ffap elevacioli the fociol bone watt is exrmsively ex- Fie 17d The sharp bone scraper rs able to harvest aut~ous bone chips
posed ro harvest bone chips with a bone scraper. of 1.5 to 2.0 mm ;n size.
Simultaneous placemenl
I
Graft material Autograft-41one I No second-stage sur.gery 3 -4 months mer surgezy 1
Autograft/bone No second-stage surgery 3- 4 m<>nths after surgery 1
Subantral substitute (1 :1)
Bone substitute alone No second-stage surgery 6 months .after surgery 1
bone - -
height Primary implant stability not obtainable
3-5mm --
Staged implant placement
Auto graft alone
-3 months after surgery 2
Graft materi.l.I 4-5 montlts after surgery 1
Autograftlbone 6 months after surgery 1 3 months afte-r surgery 2
substittste (1 : 1)
Bone substitute a.lone 9-12 months after surgery 1 3 montlls after surgery 2 •
Fig 27e The collected auwerott chips are sroted in a surile glass dish. Fit Z7f Mixed with D68M particles. rhe composite graft ;s ap(Jied in rhe
SFE (lateral window technique) created defect follort'if1£ elevation ofthe SchneW:lerian membrane.

Subantral Staged implant placement

bone Autograft .alone the harvesting can be extended to the tuberosity area.
height Graft material 6 months after surgery 1 3 months after surgery 2 4.3.4 Harvesting Site
Auto graft/bone 6 - 8 months after surgery 1 3 months after surgery 2 Autologous bone chips harvested in this way are com-
<3mm substitute (1 : 1) Autogenous bone for grafting should be harvested from bined with xenogr.aft or allograft if a composite graft is
Bone substitute_alone 9 -12 months .after surgery 1 3 months after surgery 2 intra.oral rather than extraoral sites. as postoperative preferred by the surgeon. When a large volume of autog-
discomfon and complications will be less severe (Chia· enous bone is required (e.g. for bilater.11 augmentation
pa.sec et al. 2009). Whenever possible. bone should be of severely pneumatized sinuses), sufficient amounts of
harvested locally from the surgical area. The large area bone c.an usually be harvested from the mandible. Har-
of exposed facial bone surface allows the harvesting of vesting from extra.oral sites like the iliac crest becomes
large amounts of autograft chips with specially designed necessary when larger amounts of bone are required
bone scrapers and other bone collection devices-. They (e.g. for additional onlay grafts in the horizontal and/or
are used on the lateral bone surf.ace of the planned win· vertical dimensions). The r.amus and symphysis are most
dow site to harvest bone chips (Figs 27•-f). If needed, commonly selected as intra.oral donor sites.

ITI Treatment Guide • Volume 5 53 54 m Treatment Guide . Volume 5

 H. Katsuyama. S. S. Jensen 4 Treatment Options for Sinus Floor Elevation

While the maxillary t uberosity can be an alternative,

the quality and quantity of bone harvested from t his
area is often poor. The mandibular ramus ha.s been rec·
•• ommended as the area of choice for intraoral bone har·
vesting, as this location offers low complication rates,
relative ease of access. and sufficient aV<lilability of
bone (Figs 28a·c_, 29a·b). Bone from the ramus is most·
ly cortical (Misch 1997), however, and contains limited
concentrations of osteoinductive proteins and osteo·
genie cells. The second option is the symphysis area,
which offers good accessibility, bone density, and bone
Incision Jjne for halWSling from rhe symphysis.
composition, inc1uding both canceflous and cortical tis·
sue (Capelli and Testori 2009; MiS<h 1997) (Figs 30a-b,
31 a-c). It should be noted that grafts of symphyseal ori-
gin are associated with higher complication rates and
morbidity than ramus grafts (Chiapasco et al. 1999;
Cl•vero •nd Lundgren 2003; Nkenke et al. 2001, 2002;
Raghoebar et al. 2001 a, 2007; Misch 1997). Major com-
plications include damage to the mandibular incisors,
paresthesia, and unexpected intraoperative hemor·
rhage due to rare anatomicat situations such as proxim·
ity of the lingual fora.men. The literature indicates that
paresthesia affecting the mandibular anterior teeth ha.s
an incidence of approximately 13% in t he first year af·
ter bone harvesting from the symphysis (Ch iapasco et
• I. 1999; Nkenke et a l 2001; Raghoebar et al. 2007).
Bone hatvesting with ttephine drilf or other instruments.
De.spite the attractive prospect of obtaining good bone
substance, harvesting from the symphysis should nev-
ertheles.s be regarded with caution. It should only be
considered if a large volume of autogenous bone (as
fo r bilateral SFE) is required and not without inform-
ing patients of the risk of protracted paresthesia affect-
ing the mandibular anterior teeth (Nkenke et al. 2001).
Bone harvesting from the ramus, on the other hand,
carries a risk of damaging the inferior alveolar nerve. In
other words, both donor areas will require meticulous
preoperative assessment. Three-dimensional informa-
tion from preoperative CBCT or MCT scans may help
avoid complications.
Figs 19o-b Bone harvesting from the mandibufat tamus. fn this specific nn<. bone harvesting MZS pe!formed in combif'llJfion ttfth guN:led bone 1ege_nera-
tiori (GBR). For bone hatVeSting only. the indsion line would be placed fur buccal!y. White a CTscan is n« required fol bone hat11eSting from the ramus.
anatomical limitations should be respected sc as not to dam(\fe the nerve and vessels; Once bone has been harvested from the romu.s. a collagen sponge
or some ocher hemostatic biomatetial rs applied to avoid continued bleeding. The bone 't'Olume harvested from the ramus ofthis patimt was sufficient {a).
Bone. graft. matetiol could be ha.tvested as bone chips ot bone block (b}.

Figs. 310< Clinical sequence of bone harvesting from rhe mandibular symphysis. Hatve'Slirw bone from this 1egjon is easier in patienrs whose anterior
mandible is edenwtous. ~r vol1Jmes ofbone can be harvested with a uephine dfitl or other insttumencs;,, rhese cases (a). Note the intact tN?euoJ
conicalplat.e after harvesting ofthe cOfticoconceflous bone chips (b}. The hatwsted bone (d is reduced to appropriately-sized particles for grafting using
a bone miil.

ITI Treatment Guide• Volume 5 55 56 m Treatment Guide • Volume 5


4.3.S Managing Septa and
Compromised Cases
The anatomy of the maxillary sinus may be complex, and
preoperative diagnostics based solefy on two-dimension-
al radiographs may prove inadequate, especially when
sinus septa are present. These are considered to com 4
promise SFE procedures by involving a higher incidence
of complications such as membrane perforation. Meticu-
lous diagnosis and careful treatment planning are man 4
datory to avoid these complications and resultant fail-
ures. The 1iterature indicates that septa and sinus floor
irregularities will often go unnoticed by two-dimensional
radiographic asses.sment (Krennmair et al.1999). Recent
developments in CT scanning enable surgeons to obtain
detailed information about internal sinus anatomy be·
fore SFE. In this way. they can evaluate the various sur·
gical options prior to opening the sinus cavity. Surgical
procedures are illustrated in the DVD version of this vol-
ume (under the heading 11Various Surgical Procedures»).
What follows is the outline of how to select appropriate
surgical procedures for managing septa within the sinus
cavity.
Surgical guidelines in the presence of septa
1. The septum is higher than the length of the planned
implants; the sinus cavity may be separated into two
or more companments.
In this situation, it may be impossible to remove the
septum and manage the case as one cavity for sinus
augmentation ~ Thus opening a separate window
for each compartment is recommended, although
opening of more than two windows is not realistic.
Complex anatomical conditions like the presence of
completely isolated compartments will render the
procedure more difficult.
H. Katsuyama. S. S. Jensen
2. The septum is lower than the length of the planned
implants; the sinus cavity is not separated into com·
partments.
In this situation, it is possible to remove the septum
and manage the case as one cavity for sinus aug·
mentation. Depending on the orofacial dimension
of the septum, it may still be advantageous to stan
out by preparing two separate window openings
until the septum is identified and removed. Depend-
ing on the clinical situation, the opposite procedure
may also be an option. When the height of the
septum is limited on the facial aspect. the case may
be approached as a single cavity in terms of initial
window opening.
In conclusion, septum surgery in conjunction with SFE
calls for meticulous and careful analysis of the underly-
ing anatomy. Appropriate radiographic imaging is essen·
tial to increase the predictability and reduce complica·
tions of septum surgery. Clinicians should be aware that
some c.ases may be too severely compromised to achieve
predictable sinus floor elevation.
Acknowledgments
Research Support
Or. Toshifumi Kuroe - Center of Implant Dentistry,
Yokohama. Japan
Instrument Photos
Or. Eiju Sen - Center of Implant Dentistry,
Yokohama., Japan
Or. Kotaro Nakata - Center of Implant Dentistry.
Yokohama, Japan
ITI Treatment Guide • Volume 5 57
 S Guidelines fOf COOo.sing the Surgical Technique and Graft.ins Protocol for Sinus Floor Elevation

Potentia l candidates for SFE should be carefully evaluat· Three main decisions need to be made once the indica·
ed prior to considering the surgical technique and graft- tion for SFE has been confirmed:
ing protocol co be adopted.
1. Techn;que (lateral window technique versus trans-

5 Guidelines for Choosing A complete medical history (health status, medi·

ations~ allergies, smoking, drinking) should be
crestal technique). Indications for the transcrestal
technique are limited because exacting require-
obtained .and the patient should be evaluated for ments need to be met: favorable interarch relations,
the Surgical Technique compliance. The purpose of this assessment is to
identify the presence of any general risk factors.
adequate width of the alveolar ridge, adequate bone
height(> 6 mm), and horizontal anatomy of the
A t horough clinical examination should be conduct· sinus floor. However, the t.ranscrestal technique is
and Grafting Protocol ed prior to SFE. The parameters of this examina-
tion should include interarch ret.ations, periodontal
preferable if these requirements are met. given its
lower morbidity than laterdl window SFE.
status, evidence of bruxism, .and distance to the 2. Timing of imp/ant placement (simultaneous versus
for Sinus Floor Elevation neighboring teeth and opposing dentition.
A radiographic evaluation should be conducted.
stgged approach). Simultaneous implant placement
is generally preferred whenever primary stability can
This evaluation should preferably include three-- be obtained, reducing the number of surgical proce·
dimensional information about the residual sub- dures and. hence, morbidity. This treatment option
antral bone (volume and density), the peri.apical is a.l:so contingent, however, on achieving an ideal
status of any neighboring teeth, sinus floo r anatomy three~ i mens ion al position of the implant from a
S. S. Jensen including the presence of any septa and second- restorative viewpoint.
ary cavities, .and evidence of sinusitis or any other 3. Grafting protocol (autogenous bone and/or bone
pathologic alterations in the maxillary sinus. The substitute material). Any autogenous bone included
purpose of these clinical .and radiographic. assess- in the grafting protocol will accelerate bone forma·
n1ents is to identify any local risk facto rs. tion compared to protocols using bone substitute
An overall risk assessment should be performed materials a lone. Bone substirute materials with a
based on any general and/or local risk factors that low substitution rate, on the other hand, are helpful
have been identified in this process. tf any .absolute in maintaining the volume of augmentation.
contraindications to SFf: or associated procedures
are present, alternative modalities should be consid· The decision trees in Figures 1 and 2 offer clinic.al deci-
ered. Potential alternatives in t he presence of con· sion guidelines.
tr.aindications to major bone augmentation proce-
dures may include the placement of short1 tilted, or
zygomatic implants. Tooth-supported fixed restora·
tions or removable dentures should be considered if
surgical procedures as such are contraindicated.
Informed consent should be obtained from each
patient based on a risk assessment. and the clini·
cian should supply expJanations about the advan·
rages and disadvantages of the planned treatment.

m Treatment Guid.?•Volume .5 59 60 m Treatment Guide • Volume 5

 ~ r
Atrophic posterior maxilla '
Insufficient bone height for standard Implant placement

I
Favorable Inter- Inadequate widt h ~ Severe ver\lcal I Severe vertfcal
an:h relulonshl p of ..atv·eolar crest bone remrption bone resorption
Fa\/Orable Inter· Adequate width of lnadequ ate width
arch relationship alv~ol arcrest of alveolar creS-t
( In the vertical
plane)
;._ 1r.,.
-· ' I
' (
SFE al\)ne SFE co1nbined ~ Vertical ri dge
' ,r Horizontal and
' Le Fort 1 osteoto·
wilh horizontal augmentation I vertical ridge my wfth fnteqx>S;.
ridge au11111enta· (possibly com· augmentation tlonal bone graft
cion bi n<>O wi th SFE) (po!Slbly com·
bined with 5FE)
I

!,.. ~- 'IL I l~
- - -

r {
:; Mtogenous bone ( 4utogenous Autogenou s 4utoge 0ous blcxk Autogenou$ bfock
and/or bone block gr aft from
' block gran from graft from Intra· or grafts from
subitltute intraoral donor lntraoral or ex· extra.oral donor extraoraf donor
material slle for horizontal traoral donor site site for vertical and site
ridge augmenta- for vertical ridge horizontal ridge
tion augmentation augmentation
I~
Autogenous bone Autogenous bone Autogenous bone
andl9r bone sub· ano/or bone sub- and/or bone sub-
~
f stltute material stltute material
I
stllute material
,,.,,.
ror SFE fpr SFE fQr SFE
2l l\ : \.
... t \.. r

~ ~
N ~
N

:; s1.nuow E JalJe s41vow EJC>lJe

.."'
... BUll"?Oj >!lat!l<Pld BU!P"OI >!1•4lSOJd
~ 1. fil'
•3 --~---
0
a
c
"'~ I
~ s41uow u s41uow 9 s41uow 9 i
c Ol 6 JalJe iuaw Ol tr Jt>l)! lUaW "l £ JOlJ• ~
30
·•,.Jd iu•1dw1 ·•>•1d w•1dw1 8u1 peo1 :>!1a41s0Jd '[
~
{ll!JJele·w i
,. ~l O l!lSqns auoq B.
• 41JM paulqWO> ~
"
Jo auo1•)
~01! lf!JQl\?W auoq snoua8o'.lne lUaWOJJejd ~
Nwow r»v• a1n11lsqns paw1n>1ued 1u•1dw1 ~
Bu1p•o1>1lat1!<0Jd auoq 4l!M 8Ut1J'J!l 4l!M li'ujljOJ!) snoau?11nw1s [
il'
~
aJQOA~fl/JO JOO NNRtns wo,vlw1 hQwµ<J a1Qc.Y.11JJD~q.qo1S wo,vJw1 hmu!)d ~
,,.
lUaW9Jeld
i
lU•tdW! anb!u4:>al
tno-aue11nw!S LU!M MOPLIIM 1ua1•1
3:1:5 1eltaJJSU!Jl a41 li'u1sn 3~S

XlOiJ Sl1tl!S ft'lt/02µ0!/ fXJD wr,u9 < :JqBJ;q auoq JOJ/UaA KXliJ SJiU.tS at1bri~o JO ww9 J :"'Bt-a!f a:xiq fDJ.~aJ\

14•w»•1d 1ue1dw1 pJ•P•"IS JOJ 141104 ouoq 1••1>w~1u 1

d!ttSUOJl~taJ ~JJllU91U ! a)q1!JOA•::j
9111Xl!W JOIJilSOd lJLldOJlY
 6 Oinical Case Presentations

Tran scr estal Prot ocols

6 Clinical Case Presentations 6.1 Implant Plarement with Simultaneo11s Sr~:
Transcrec;tal T clmiq_ue witl1 DBBM
S.S. Jensen

The patient was cin 87-year-old woman with no general

diseases, no medication, no allergies, <1.nd a non-smoker.
Her maxillciry left first molar had been extracted 6 weeks
previously due to a root fractu re.

The clinical examination revealed a complete dentition.

e.xcept for the maxillary left first molar, which was miss-
ing. Generalized but m ild ho-rizonta.I bone loss without
any pathologic periodontal pockets was observed. Oral
hygiene was good.

Both the second premolar and the second molcir had

been restored with adequate gold inlays and showed
2 mm of gingival recession facing the edentulous site.
The cours.e of healing had been uneventful after extra.c-
tion of the maxillary ~eft first molar, and the width of the
alveolar process was intact (Figs 1 and 2).

A periapical radiograph obtained using p.ara.JleJing tech-

nique, including a steel ball for calibration, revealed
7 mm of s.ubantral bone height and a horizontal anato-
my of the sinus floor (Fig 3).

Fig 2 Ocdusal view show'ing complete soti tissue healjng 6 weeks after
extroction oftooth 26 and suffkient vridrh ofthe alveolar aest

Fig 3 Preoperori..-e periapica/ rodiograph (induding o 5-mm rtee/ boll for

cofibrati0'1) revealing 7 mm ofsubontral bone he.ighr. The yeJl(JIW line de-
picts rhe sinus floor, which had o horizontal o.ppeafOfla at site 26.

ITI TreatmentGuide .. Vd ume S 64 m Treatment Guide • Volume 5

 S. S. Jensen 6 O inical Case Presentations

Surgical Procedure
Under local anesthesia using lidoaine 2% with adren·
a.line, a full -thickness cre.stal incision was made at the
site of the maxillary left fi rst molar.. The implant bed was
prepared to a depth of 6 mm. An osteotome was used to
fracture the sinus floor (Fig 4). The integrity of the sinus
membrane was checked using the Va.Isa.Iva maneuver.
Fif 4 After preparation of the
implant bed to a depth of 1 mm
Using the depth gauge, deproteinized bovine bone min· cmdtt the sinus floor, an osteo-
eral (DBBM) (Bio-Oss; Geistlich Pharma, Wolhusen, Swit- tome was gmdy used ro fiucrure
zerland) was gently introduced into the implant bed die sinus floor.
Fig 6 Deproteinized bovine bone minetol(DBBM) was inrrodl.lw:I through
(Figs 5 and 6). An implant (Stldumann Wide Neck SLA, the implant bed and gently adw:ma:.d apkart_y using the depth gauge.
0 4.8 mm, length 10 mm) was placed with good primary
stability (Fig 7}. Two interrupted monofilament sutures
(5-0) were placed for wound closure (Figs 8 and 9). An-
tibiotic prophylaxis with penicillin G was started 1 hour
preoperatively (1.6 g) and was continued for 3 days post·
operatively (0.8 g three times daily). Chlorhexidine digltr
conate 0.1 % was pre-scribed for mouth ri nsing twice daily
until the sutures were removed 7 days postoperatively.
The postoperative course was uneventful. Fig 5 A depth gauge ww- ~d to
ched the integrlrj of the Sehr&
derian membrane., toge.ther with o
nose-blowin g test. AwikJble space
for an implant 10 mm in kttgrh is
vetified.
FJC 8 Loreta! view ofrhe postopen:ttM s.ttK!tion aftet simultaneous implant Fig 9 Ocdusal view ofthe postopemrive sitJ.l<llion.
placement

ITI Treatment Guide• Volume 5 65 66 m Treatment Guide • Volume 5

 S. S. Jensen 6 Oinical Case Presentations

Acknowledgments

Restorative Procedures
Dr. Jens Malte - Priva.te practice, Copenhagen,
Denmark

laboratory Procedures
Lene Hyldga.ard, COT - Oenta.1technician, Copenhagen.
Denmark

Fig10 Ginio:llsituation8wrekspost0perotiwlyatthe6'meafcooneaing Fw 11 Clinical situatian after connecting o so6d abutmenr (heitJ1r: Fig 1S Lateral view aftet one year of prosthetic loading showing stable
the abutment. Nore the heohhy condition ofthe peri-implant soft tissue. 5.S mm). and healthy perHmplant soft tissue.

Fig 13 Ocdusol view after cementation ofthe meta'-ceromk cfO'Wn. P1g 16 Ocdusat viewafter one year ofprosthetic loading showing a minor
ceramic fraaure or the distopalar.al aspect.

Prosthetic procedure
Eight weeks postoperatively.. a solid abutment (height:
5.5 mm) was connected (torque: 35 Ncm), and impres·
sions were taken (Figs 10 and 11).A metal-ceramic crown
was cemented 12 days later (Figs 12 to 14) and showed
stable and healthy peri-implant soft tissue at 1 year de-
spite a minor cera.mic fracture at the distopalatal aspect
(Figs 1 S to 17).
Fig 17 Pe!iapicat radiograph aftet one year of(Jlf'.ISfh«ic loading showing
stable condmorts in the augmented area. around the. apex ofthe implant.

Fig 14 ~iapical radiogroph after cementa!ion of the metol<eramk

Cl<M'n.

ITI Treatment Guide• Volume 5 67 68 m Treatment Guide • Volume 5

 B. E. PjetutsSOn 6 O inical Case Presentations
6.2 [mp)_ant Placement with Sim.llltan QUS Sf<'E·
Transcrestal Techniq11e with DBBM
B. E. Pjetursson
Fig 4 Ottflopan[Ol'f'/Ol7Gph ofthe. initial situation, which involved genera/·
ized horizontal bone loss a:.mbffled with wrticol bone defeas. No patho-
logical changes \ln'.re vislb/e in d?e maxiDoty s.inuses-.
A SO·year·old man presented a.t the Department for Peri 4
odontology and Fixed Prost hodontics. University of Bern.
Switzerland {Fig 1). His chewing function was impaired.
as he had lost multiple teeth in the maxilla (Fig 2) and
mandible (Fig 3). Four teeth remained in the mandible, Radiographic analysis revealed generalized horizontal
a.fl showing increased mobility. The patient had received bone loss combined with vertical bone defects at teeth
a telescopic removable partial denture (RPO) in the max· 14, 11, and 45 (Fig 4). All four residual teeth in the man-
iUa and a met.at-framework RPO in the mandible about dible showed horizontal bone loss, generally down to
10 years previously. At that time, he could not adapt the root tips {Fig 4). Teeth 1S .and 13 were non-vital and
to the RPOs due to a strong gag reflex, and after a few visibly involved, as the periapical radiolucencies showed
weeks of trying, he s.topped using them. At the time of (Fig S). The baseline radiographs revealed a bone height
presentation at the University of Bern, he had been with4
adequate for standard implant placement at sites 14, 24,
out molars fo r over a decade. and 25. The preoperative bone height was S mm at site
15 but only 1 mm at sites 16 and 26. No pathological
The patient requested a complete oral rehabilitation and changes were visible in the maxillary sinuses (Fig 4).
insisted on fixed reconstructions after his negative expe
4
rience with removable dentures. Tooth 14 and all residual teeth in the mandible were con-
sidered irrational to ere-at based on a single-tooth preop-
The general medical risk assessment did not reveal erative risk assessment. Teeth 15 and 13 were considered
anything remarkable. The patient was in good general questionable, due to the presence of large periapical le·
healt h. was not on any medication, and did not smoke. sions and attachment loss. The five residual teeth in the
The-re-fore, after comprehensive periodontal treatment, maxillary anterior segment were regarded as safe.
there was no contraindication to implant therapy.
The treatment was to cover four phases:
Prosthodontic diagnosis yielded Kennedy class I in the
maxilla and Kennedy class I/modification 1 in the ma:n 4
1. Systemic phase. The patient was in good general
dible . The patient also showed generalized chronic health and did not smoke. There was no need for any
p-eriodontitis as defined by the European Academy of additional examination or therapeutic measure in
Periodontology. There were 12 remaining teeth, all vital the systemic phase.
except teeth 15 and 13. Teeth 14, 13, and 23 had been 2. Hygienic phase. It was planned to extract all teeth
restored with telescopic crowns. Tooth 15 had been re 4
that were classified as irrational to treat in this phase.
stored with an amalgam filling and teeth 12, 11. 21 , and The main issue was tooth 1 s. which had a doubtful
22 with composite filli ngs. Attrition was found in both prognosis due to its periapical lesion and attachment
jaws {Fig 2 and 3), but within the normal range expected Joss. One of the treatment options in the first quad·
in a patient who had been using only his anterior teeth rant was to provide a three-unit tood1 supported 4
for mastication over more than 10 years. fixed partial denture (FPO) from tooth 1S to 13, leav·
ing the patient with only two functionaf units or a.
premolar occlusion. When this treatment option was
discussed with the patient, he requested an addition·
Fig 3 Ocdusal v.iew ofthe mandible before treatment. al functional unit. Several longitudinal studies have
shown that rhe use of both endodontically treated
ITI Treatment Guide • Volume 5 69 70 m Treatment Guide • Volume 5
Fig 5 PeriopKo.I raOIOQOPhs ofthe rl!Stquadram. m>ealing petiopkal ra-
diolucencies at teerh 15 Olld 13 and the vertical bone defect at site 14. The
preoperative rad.iogrophs also revealed that. bone hdght itns reduced 11t
site 15. whkh was inadequate for stlJl'ldard jmplam placement.
abutment teeth and cantilever units in tooth-sup 4
ported fixed dental prostheses (FOP) is associated
with a high failure rate. It was therefore decided to
extract tooth 15 and to restore the first quadrant
with implant supponed FDPs. In the hygienic phase.
4
the six residual teeth in the maxillary anterior seg 4
ment were periodont:ally treated by scaling and ro-ot
planing. Additional endodontic treatment was per 4
formed on tooth 13.
3. Corrective phase. In the surgical part of the cor-
rective phase, the plan was to place six implants
(Straumann Regular Neck, Standard Plus, 0 4.1 mm)
6 weeks after extractjon of the remaining mandibu 4
lar teeth (Type II implant placement). In the second
quadrant~ the plan was to place two implants (Strau 4
mann Regular Neck, St<indard Plus, 0 4.1 mm) at
sites 24 and 25 to suppon a premolar and a molar.
In the first quadrant. the plan was also lo replace
teeth 15 and 14 with two implants (Straumann Regu 4
lar Neck, Standard Plus, 0 4.1 mm). Bone height and
crest width at site 14 allowed for standard implant
placement; at site 15. however, the preoperative bone
height was only around 5 mm (Fig 6). Therefore, sinus
floor elevation using the tra.nscrestal approach was
planned. Jn the re<onsuuctive part of the corrective
phase, the plan was to restore the edentulous man 4
dible with three four·unit impla.nt supported metal-
4
ceramic FOPs: two cemented FOPs at the molar sites
and one screw-retained FOP in the anterior segment.
In the maxilla, the old telescopic crowns were to be
replaced with new metal-ceramic crowns; the miss 4
ing posterior units were to be reconstructed with a
premolar shaped crown at the site of the first premo
4 4
lar, along with a molar·shaped crown at the site of the
second premolar. As a result, the patient would have
three chewing units on each side.
 B. E. PjetutsSOn 6 O inical Case Presentations

With round burs of two sizes (2.2 and 3.1 mm), the prep-
aration apertures were widened to a. diameter about
0.5 mm smaller than the proposed implant diameters
(Fig 10). At site 14, a standard surgial pro-cedure was
selected to insert an implant {Straumann Regular Neck,
Standard Plus, 0 4.1 mm, length 12 mm) (Fig 11 ). Prior to
placement, the distan-ce from the cresta.I ridge to the cor-
tical bone at the floor of the maxillary sinus was S mm,
as measured on the preoperative radiograph. During sur-
Fig 7 A mid<restal ind--
sion w;rh a small T-telel.lsing
ffKision •'OS made.
Fig 6 Periapkal radiogroph taken immediately before imptom pklamenr
showing a residual bone heigtlt cfapp.'O'hmotely S mm.
gery, this finding was confirmed by introducing a blunt
periodontal probe into the preparation apenure and ad-
vancing it through the soft trabecular bone (type Ill or
IV bone) to the sinus floor. The presence of soft (type IV)
bone at site 15, together with a residual bone height of
5 mm~ did not require the use of pilot drills. All that was
needed for the preparation was to perforate the cortical
bone at the alveolar crest with round burs (Fig 10) and
then to proceed with osteotomes (Fig 12).

4. Maintenance phase. Following completion of the

corrective phase, the plan was to recall the patient at
Fig 10 The exact position
&month inte.iva1s to eva.luate the residual dentition, ofthe implant site was first
the peri-implant soft tissue, and the reconstructions. marked with a smaD round
but rhen widened with
round buts- of rwo sizes to
Treatment of the mandible proceeded according to plan. a diameter f'O'Udlfy Q.5 mm
In preparation of the surgical intervention in the maxilla. smaller than the proposed
the patient rinsed with chlorhexidine digluconate 0.1% implant diameter.
Fig 11 The implant at site 14 was- placed in a sttJndard surgi«1J proadure.
for 1 minute. local anesthesia was administered buccalty
Fig 8 A fulkhkkness mv--
and palatally to the surgical field. A mid-crestal incision copedasteal flap MI'S' ra'ised
was made, including a smaH T-releasing incision in the for good OCttSS to the bane
distal area {Fig 7) and the raising of a full-thickness mu- a est.
coperiosteal flap (Fig 8). With a hetp of a distance indica-
tor {Fig 9), the center of the first implant at site 14 was
marked with a small (1.2 mm) round bur on the_alveolar
c.rest. The distance between the distal aspect of tooth 13
and the marked position, indicating the center of the im-
plant. wa.s between 4 and S mm. The distance between
the center markings for the first and second implants
\:vas 8 mm, allowing for two implant-supponed crowns in
a premolar-and-molar configuration {Fig 9).
Fig 12 Set cf capered osre«omes with differe:rt diameters, usea to com-
press the tesidual bone. and push it from the implant preparation into the
sinll:\ elevating the sinus membtane..

Fig 9 A distance indk:otor

of the same d'iameter as
the imp/om shoulder was
used to locate the implanr

"'"""'

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The first osteotome applied to the Implant site was a
small-diameter tapered design (Fig 13). It was pushed
toward the cortical bone of the sinus floor with light
maUeting. Having reached the sinus floor. the osteotome
was pushed .approximately 1 mm further, again with light
malleting, t o create a ..,greenstick" fracture of the cortical
bone of the sinus floor. A small-diameter tapered design
\:vas used to minimize the force needed to fracture the
conical bone. The second osteotome also had a tapered
design, but with a sfighdy larger diameter than the first
one (Fig 14). It was used to increase the fracture area at
the sinus floor and was applied to the same depth as
Fig 13 The~ osteotome used at the implant site was a small-diameter
tapered osreotome. This design was selected to minimize the force nttded
to fracture the cottical bone.
Fig 15 The third osreorome wm ofa stroighr design, Z.8 mm in ciamew:
B. E. PjetutsSOn
the fi rst one. The third osteotome was of a straight de··
sign. 2.8 mm in diameter and thus significantly narrower
than the implant to be placed (Fig 15). After pushing the
2.8-mm ost eotome up to the sinus floor but before intro·
ducing any grafting material, the sinus membrane was
checked for perforation. This was achieved by using the
Va.Isa.Iva maneuver, i.e . the patient was asked to blow his
nose against the resistance of his closed nostri ls {Fig 16).
leakage of air from the implant site in this situation
would indicate that the sinus membrane has been perfo·
rated .:ind that no grafting material should be introduced
into the sinus without closing the perforation first.
Fig 14 The ~cond osteot.ome •us also a wpered design but hod a sli'lfidy
fcuger diamttet to increase the froaured area at the sin.us floor.
F« 16 To check the integrity of the sinus membrane. the patient W12S
asked to blow against the resislona of his dosed nostrils. In this sirucrtion,
leakage of ait from the implant site would indicate that the sinus ~
Mme is perfOrated and tha.t no grdting material shoukl be introduced
into rhe sinus covii)t
ITI Treatment Guide• Volume 5
6 O inical Case Presentations
Ftg 17 As the sinus mem-
btane M1S intact, four
cycles of fllling with the.
wafting material could be
app/i«I.
FJt 18 Using a sttai€ftt osteor.ome 2.8 mm in diamet~ the grafting mate-
rial was slowly pushed into the sinus covity.
Fig 19 The last osteorome
used was 3.S mm in diam-
eter l'tith a shape and di-
mensions suitable for the
proposed 4. 1-mm implafll.
It ;s imponont that rhe last
osteotome enters the prepa-
ration sire on~ once.
74 m Treatment Guide • Volume 5
As the sinus membrane was judged to be intact, the
preparation was filled with deproteinized bovine bone
miner.ii (DBBM) (Fig 17). Using the same straight 2.8-mm
osteotome, the grafting material w-as then slowly pushed
into the sinus avity (Fig 18). This procedure was repeat·
ed 4 times or until around 0.2 g of grafting material (Bio-
Oss: Geistlich Pharma, Wolhusen, Switzerland) had be<!n
pushed into the cavity below the sinus membrane. At
the third and fourth entry, the tip of the osteotome was
advanced roughly 1 mm into the sinus cavity to check if
there was still resistance in the preparation site.
The last osteotome was a straight design 3.5 mm in di··
.:i.mete-r (Fig 19) with a shape and dimensions suitable for
.:i cylindrical implant 4.1 mm in diameter. It is important
to let the last osteotome enter the preparation site only
once. Multiple anempts will risk widening the prepara:·
tion and jeopardize- the primary stability of the implant
in soft (type Ill or IV) bone. Conversely, if the diameter of
the last osteotome is too small relative to the implant di·
.:i.meter, excessive torque will be needed to insert ~he im·
plant; overcompression of the bone will result in great er
bone trciuma and bone resorption, potentially delaying
osseointegration. Especially when implants .:i.re placed
cit sites with reduced bone volume, it is imponant to
strike a fi ne- balance between good primary stability and
bone trauma. Throughout the preparation procedure, it
is crucial to maintain precise control of the penetration
depth. Regular osteotomes have cutting edges that in·
crease the risk of membrane perforation upon entering
the sinus cavity. For the osteotome technique performed
with grafting materiaJs, the osteotomes should not en·
ter the s inus cavity. Repositioned bone particles, grafting
mate-rials, and trapped fluid will create- a hydraulic effect~
moving the fractured sinus floor and the sinus mem·
brane upward. This type of fluid pressure is les:s likely to
cause a sinus-membrane perforation.
 B. E. Pjerursson 6 O in ical Case Presentations

The final step before placing the implant was to verify Healing was uneventful. After 10 weeks,. surgical reentry
that the preparation was patent to the planned insenion was performed. Rather than using the punch technique,
depth of 8 mm. A depth gauge suitable for the implant risking the loss of all anache-d keratinized mucosa to
diameter was advanced to the predetermined length the buccal of the implants, a small crestal incision was
(Fig 20). After repeatjng the Valsalva maneuver, an im· made a.long the center of the implants, combined with a
plant (Straumann Regular Neck, Standard Plus, 0 4.1 mm, Fig 13 Unccwering the im· se-milunar incision toward the palate (Fig 23). The cover
plants. The punch technique
length 8 mm) was placed with excellent primary stability. Fig 20 The final step before K'OS avoided as it jeopardizes
S(rews were removed and two 3-mm healing caps insert·
Two cover screws were inserted into the implants at sit e-s placing the "11plant was to verify' cmadled keratinized mucosa ed. No suturing was required, a.s the incisions followed
15 and 14 (Fig 21 ). The mucoperiosteal flap was closed that the preparation ~ pattnt buccol to the implants. A small the outlines of the implants (Fig 24).
to the planned insertion depth. crested indsion was made along
using seven interrupted 5.0 sutures, and the implants A depth gouge suitabJe fol the the center of the implams, com·
were allowed to osseointegrate in a submerged position ;mplant diameter was- inserted b;ned with a setn#unar ;ndsion
(Fig 22). In the same surgical session, two implants (Strau· to the predetermined length. toward the pa.'ate.
mann Regular Neck, Standard Plus. 0 4.1 mm, length
12 mm) were inserted at sites 24 and 25.

Postoperative care, in addition to standard self-per-

fo rmed hygiene, included chlorhexidine gluconate 0.1%
twice daily for the fi rst 3 weeks after implant surgery.
Since bone substitutes had been used, the patient was
also placed on antibiotics fo r the first week.

Fig 21 Ttt'O implants Mvtre pkl<ed at sites 15 and 14. Exce/l.ent primary
stobi/iry M-US obtained.

F1g 24 Clinical view cf the freshly uncu.'efed implants after replacing the
cover saews with 3-mm heaffnc aboouems.. No suturing l'll2S required.

Fig 21 The mucoperiosteal flap

M'OS dosed using 'interrupted
sututes (S.0), and the implants
were allowed to osseoinregrate
in a submergedposirjon.

ITI Treatment Guide •Volume S 75 76 m Treatment Guide • Volume S


Fig. 25 Tueth 13 and 23 were prepared for meri::rl-m'tlmic crowns. In addi--
rion, four 7-mm solid abutments were onached.
Two weeks later, the old telescopic crowns were removed
from teeth 13 and 23. Both teeth were prepared for
metal-ceramic crowns. Four 7-mm solid abutments were
attached to the implants at the posterior sites with a
torque of 35 Nern (Fig 25). An impression was taken in
polyether material (lmpregum Penta; 3M ESPE, Seefeld,
Germany) using impression baskets and position cylin-
ders. The restorations were rabricated in the laboratory
based on the master casts {Fig 26). Tooth-supported
met aJ·ceramic crowns were fabricated for sites 13 and
23 and implant-supported splinted crowns for sites 1S
and 14 as well as 24 and 25. Great care was taken to en·
sure that the interproximal spaces between the implants
were accessible with lnterdental brushes. After trying in
B. E. PjetutsSOn
Fw 26 The masrer am.
the metal frameworks (Fig 27). the technician proceeded
to add the veneering ceramic. Once it had been veri·
fied that the occlusal relations and lateral movements
followed the occlusal scheme of canine guidance. the
reconstructions were cemented with glass-1onomer ce-
ment (Ketac Cem; 3M ESPE, Seefeld, Germany). The
implant-supported crowns at the second premolar sites
were shaped like molars. The patient's request to have
three complete chewing units on each side was met in
accordance with Kayser's definition {Fig 28).
The final step of this extensive treatment was to fabri-
cate an occlusal stent for use as a. night guard to protect
the ceramic work against fracture and chipping.
ITI Treatment Guide• Volume 5
6 Oinical Case Presentations
The patient was recalled at 6-month intervals.
Both the clinical {Fig 29} •nd the radiographic findings
(Fig 30) obtained 2 years after completion of active treat-
ment indicated that the periodontal and peri·implant
situation was stable. A new sinus floor was identified
above the apex of the 8-mm Suaumann implant at site
1S, indicating 4-S mm of bone gain from the time of
transcrestal sinus floor elevation. No technical compli-
cations like ceramic chipping occurred within the first
2 years of function, even though the patient w.as unable
to wear the night guard due to an excessive gag reflex.
Fig .29 Final recorrstnJttions 2 yootS" after ueatment.
He was satisfied both with his chewing ability and with
the esthetic outcome (Fig 31 ).
Acknowledgments
laboratory Procedures
Labor Nowaki and Kernen, Master Dental Technicians -
Bern. Switzerland
F1g 30 Orrhopant«no/7(JPll shewing a stable dinkal sitJ.NJtion 2 yeors
after treatment. A dome-shaped structure M1S apparem at sire 1S. iodkal·
in2 a substtlntial inoeose. in bone WJlume compared to die initial situation.
The dome was surrounded by o new conkal bone plate.
F1g 31 Stm1e ofthe pa6em afrer completion d ttearmtllt.
n 78 m Treatment Guide • Volume 5

Lateral Window Protocols
6.3 In1plant Plaren1ent with Sin1ultaneous Sf'E:
Lat ral Window Tecl1nique
with a Con1posite Graft
V. Chappius
A 68-year-old woman presented for tre.atment to replace
her maxillary right second premolar and first molar.
Three years previously, her general dent.al practitioner
had extracted toot h 16 because of a perforated root ca-
nal with a developing interradicular lesion (Fig 1). The
patient was satisfied with the chewing function of her
premolar occlusion untjl tooth 15 became symptomatic
2 months before presentation. Since a root fractu re had
developed. this tooth had to be extracted as well (Fig 2).
Fig 1 Periapical radiogfaph ofthe fidlt postedor segment ofthe maxilla
3 years prior to rrferraL Presumabty due to a root perforatiOll. the rll'Sl.
molar fto«h 16) showed an interrodicular rodiofucency ond had to be a
trotted by the patient's general demist.
V. ChappfU$
The patient reported an uncomplicated medical hi.story.
She had m ild allergic asthma induced by hay fever, re-
quiring the use of a cortisone spray on very rare occa-
sions during acute episodes. In addition, she reported
some allergic reactions to penicillin and mefenamic acid.
Fig Z The second premolar (tooth 1SJ bectJme sympromatk Z months
prior to referral. Emoaicn was required.
ITI Treatment Guide •Volume S
6 O in ical Case Presentations
The patient was a non-smoker. She had continuously re-
ceived dental care by her private practitioner. Her plaque
control and gingival health was, fo r the most part, excel-
lent. Periodontal probing de-pths never exceeded 3 mm.
She displayed a medium smile line: her esthetic de-
mands were moderate to high. Her ging·ival biotype was
classified as medium, and the dentition revealed signs
of bruxism (Fig 3). Two months after the second premo-
lar had been extracted, the right posterior segment of
the maxilla had a clinical appearance of good soft tis-
sue healing with obvious buccal flanening of the alveolar
crest at the site of the first molar {Fig 4).
Fig 3 The parienr's orol status was- generolly excetlent Her gineNal bio·
rype was dassified as medium, and her dentition exhibited some ~ of
bnDtism.
Fig 4 Ginkaf riew ofthe maxillary right posredor ~em. Good soft tis·
sue heolirvr MlS" obsem:d 2 months afte exttaaion ofthe secood pmnokJr.
with obvious bU«OI fkmvl"'1g of the alveolar ere.st in the area ofthe first
molo<
80 m Treatment Guide • Volume S

Rad iographic Analysis
Cone-beam computed romogr.iphy (CBCT) was per-
formed for radiographic analysis. The Schneiderian mem-
brane did not reveal ciny abnormalities. A bony septum
Wd.S observed in the anterior portion of the maxillary
sinus (Fig 5). Site 16 exhibited a vertical bone height of
6 mm and a crest width of S mm (Fig 6). The correspond-
ing figures for site 15 were 8 mm and 5 mm (Fig 7). The
septum extended all the way from t he basal to the cra-
nial aspect of the maxillary sinus, progressing from its
mesial anterior to its distal pal.ltal wall (Fig 8). This con-
figuration was clearly visible in the t hree-dimensional re-
construction image (Fig 9). The bone volume would allow
for implant placement with simultaneous augmentation
of the maxillary sinus. Oue to the compfe.xiry of the bony
septum, a lateral window technique was indicated and
recommended to the patient.
Fig 6 C8CT: Sire 16 exhibited a vettkal bone
height of6mm and a aesr •idth ofS mm.
F1g 8 The septum extended aH the wny fiom
111• ba'4116 m. "'"""' MJJ«! cfm. maiillmy
sinus, progressiog from its mesial anteriot to its
distal paio"'1 wall.
V. Chappius
fig S Cone-beam axnputed too'IOPJO.phy
rcscn was per(Ormed fot rodiographk artaly-
sis. The Schneiderian membrane tfJd nor reveal
any abnormalities. A bony septum was ob-
served ;n the anterior portjon of the maxiNory
sinus. The septum o.tt.11ded oN the WO)' from
rhe basal to the cranial aspect of the maxi~
IOly sil'lus.
Rg 7 CBCT: Site 15 exhibited a ~oJ bone
height of8 mm and a ae.sf width of 5 mm.
Ffg 9 This cc.ef.igurarion •us ckatfy vis;bk "in
the 3D reconstruction imQBf..
ITI Treatment Guide• Volume 5 81
6 Oinical Ca.se Presentations
Figs 10a-b Altet local anesthesia. a ctestal incision wasmade along a slightlypalato.I fCll.Jte from site 14 to site 17, including nwo verrkaf releasing incisions
mesial to tooth 14 and or site 17. A full-diid:ness mucoperiosttal Rap was raised.
F'1g 11 Aurologous bone chips we1e hatvesttd locally with a bone scrope1.
The aesr was: ffaaened ro creme suffldem interoccluso/ space. Diamond
bUIS were used to reduce the bucco/ bone wof.1.
Treatment Plan
The patient requested a fixed restoration in the right
posterior segment of her maxilla. Two tre.atment options
were discussed:
1. Placement of one implant at site 1S with simulta.ne·
ous guided bone regeneration (GBR) and sinus floor
elevation. A single crown would have been provided
for prosthetic restoration. This solution would have
offered a second·premolar occlusion.
2. Placement of two implants at sites 15 and 16 with
simultaneous GBR and sinus floor elevation. Two sin-
gle crowns would have been provided for prosthetic
restoration. This solution would have offered .a first·
molar occlusion.
The patient selected the latter option, as she also felt
esthetically compromised.
82 m Treatment Guide • Volume 5
Fig 11 Due. ta the presence of a boo)' sepcum. the bone in the window
0te0 had to be completely reJTKNed..
Surgical Procedure
An oral dose of clindamycin 600 mg was given 2 hours
before surgery. Following local anesthesia, .a. crestal inci·
sion wa.s made along a slightly paJataJ route from site
14 to site 17, including two vertical rel ea.sing incisions
mesial to tooth 14 and at site 17. A full-t h"ickness muco·
periosteal flap was raised (Figs 1 l)a·b).
Autofogous bone chips were harvested loccilly with a
bone S<raper. The crest was slightly flattened to create
sufficient interocdusal space. Diamond burs were used
to reduce t he bucul bone wall (Fig 1 1). Oue to the pres-
ence of a bony septum, the bone in the window area
was completely removed (Fig 12). The bony septum was
resected with a piezosurgic.a.I insttument (Mectron Piezo-
surgery; Mectron, Carasco, Italy) to minimize the risk of
perforating the Schneiderian membrane (Fig 13). In ad-
dition, the Schneide1ian membrane was elevated from
the anterior and palatal aspects of the sinus, thereby fa·
cilita.ting bone regeneration from the intact palatal bone
wall (Fig 14).
 V. ChappfU$ 6 O in ical Case Presentations

The implant at site 1S exhibited an apical fenestration

defect (Fig 17). This defect was repaired by autologous
bone chips, which were placed over the implant surface
along with a second layer of DBBM for contour augmen·
mion (Figs 18a-b) (Bio-Dss, small granules; Geistlich
Pharma, Wolhusen, Sv1itzerland). Two layers of a collagen
membrane (Bio-Gide; Geistlich Pharma. Wolhusen, Swit·
zerland) were applied to cover the grafted site (Figs 19a-
b). After a releasing incision of the periosteum, primary
wound closure was achieved (Fig 20).

Fig 13 The bony s.eprum was remolled with a piezosurgical insuument Fig 14 The Schneiderio.n membrane was elevated from the anterior and Fig 17 Both implants were placed Mith good primary srability. 7be "11·
(Mecrron Piezosl.Jrcery; Mectron, Carasco, Italy) tom'inimi2e the risk ofper- palatal aspects ofthe sinus to fadlitate bone regeneration from me inwct plo.nt at site 15 m;bited an apical knest:ration dm:oct.
foration. palatal bone wali.

Figs 15a.c Site 15 Jt(lS" prepared to receive a swndard-diameter implant

(Stroumann Regular Nee* 4.8mm,B 4.t mm. leflgfh 10mm).Site 16 was
prepared to receive a wide.cJiame.re.r implofll (Straumann Regular Neck
4.8mm,B4.8mm, length 10mm).

The next step was to prepare t he implant bed. Site 1 S

was prepared to receive a standard-diameter implant
(Straumann Regular Neck 4.8 mm, 0 4.1 mm, length
10 mm). Site 16 was prepared to receive a wide-diameter
implant (Straumann Regular Neck 4.8 mm, 0 4.8 mm,
length 1O mm) (Figs 1Sa-c). The autologous bone chips
were mixed with deproteinized bovine bone mineral
(DBBM) approximately 1 1 (Bio-Oss. large granules;
Geistlich Pharma, Wolhusen, Switzerland). This compos·
ite graft was then introduce4 (Fig 16). The implants were
placed with good primary stability.
Fig 16 The composhe graft (auto/ogous bone chips and deptoreinked b<> Fig 20 Alter a rdeasing incision ofthe periosteum. primary wound dosvre
vine bone mineral mixed approximately 1: 1J was inserted before placing was achieved.
the implants.

ITI Treatment Guide •Volume S 83 84 m Treatment Guide • Volume S

 V. ChappfU$ 6 O in ical Case Presentations

A postoperative radiograph was obtained {Fig 21). After

a healing phase of 6 months, implant stability quotients 6.4 Bilateral lmJJlant Pl eme11t with
(ISQ) were analyzed and found to be 83 (implant at s ite
1S) and 82 (implant at site 16). At this point, the patient Sin1ultai1eous SFE· Lateral Window
was refe rred back to her practitioner for prosthetic treat-
ment. Terhniq11e with a C,om_J>osite Graft
At the 1-year recall, the peri-implant soft tissue was
healthy and t he bone condition stable (Figs 22a-<:). The A. Tahmaseb
restorative dentist had added a non·occlusal distal canti-
lever fo r esthetic reasons.

Acknowledgments

Restorative Procedures
Or. Reto Meier - Kirchberg, Switzerland
Figs 220-c At the 1.year recall, fhe perHmplant soft tissue was healrhy
and the bone condition stable. A nan-occlusa/ distal cantilever had been
added.
A 57-year·old woman was referred for dental implant
treatment. Her maxilla had been edentutous for at least
20 years (Figs 1a·b). In the mandible, the residual denti·
tjon consisted of teeth 43 to 35. The left second premo-
lar v1as extremely weak and had deep caries. The residual
dentition was mutilated due to parafunction and the
framework present. At the time of presentation, the pa-
tient was on her third complete denture in the maxilla
and her fourth partial denture in the mandible. Despite
several adjustments and remakes, her maxillary com-
plete denture had been unsatisfactory over the previous
S years, while her mandibo lar partial denture had never
functioned adequately. She complained about poor sta-
bility as well as pain and discomfort in both jaws.
The patient's medical hist ory did not reveal any signifi·
cant fi ndings. An intraoral examination was performed
and revealed considerable bone resorption in the max-
illa. Jn the mandible, extreme resorption was noted in
the edentulous posterior segments. Less resorption had
occurred in the anterior segment due to the residual
teeth in that area. As a result, t here was a signific.ant
discrepancy of bone height between the posterior seg-
ments and the anterior segment of the mandible.
The residual height and width of the maxillary anterior
segment, characterize<t by a knife-edge ridge close to the
nasal cavity, was insufficient for implants. Starting from
the canines into the posterior segments. bone width was
adequate while bone height was not suitable for implant
placement (varying from 1 t o 4 mm) due to extreme re-
sorption and pneumatization of both maxillary sinuses.
Due to this extreme bone loss, we recommended a re-
movable prosthetic solution in t he maxilla so that ad-
equate support could be established for the upper lip to
meet the patient's esthetic and phonetic expectations.

Fig 1a Preoperative rod'iograph.

ITI Treatment Guide •Volume S 85 86 m Treatment Guide • Volume S

 A. Tahmaseb 6 O inical Case Presentations

The followlng treatment plan was proposed: Surgical Procedure

1. Extraction of the mandibular residual dentition
2. Bilateral sinus floor elevation
3. Two endosseous implants in the mandible
(interforaminaJ region)
4. Mandibular overdenture supported by one bar
5. Four endosseous implants in the maxilla
6. Maxillary overdenture supported by two bars
The treatment options were discussed with the patient.
Our recommendation was to complete the surgical pro-
cedure in a single session - including extraction of the
mandibular dentition, bone harvesting at the extraction
sites, placement of mandibular implants, bilateral sinus
floor elevation, and immediate placement of maxillary
implants (provided that sufficient primary stability could
be achieved). The patient was informed of the risks and
gave her written informed consent.
The existing maxillary denture was duplicated, and a car·
responding surgial guide was fabr icated for intra.opera-
tive use (Fig 2). In the mandible, the residual dentition
was extracted in local anesthesia, followed by elevating
a flap in the interforaminal region {Fig 3). Using a piezo-
surgical device {Mectron Piezosurgery; Mectron, Carasco.
Italy), bone was harvested by collecting the interproxi-
mal bone chips and cutting back the a.fveolar ridge. Two
standard implants {Straumann Regular Neck 4.8 mm.
0 4.1 mm, length 12 mm) were inserted at the canine
sites of the mandible at a safe distance from the mental
fora men. The procedure was completed for transmucosal
healing (Fig 4).

A bone scrapB was used both to partially re.m<We the bucrol d d rhe maxillary sinus and to s.imutc~ collect the bone thus removed.

Fig 2 Duplicate cfthe existing maxi/loty denwre. used ro fQbrirore a sutgi- Fig 3 Ah<eolar ridge knmediately after exuoction. Fte 9 Clinical view after complete remOllOI of the bucral sinus Ml'IL The
cal guid<. Sdlneiderian membrane is visible.

In the maxilla, .a mucoperiosta.I fl.ap was elevated from
the mesial aspect of the canine to the tuberosity under
local anesthesia (Figs 5 and 6). A bone m•per (Meta,
Reggio Emilia, Italy) was used to harvest bone by remov-
ing the buccal bony wall of the maxillary sinus. The buc-
cal wall was thinned out until the Schneiderian mem-
brane became visible (Figs 7a-b). Then .a piezosurgical
device (Mectron Piezosurgery; Mectron, Carasco, 1t.aly)
was used to complete the sinus osteotomy by enla.rging
and rounding off the access to the sinus (Figs 8 and 9).

Fig 4 The alveolar ridge of rhe mandible was cut down tf) ha!YeSt bone
and to arot.e verriaJI jpCJtt for the future prostr.esis. Two implants were
inserted.

ITI Treatment Guide• Volume 5 87 88 m Treatment Guide • Volume 5

 A. Tahmaseb 6 Oinical Case Presentations

The next st'ep was to elevate the Schneiderian membrane Before placing the implants.the palatalaspect of the sinus
using a wide sinus elevator (PESIM1 ; Hu-Friedy, Tunlin- cavity was partially filled with DBBM (Bio-Oss; Geistlich
gen, Germany}. To release the tension in the membrane, Pharma, Wolhusen, Switzerland), ensuring that the space
this elevation procedure was commenced from an apical palatal to the implant was filled {Fig 13). Two implants
direction so any membrane perforations could be man· (Straumann Tapered Effect, Regular Neck 4.8 mm, 0
aged more easily (Fig 10). The membr.ane was complete- 3.3 mm, length 10 mm) made from a tit'anium-zirconi-
ly elevated all the way to the medial wall of the maxillary um alloy {Roxolid; Straumann, Basel. Switzerland) were
sinus (Fig 11 }. After placing the surgical guide in the oral inserted at the canine site and between the premolar/
cavity, the stage was set for implant positioning and ori· molar sites (Figs 14a-b). Then the bone chips, which had
entation (Fig 12). Given the very thin residual crest, the been harvested from the buccal walls of the mandible
osteotomies were slightly underprepared in diameter to and maxilla, were used to partially fill the remainder of
optimize primary stability. Fig 13 DBBM was used ro panio/Jy fill the sinus awiry befote placing the
the sinus cavity adjacent to the Implant threads {Fig 15).
Fig 10 The Sdmeidetian membrone was gently eJe.-ared usUf2 a wide si-
nus elevator. impkmts. DBBM was used for coverage. The small fenestrations at
the implant necks were grafted with a double layer of
autologous bone chips and DBBM (Fig 16). A resorbable
collagen membrane (Bio-Gide; Geistlich Pharma, Wol·
husen, Switzerland) was used to cover the defect (Fig 17).

Fig 11 The membtane was- axnpletdy elevated all the way from the buc..
caf ro the medial wail ofthe moxilfory sinus..

Fig 12 Pfocemetlt of the stngia:li

guide to facilitate ideal implant F11: 16 Implants in situ. Bone chips
positionir1£. The osteotomy was M:re used to cover the smaH {fen.
executed before placing the graft estla"°'1-<ype and <khis<Mce-<ype/
material. defects at rhe impkrnt necks.
Fig 1S The sinus cavity was additionally filled ttrith hOIV'e'Sted ou[Q£J"Oft
and more DBBM.

F1g 17 A resorbable colJagen membrane was used to cowr the sinus and
the fenestration at me impklm ned:.

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 A. Tahmaseb 6 O inical Case Presentations

The procedure was repeated on the contralateral side. After ta.king impressions. standard prosthodontic proce-
Once again, two implants (Straumann Tapered Effect. dures with bite registration, wax-up and framework try-in
Regular Neck 4.8 mm, 0 3.3 mm, length 10 mm) made were performed to fabricate the overdentures. The man-
from a titanium-zirconium alloy (Roxolid) were placed dible was restored with one bar on two implants and the
with the help of a drill guide. Primary stability in the ma.xiii~ with two bars, one on each s ide and both being
range of 20 to 25 Nc~m was obtained for all maxillary ;upported by two implants (Figs 21to23).
implants. Finally the flaps were closed for submerged
healing. An effon was made to achieve tension-free clo-
sure with Gore-·Tex (Wl Gore & Associates, Flagstaff. Ari-
zona, USA) suture material (Fig 18). A panoramic radio-
graph was taken to evaluate the postoperative outcome
(Fig 19). Fig 18 Mulriple continuous sunues were us.ed to close rhe incision. The
flap was d osed in a tensiOt>free manner.
Postoperative prescriptions included analgesics, antjbi-
otics, -and chlorhexidine digluconate 0.2% for rinsing.
The patient was instructed not to wear her dentures for
2 weeks. She returned to our office 2 weeks after surgery.
Removal of the sutures was followed by soft relining of
the dentures.

At 3 months after surgery, a panoramic radiograph w.as

obtained to document the healing progress and peri-im-
plant bone condition (Fig 20). The graft was found to be
stable in the radiograph. No significant problems were
noted. At 6 months after surgery, a minor flap was e l-
evated under local anesthesia to uncover the implants.
Fig 19 ~cperotft.'e panoramic rodiograph.
Resonance frequency analysis (Ostell, GOteborg, Sweden)
\:vas used to verify that the implants were stable.. Values
::?: 70 were obtained throughout, indicating that the im-
plants had integrated successfully by that time.

Fw '10 Panoramk tarJiogoph 3 months ofter ~ demonstrating sta- Flf:S Z3a< ~fol the maxilla and TMndible.
ble peri-Nnpianr conditions.

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 A. Tahmaseb 6 O inical Case Presentations

The patient was pleased both with the esthetic outcome Acknowledgments
and with the wearing comfort (Fig 24). She returned to ch
the office twice for minor adjustments. Laboratory Procedures
c. -v erschuren, Dental Lab Van Oer Bijl - Tilburg,
After 1 year, a clinical and radiographic follow-up took Netherlands C. ten Bruggenkate
place, revealing stable conditions of the peri-implant soft
and hard tissues (Fig 25). E. Schildermans, ES Healthcare - Hasselt, Belgium

A S3·year·o1d woman was referred to the Department of

Oral and Maxillofacia1 Surgery for implant treatment of
her partiaJly edentulous right maxilla. Teeth 1 S and 16
had been extracted 1 year previousty. The patient com·
pla ined of inadequate chewing ability on t he right side.
She had tried a partial removable denture but found the
discomfort unacceptable. Her teeth were in a fairly good
condition, although tooth 14 had been endodontically
treated without success and was recurrently causing dis·
comfon. In the panoramic radiograph. it was found to be
associated with a periapical lesion. Teeth 41 and 31 were
congenitally missing (Fig 1).
P1g 1 Baseline orthopan~ disdosing that subatrtral bone he.iQll
was lffnired at sites 15 and 16.
The patient was in a good state of health overaJI. She did
not use any medication and did not smoke. Her alcohol
use was confined to limited amounts at social events.

She had been referred by her denta1 practitioner for im·

plant placement in the upper right space. The referring
dentist a lso suggest ed that tooth 14 should be removed,
due to its poor prognosis. The height of the aJveolar
crest (5 mm) was inadequate for implant place·ment. Si·
nus floor elevation was suggested to prepare the implant
site.

A decision was made to extract tooth 14 and to elevate

the sinus floor, such that two implants could be in·
serted at sites 14 and 16 for a three-unit fixed partiaJ
denture {FPO). Biphasic calcium phosphate {Straumann
BoneCeramic; Straumann_. Basel, Switzerland) was select·
ed as gr.lfting material with hydroxyapatite and tric.alci·
um phosphate at a 60: 40 ratio_. since the native alveolar
bone height of S mm would ensure that the proposed
implants could be placed with reasonably good stabif.
ity. A staged protocol was planned, involving a delay of
6 months from sinus floor e levation to implant surgery
(Figs 2 and 3).

ITI Treatment Guide • Volume 5 93 94 m Treatment Guide • Volume 5


Treatment
Sinus floor elevation was performed in accordance with
Tatum's lateral window technique 1 month after removaJ
of tooth 14. Local anesthesia was administered and a mid-
crestal incision placed from site 14 to site 16, including
a releasing incision on the distal side of tooth 13 (Fig 4).
A round diamond bur was used to create the lateral
trap-door preparation. The outline of the preparation fol-
lowed t he outline of the ma.xill.ary sinus as envisioned in
the orthopantomcgram.
Fig 4 Moxiikuy right posreri01 segmem upon exp&SJJre. Note the heoiing
emaaion sodets at sftes 14 and 15.
C. ten Srusgi'nkate
The next step was to luxate the trap door. turning it in·
ward .:ind upward. At the same rjme, the Schneiderian
membrane wa.s carefully prepared with hand instru·
ments specially designed for sinus floor e levation (Satvin
Dental Specialties Inc., Charlotte, North Carolina, USA)
until the trap door was lifted into a horizontal position.
Then the Schneiderian membrane was elevated at the
nasal sinus wall to the same level as the trap door (Fig 5).
A small septum was noticed between sites 16 and 15.
Neither perforations of the Schneiderian membrane nor
hemorrhages were observed.
mucosa intact.
ITI Treatment Guide• Volume 5 95
6 O inical Case Presentations
Fig 6 Sipho.sic calcium phos,phare {Srmumann BoneCuamic;: Stnnnnonn. Fig 7 The sinus floor was filled with rhe bone subsritvte, filling up rhe
Base.(, Swiuertand} with hydroxyapatit.e and fria11cium phosph<tte at 6C: 40 space below the lifted uap door <Jlld the Schneiderian membrane.
wns mixed with rhe ~.kn<'s fresh blood.
Fig 10 ~sutured and covered with Sdcoseryl (JCN Pharmoceuticds,.
fron/Wn., Germany) oral wound dressing.
The space created underneath the lifted trap door was
filled with two containers of biphasic calcium phosphate
(Straumann BoneCeramic; St.raumann. Basel, Switzerland
soaked in blood (Figs 6 to 9). No barrier membrane was
placed over the lateral window into the sinus wall. The
flap was repositioned and sutured with non·resorbable
exJl'lnded polytetrafluoroethylene (ePTFE) sutures (Wl
Gore & Associates, Flagstaff, Arizona, VSA) {Fig 10). The
postoperative orthopantomogram showed proper graft
placement and fill of the sinus floor. The patient was pre·
scribed 0,5 g of amoxicillin four times daily during 7 days.
96 m Treatment Guide • Volume 5
 C. ten Srusgi'nkate 6 O inical Case Presentations

Postoperative heating was uneventful. The sutures were

removed after 10 days. Ridge-mapping and orthopanto-
mogra.phy was conducted S months after sinus floor e l-
evation and revealed favorable bone dimensions for the
implant procedure scheduled to take place 1 month later
(Figs 11 to 13).

Six months after sinus floor elevation. a second surgical

procedure was performed to place the implants. A single
dose of 3 g amoxicillin was administered 1 hour before
implant surgery. Under local anesthesia. a. midcrestal in-
ci:sion was made from site 14 to site 16. A mucoperios- Fig 16 Onhopanrcmcgram obtained aftu implant placement or sites 14
te.aJ flap was raised, including a papilla·sparing releasing and16.
incision on the distal side of tooth 13 (Fig 14). The alveo-
lar crest was found to exhibit good healing and favorable
dimensions for implant placement.

Fig 12 Clinical view of the manuary posterior segment & months after F°'I! 17 OrrhopontM1ogrom taken at the end ofthe J.month osseoimegra·
s.inus floor eJevatjon and graftjtlg. don period. The Qait was found to be uable.

Two implant·bed preparations were made with regular

spiral drills to accommodate the proposed implants
(Straumann AG, Basel, Switzerland}. Two implants (Strau·
mann Regular Neck, Standard Plus, 0 4.1 mm, length
10 mm) were placed at sites 14 and 16 (Figs 15 and
16). Once inserted, healing caps 3 mm in height were
attached. The mucoperiosteal fla.p was repositioned
and closed with ePTFE sutures (WL Gore & Associates,
Flagstaff, Arizona, USA}. The postoperative orthopanto-
mogram revealed that the implants were bvorably posi-
tioned and surrounded by sufficient amounts of grafting
material.

Postoperative healing was uneventful. The sutures were

removed after 10 days.

After 3 months of healing, an orthopantomogram wa.s

obtained and the stability of the implants evaluated
(Fig 17). They were well integfdted.

Fig 14 S111giaJI field after reflection of a filn.thic.kness mucope.riosteat

flap.

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 C. ten Srusgi'nkate 6 Oinical Case Presentations

6.6 S}'E witl1 Comp ~ite Gr ft u in,g

~ Combined Simultaneou_s and
Stag_ed A_p_proach
D. Buser

Fw 19 Thftt..unit FPD on implants f 4 and 16. Orrhoponcoo;ogram offv'

3months.

A 38-year-old woman was referred to our department for
implant therapy. She was healthy and a non-smoket The
referring dentist had been forced to extract the second
premolar in the right maxilla and requested a detailed
examination for implant therapy. The clinical examina·
tion revealed a single-tooth gap with healed mucosa.
The crest width was considered adequate for implant
placement (Fig 1). The adjacent fim molar had been re-
stored with a crown and displayed a metal margin, which
bothered the patient from an esthetic viewpoint (Fig 2).
Fig 11 Three-unit FPDon imp/oms 14and16. Orrhopantomogrom after
A periapical radiograph was obtained, showing remnants
of the extraction socket and sufficient bone height in the
edentulous area. The adjacent fi rst molar was associated
with a periapical radio1ucency, although the extent of
this chronic lesion was unclear (Fig 3). ft was decided to
use a cone-beam comput ed tomography (CBCT) system
(Accuitomo; Morita, Kyoto, Japan) to evaluate the ana-
tomiccil situation in detail. The three-dimensional image
revealed a surprisingly large cystic lesion {Figs 4 and 5).

-
f year offunctioo

.
~
.
ti' -

,,
• .fll j

... ..
I

Fig ZZ Three.unit FPO on implams 14 and 16. Laterol !!'kw aftFd Z years
offunction.
_,,~.
.......... .
. ' FIC 1 Initial clinical SllJtus with a singfND«h gap at site 1S foaowing
extraction by the referring dentist. The mucOStJ was healed, and the crest
fie 2 This fi:1cial view dk:I show any significo.nt boccal flattening. However,
rhe visible metal margin ofthe crown resY>ration on the FllSt molar greatly
showed adequate wirJrh fot implant placement in the edenrulous area. bothered rhe patient.
Fw 23 Thftt..unit FPD on implants 14 and 16. Orthoponcoo;ogram ofter
2 years <Kfunction

Prosthetic treatment consisted of taking impressions Acknowledgments

with the respective impression components. A three-unit
ceramic fixed partial denture on a gold framework was Prosthetic Procedures
made by the patient's dental practitioner. The patient Dr. J. W. Roeloffs - Katwijk, Netherlands
expressed her appreciation of her ne-w teeth, stating that
they felt just like natural teeth (Figs 18 and 19).

After 1 and 2 years, the peri-implant soft tissue was

found to be healthy, without any pockets or bleeding on F1g 3 In the periapicol todiogfflph, the previous extraction fie 4 The panoromic view rf the FJt 5 Th;s oro/Udal section of rhe:
socket at site 15 could still be kknrirted. The FN'St molar C8CT scan revealed o latge cystic CBCT scnn dearly ;uustrated rhe ex--
probing, and the peri-1mplant bone levels were stable was assodated with o petiapicol tadiolua:ncy. althoutft lesion ot die two buccal roots of tent ofthe tadicular cyst.
{Figs 20 to 23). the extent ofm;s lesion was not dearly visible. the first molar.

ITI Treatment Guide• Volume 5 99 100 fTI Treatment Guide • Volume 5

 D.Buser
After discussing the situation with the patient" the fo l·
lowing treatment plan was agreed upon:
1. Flapless extraction of the first molar.
2. After 3 months of healing, placement of an implant
at site 1 S with simultaneous sinus floor elevation and
ridge augmentation at site 16 (window technique
with a collagen membrane).
3. After another 2 months, restoration of implant 15 with
a provisional crown.
4. Around 6 months after sinus grafting/ridge augmen-
tation, placement of a.n implant at site 16.
5. Loading of the implants with cemented crowns.
The fi rst molar was extracted without flap elevation
(Figs 6 and 7). The extended bone lesion was degranu-
lated, rinsed, and filled with a collagen plug (Tissuecone;
Baxter, Vo1ketswil. Switzerland) to stabilize the blood clot
(Fig 8). This .lpproach was chosen to achieve intact soft
tissue with additional keratinized mucosa at the pro-
posed surgical site.
m Treatment Guide · Volume S 101
6 Oinical Case Presentations
Fig 11 lnuaoperotive view after ekvotion of o tropeZDidal fulJ.thickness
flap, removal ofexistinggranula!;on tissue, and prepo.rofion ofa window to
elevote rht Schneiderian membtone. The buo:oJ bone twH ofthe ridge was
«Jmpletely absent at site 16.
After an uneventful soft tissue healing period of 3 months,
a p-eriapical radiograph was obtained (Fig 9). Extraction
site 15 had normally healed and revealed a bone height
of approximately 1O mm. Site 16 exhibited .ln extended
bone lesion and was opened with a trapezoidal mucope-
riosteal flap (Fig 10). As anticipated, the ridge at site 16
showed a large defect in the facial wall. due to resorp-
tion of bundle bone following exuaction. As expected,
implant placement was not possible at that site, and hor·
izontal and venical bone augmentation was necessary
to allow implant placement in a second surgical proce·
dure. To do this, a staged sinus floor elevation using the
window technique was combined with a horizontal ridge
augmentation procedure using GBR. A typical window
was prepared with diamond drills and a piezosurgical de·
vice (Meruon Piezosurgery; Memon, Carasco, Italy) 10
mobilize and elevate the Schneiderian membrane. This
was successfully achieved without tearing the mucosa
(Fig 11).
102 fTI Treatment Guide • Volume S
Fig 10 The periopkal rodiograph coefumed a large bone defixr at the
rJrSt-molar sire. Bone healing was more OfNanw:I or site 1S.
Fie 11 At site 1S, a tissue-1~-e.I impklm. was inserted wfth good primary
stabt1ity. Al. site 16, the bone Mons Jocalty augmenttd with a composite graft
in Mier to ga.irl height and to re-establish o bl.Jee/JI bone wail A composjte
graft with locally harvested autologous bone chips and D6BM partides
was- applkd.
The space created was then filled with a composite
graft (Fig 12). We routine ly use a 1: 1 mixture of autolo·
gous bone chips on the one hand, and a hydroxyapa·
tite·based bone substitute offering a low substitution
rate on the other. The bone chips are routinely harvest·
ed with a bone scraper (HuFriedy, Chiago, Illinois, U SA)
from the facial bone wall wit hin the same flap. Our pre·
fe rred bone substitutes are DBBM (Bio·Oss; Geistl ich
Pharma, Wolhusen. Switzerland} or. as an alternative.
biphasic calcium phosphate (Stra.umann SoneCeramic;
Straumann, Basel, Switzerland). Both fi llers are well
documented and offer a low substitution rate. which
is important for long-term maintenance of the bone
volume created (Jensen et al. 2006: Jensen et al. 2007;
Cordaro et al. 2008).
 D.Buser 6 Oinical Case Presentations

Fig 11 Fol/owif1€ the principled fµided bone 1egeneration (GBRJ. the Fw 14 ~wascompletedwithtension.freeprimoryittnmddosure.. Fig 18 After elcwting cwo small flaps to minimize morbidity. a second
augmentation maurial was COWied with a resc1bable coJJagen membrane Saaumann im{:Jam was- inserted. Note rhe mai:netic post, which was m.-
as a tempotal)' barrier. toched to measure the IS() value.

Fig 15 PostoperotM! radiograph showing the tissue--le-.'d im- F'I£ 20 Adaprif11 the small flaps marted the beginning ofnon-submerged Fig 21 PostopeJatire rocf'rograph with both implants appropriateJy posi-
p/onr ar site ts and the bone graft at site 16. heafing. 6oned and indined.

In the present case, a composite graft with DBBM par-

ticles was applied, followed by the insertion of a standard
tissue level implant (Straumann Regular Neck, SLActive,
0 4.1 mm. length 12 mm) at site 1S in accordance with
the treatment plan. Following the principle of guided
bone regeneration (GBR), the augmentcition site was
then covered with a non-crosslinked, porcine-derived,
resorbable coUagen membrane (Bio-Gide; Geistlich
Pharma, Wolhusen, Switzerland) used as a temporary
barrier during initial bone he.aling (Fig 13). The surgery For the second implant procedure, a minimally invasive ic post was attached (Fig 18) to measure the ISQ value
was completed with a primary wound closure for sub- approach with small flaps and short releasing incisions (Implant Stability Quotient; Osstell, Goteborg, Sweden).
merged healing of the biomaterials applied (Fig 14). The was utilized. The ridge had nicely regenerated and <ii- The obtained reading of 56 was sfightly less than average
Fig 16 After 6 mMlhs.. the inpkmt MIS wet/ in< egrored. Bone hed-
postoperative radiogra,ph demonstrated the inserted and ing hid readied an ad\ianced st.age at site 1S. while at site 16, bone lowed the insenion of a wide-body implant {Str.lumann (Fig 19). Subsequently, a 3-mm heafing cap was anached
well-positioned implant at site 1S and the applied graft heding hod progressed wetl and olbwed rhe fiaament ofthe sec- Regular Neck. 0 4.8 mm, length 12 mm) featuring a for non-submerged healing of the implant at site 16
material used fo r sinus floor elevation and ridge aug· orwl inrp'ant hydrophilic SLA surface with a micro-rough topography (Fig 20). A postoperative radiograph was obtained, show-
mentat ion at site 16 {Fig 1S}. (SLActive; Straumann AG, Basel. Switzerland}. A magnet- ing that both implants were favorably positioned (Fig 21 ).

The originally planned provisional restoration of im-

plant 15 was declined by the patient due to budget
constraints. The imp1ant remained unrestored over the
entire period of bone healing. A radiograph was ob-
tained 6 months after sinus grafting, revealing a well-
integrated implant at site 15 and advanced bone heat-
ing with adequate bone height at site 16 (Fig 16). An
occlusal view showed a well-preserved ridge at site 16
and the absence of peri-implant mucositis at implant
1 5 (Fig 1 7). Fig 17 Ocdr.tsotviewdthelocalstatus6monthsaftetbone auemenrooon.

m Treatment Guide· Volume S 103 104 fTI Treatment Guide • Volume S


Fig 22 Occlusal view 6 weeks later, showinc good healing of the peri-im·
plant soft tissues.
A clinical examination performed 6 weeks later re-
vealed good integration of both implants without any
signs of inflammation (Fig 22). The ISQ of implant 16
had markedly improved to 78 (Figs 23 and 24). Implant
15, by comparison, showed an 15Q of 80 (Fig 25). Suc-
cessful tissue integration of both implants was also
o.a...r 6 O in ical Case Presentations
Fig 23 Repeated evaluation oftM ISQ values to monitor the progress of Fig 26 Periapknl roWograph cortrllming normal bone. Nrtegration ofboth Fie 27 Clinicolvie.w after both implants had been restared with cemented
osseoimegration. implants. Some temodeliflt: hod taken place at crest level. dentist. Treatmenr had tesufted ;n a pleasing out-
CJOWl'IS by the refetring
com._
Fig 28 Periapicai radiograph «.Jf'Nllming nonna/ bone imegration of bo.rh
imp/Otlts.
confirmed radiogr.>phically (Fig 26). With both 15Q
v<tlues clearly exceeding the threshold of 70, indicat-
ing that restorative treatment could be initiated. the
patient was refe rred back to her dentist, who proceed-
ed to restoring both implants with cemented crowns
(Figs 27 and 28).
ITI Treatment Guide· Volume S IOS 106 ITI Treatment Guide- . Volume S

Fjg. 29 Clinico/ Yiew mOt"e man 5 years after the second implant proce-
dure. demonst1ariog £00d mttgrotion of the implants and stability of the
peri-implant soft tissues.
More than S years after the second implant procedure.
a follow-up examination confirmed that both implants
were successfully integrated and that crestal bone levels
were stable (Figs 29 and 30). Thanks to the successful
regeneration of the large bone defect at the molar site,
both implants have an excellent long-term prognosis.
Discussion
This case required a staged approach to sinus floor eleva-
tion combined with ridge augmentation. due to a large
bone defect at site 16 associated with inadequate bone
height and complete absence of the buccal bone wall.
A-s the crest was over 6 mm wide. a particulate compos·
ite graft could be used for the bone augmentation pro·
cedure. A block graft was not required, eliminating the
need for an additional donor site in the chin or man·
dibular retromolar area, which would have involved extra
morbidity. At site 15, a sinus floor elevation was simul-
taneously conducted to accommodate an implant of ad-
equate length. Carly loading with a temporary crown was
planned to improve the chewing comfort. Mainly due to
budget constraints. however, the patient decided against
a temporary crown.
A composite graft was used for sinus grafting and ridge
-augmentation. Combining autografts with a 1ow-substi·
tution bone filler offers two advantages. Firstly, the au·
tologous bone chips with their content of non-coJlagene-
ous proteins such as BMPs and other growth factors will
expedite and reinforce the formation of new bone. Lo·
cal harvesting of these bone chips from the facial bone
wall with .a sharp bone scraper did not involve additional
morbidity. Setondly, DBBM partitles are well dotument-
ed to offer both a low substitution rate and excellent d i·
mensional stability over time.
D.Buser 6 O inical Case Presentations
6. 7 Bilat ral Sf'F with Tran ere ml
and Lateral Window Technig__ue
using Various ( omposite (}rafts
R. A. Levine
Fig 30 More than 5 )'NtS after implant placemenr., the peri./mplant. bone
levels wete stable. Boch implants have an excellent long.wm prognosis.
A 53-year old woman, a. non-smoker, presented with fail- Clinical Examination
ing crown a.nd bridge restorations in both maxillary pos·
terior segments. In addition, she was d issatisfied with Periodontal probing depths ranged up to 3 mm in the
the esthetics of her mandibular anterior sextant (Figs 1 maxilla and 4 mm in the mandible, with generalized
The use of implants featuring a hydrophilic SLActive t<> 4). She had recently lost the d istal abutment (tooth bleeding upon probing. Only tooth 14 was found to be
surface offered the advantage of reducing the healing 16) of a three-unit fi xed partial denture (FPO) to den- significan tly mobile (class. 1 mobility). Inadequate at·
periods involved (Buser et al. 2004; Ferguson et a l. 2006; tal caries, whereupon the bridge structure was sectioned tached keratinized gingiva was noted at teeth 33 and 43,
Weber et al. 2009). Early lo>ding is today routinely ap- distal to site 15. The patientJs medical history was non· including 7-10 mm of facial attachment loss and 0 mm
p lied in a distinct majority of patients. A healing period contributory. of attached gingiva (Fig 1 ). The patient was ma.de aware
of 3 to 4 weeks is commonly used for standard sites that the mandibular anterior segment wa.s hopeless. lt
(Bornstein et al. 2009b; Bornstein et al. 2010), while 6 The fo llowing periodontal risk factors were identified was decided to address this situation upon completion
to 8 weeks are used at sites with regenerated bone or and discuss.ed with the patient: of the maxillary restorations. A severe ridge defect was
with simultaneous guided bone regeneration or sinus Familial history of periodonta.J d isease. noted. which wa.s due to trauma when the patient ha.d
floor etevation. However, it is important for clinicians Poor/erratic compliance with preventive care. lost her four mandibular incisors.
to evaluate primary and secondary implant stability
objectively. Resonance frequency analysis (RFA) is now
routinely used for this purpose. !SQ values have proved
very hetpful for clinicians by d isclosing at what time an
implant can be loaded {Oates et a l. 2007; Valderrama et
al 2007; Bornstein et al. 2009). In the c.ase discussed,
the ISQ clearly improved from 56 at baseline to 78 af-
ter 6 weeks, enabling us to give the go-ahead for the
restorative phase, since a lhreshold 1SQ of 70 should
be exceeded for this decision. The restorative dentist
decided to splint the two implants, although this mea·
sure is no longer considered necessary but has ctearly
become a matter of preference.
Acknowledgments
Restorative Procedures
Dr. Markus Salm - Bern, Switzerland
m Treatment Guide· Volume S 107 108 fTI Treatment Guide • Volume 5

The width of the maxillary posterior ridge s.eemed .:ide-
quate but was significantly reduced in height because
of sinus pneumatization. Occlus.:il relations were Angle
class 1 with 4 mm of overbite and 2 mm of overjet. The
patient expressed a strong desire to have a fixed provi-
sional restoration installed during the healing phase to
.:ivoid a tran-sition.:il re·movable denture.
R. A.. l evi.ni?
Diagnosis
Inadequate vertical bone height in the posterior maxilla.
localized advanced attachment loss at teeth 33 and
43 with inadequate attached keratinized gingiva.
localized advanced periodontitis at teeth 33 and 43.
Vertical a.nd horizontal ridge defect extending from
tooth 33 to tooth 43.
m Treatment Guide· Volume S 109
6 Oinical Case Presentations
Fig S Ptetreatmem CBCT scan ofsite 16..
Prognosis
Tooth 14 was considered hopeless; 25, 28, 38, 33 and
43 were guarded. The following treatment s.equence was
recommended:
1~ Full+mouth periodontal scaling in one visit with
plaque control reinforcement.
2. Maxillary CBCT s.can to evaluate sinus. health and
bone volume (Figs 5 and 6).
3. Prosthetic planning to restore teeth 1 7, 13, 24, 28
and replace 16 (small tooth cantilever), 15, 14, 25, 26
and 27 with dental implants. Fabrication of a surgical
guide template on the basis of mounted study casts.
4. Delivery of a temporary fixed denture to the maxil-
lary right quadrant (sites 18 to 13).
S+ Extraction of tooth 14, fo llowed by immediate im-
plant placement at sites 1S (including sinus floor el+
evation using the transcrestal osteotome technique)
and 14. Sinus floor elevation through a lateral wall
approach was planned in the maxillary left quadrant.
6. Provisionaliz.:ition of the maxillary left segment (sites
24 to 28) with a surgical guide fabricated for implant
placement at sites 25, 26 and 27. Initiation of the res-
toration of the maxillary right quadrant with a single
crown at site 17 and a cantilever FPO at sites 14, 15
(16), to be performed 4 months after surgery.
7+ Another 8-9 months later: surgical extraction of
tooth 25 with placement of implants at sites 25. 26
and 27.
8. Another 2- 3 months later: restoration of che max-
illary left segment with single crowns at sites 24
through 28 (including a night guard).
9. Periodontal maintenance alternating between of-
fices at 3·month intervals.
l Q. C6CT·base4 treatment planning for the mandibular
anterior segment.
110 fTI Treatment Guide • Volume 5
Fig6 PrettearmentC.BCT scan dsite 27.
Treatment
Elevation of the maxillary left posterior sinus floor
fo llowing a lateral wall approach. Prior to commencing
the procedure and applying tocal anesthesia, blood was
drawn from the patient in the office to collect plasma-
rich growth factors (PRGF). Three fractions. were extract+
ed: fraction 1 was used as a membrane; fraction 2 was
mixed with bone graft material, and fraction 3 served
as liquid PRGF for delivery through a syringe. Sulcular
incis.ions. were made with crestal incisions. over the eden-
tu1ous site 26.
Following vertical releasing incisions on the mes.iobuccal
aspects of 24 and 28, a full-thickness flap was raised by
blunt dissection to ext.end the flap into the vestibule to
beyond 15 mm from the ridge. The flap was then sutured
to the buccal n1ucosa of the cheek to improve s.urgical
vision/acces.s and to protect it agains.t excess.ive trauma+
A window into the sinus floor was created, with the api-
cal border 15 mm and the coronal border just 2-3 mm
apic.al to the sinus floor. Using a s ize 4 round high-speed
diamond, the window was created to a point at which
the membrane could just be visualized. It was then com+
pleted with OTS and OT1 piezos.urgical instruments. tips
(Mectron Piezosurgery; Mectron, Carasco, Jtaly) to help
avoid tearing of the sinus. Further dissection was ini-
tiated with the El1 instrument tip and completed with
s.pecial hand instruments designed fo r sinus procedures.
 R. A.. l evi.ni? 6 O inical Case Presentations

After a healing period of 4 months. the fina l restoration

of the maxillary right quadrant was initiated along with
removal of the bridgework in the maxillary left quadrant,
fabric.ation of a surgical guide, and completion of a 1ab-
oratory·processed temporary fixed prosthesis covering
sites 24 to 28 (Figs 12 to 1S). At 8 months after sinus
grafting, a follow-up panoramic radiograph was obtained
and the patient scheduled for implant surgery.

Fig 8 DBBM wirh a 1 : 1 ratio of large ro small particles was mia.d with Fig 12 CfJnical riew 8 months after surgery. A laborotory1'foa.ssed ~
PR.GF and load&J into a syringe for easy delivery. porary prosthesis was used 10 replace 24 to 28 in antkipadon ofemaction
and implam surgery at 25 and ploament of"11p/o.nts at 26 and 27.

Fig 10 A resrxbable collagen n>embtane was stabilized owr the prepared F'Jt 13 Surgical t,Uide template mimicking the temporary FPO. Note the
wN>OOw wirh o single su1gical rack. small mesiodislol ammeters d rhe teem to be replaced.

Upon completion of membrane elevation, the new sinus

floor was covered with a resorbable membrane (Bio-
Mend; Zimmer Dental, Carlsbad, C.lifornia, USA) (Fig 7).
Fraction 2 of the collected PRGF was mixed with small
and large particles of DBBM (Bio-Oss; Geistlich Phar-
ma, Wolhusen, Switzerland) in equal parts to a total of
3 grams. This mixture was then delivered with a plastic
carrier and packed thoroughly with condensing sinus
instruments staning media lly and anteriorty until the
sinus cavity was completely filled (Fig 8). A resorbable
collagen membrane (Bio-Gide; Geistlich Pharma, Wot-
husen, Switzerland) (Fig 9) was anteriorly secured with
a s ingle surgical tack (Fig 10) to cover the window. The
F'« 11 Closure d the surgkal f}op.
__
Fig 14 Presurgkol panoramic radiop/oph raken 8 mondts a~er sinus
graftift&- The moxiflary right quadrant was restored with a candfevered a·
,.......
mented FPO (sires 16 to 14) and a sinefe crown (site 17).

n1embrane extended at least 3 mm in alJ directions from

the lateral wall prep.aration.

Fraction 3 of the PRGF was liberally applied under the

flap before closure, which was accomplished by replacing
and suturing with a combination of 4-0 silk and 4-0 chro-
m ic gut, also including 6-0 vicryl to suture the releasing
incisions (Fig 11). Postoperative care included 10 days of
antibiotic coverage (Augmentin), hydroco<lone with pa·
racetamoVacetamino-phen as needed, a steroid pack for
6 days, and rinsing with chlorhexidine 0.1 2% for 2 weeks. Fig 1S Completedprosthesis in the maxlltary ri£fit quadrant af«lg with a
The patient was seen for postoperative care 1 week later. temporary prosthesis covering sites 24 to 28.

m Treatment Guide· Volume S 111 112 fTI Treatment Guide • Volume 5

 R. A.. levi.ni? 6 Oinical Case Presentations

Surgic.al procedure for implant placement at sites 25 As the teeth to be replaced were reduced in mesiodis·
to 27(Fig16). After local anesthesia , lingual crestal inci- ta.I width. it was necessary to respect the inter-implant
sions were made, extending sulcularty to the distal buc- distances to allow for proper emergence profiles of the
cal of 23J maintaining the full papillae with a mesiodis- final restorations. The use of bone-level implants offe-
tal horizontal incision. Piezosurgery tips (EXl , EX2, EX3) red additional space. The presurgial plan had been to
were used to create a trough circumferentially around use bone-level implants (Straumann Bone level, Regular
tooth 25 under copious water irrigation, such that the CrossFit, SLActive; site 25: 0 4.8 mm, length 14 mm; site
tooth could be easily removed with minimal trauma 26: 0 4.1 mm, 12 mm; site 27: 0 4.8 mm, 12 mm). Type
while preserving the buccal plate (Figs 1 7 to 19). Small 2 bone density was noted throughout the preparation .
surglcal spoon excavators and an OT4 tip were used to Insertion torque values were 35 Nern at sites 25 and 26.
debride the socket. This was followed by multiple intra- 25 Nern at site 27 (Figs 20 to 23).
marrow penetrations with the OP4 tip, taking care to
avoid the thin buccal plate. A horizontcil defect dimension to the facial of implant
25 was measured as 3 mm. and a procedure of guided
bone regeneration was completed after placing the cover
screw. using an equal-part mixture of Cerasorb (Riemser
Arzneiminel, Greifswald, Germany), decalcified fre-e.ze-
dried bone allograft (DFDBA; LifeNet Health. Virginia
Beach, Virginia. USA}, and sterile calcium-sulfate pow·
der. which in turn was mixed with the patient's blood
(Fig 24). This mixture was thoroughly condensed to the
buccal and lingual surfaces (Fig 25).

F1g 21 /nse.rtion torque va.'ues were n>easUted and recorded for each ffn.
plane site.

Fw 18 Exuaaion af rooth 25 assisted by o piezowrgica.I devke. A uough F1g 22 Ginical \'few aft.et implant placement •ith the surgico/ guide in
;s aeated around the tooth to ollow for minimally traumatic remcwol. situ.

Fig 19 Tooth 25 following extraction. Note the short toot length with re- F1g 24 Bone graft consisting d an equa.J.part mixtute ofc.erascrb (small
nwva/ ofthe periodontal t.war»mt into the ap.~ thitd as a result ofusing pattides}. DFDBA, and calcium sulfate, which in turn was mUed with the
piezcsurgkal insttumentation.. patient's blood Uom under the palatal flap.

m Treatment Guide· Volume S ttl ,,. fTI Treatment Guide • Volume 5

 R. A. Levine 6 O in ical Case Presentations

A resorbable coll.a.gen membrane (Bio-Gide; Geistlich After a healing period of 11 weeks. a. second-stage pro-
Pharma, Wolhusen, Switzerland) moistened with saline cedure was conducted to expose t he implant at sit e 25.
was used for coverage (F"ig 26). A connect ive-tissue graft At the same visit, the bonle--shaped healing abutments
was harvested from the undersurface of the palatal flap were replaced with conical (6 x 4 mm) ones to "stretch"
at sites 24 and 25 (Fig 27). The graft was then placed the tissue to develop the "transition zone" for fi nal im-
over t he membrane and under both (the bucal and pressions. Papilla-sparing incisions were used mesia lty
lingual) flaps for unimpeded healing, prevention of early and distally, with an additional palatocrestal incision to
membrane dissolution, and improved esthetjc.s by fa.ciaJ maintain keratinized gingiva on the facial aspect . Prior to
contour enhancement. placing the healing abutments, the bone was tested for
each implant, using the reverse-torque test at 35 Nern
The original incisions were located on the palatal as- with Regula r CrossFit (RC) st erile implant carriers and a
pect of the ridge, thus requiring the facial ke-ratinized Straumann torque driver (Figs 29 and 30). The soft tis-
Fig 29 Seccnd-stQBe surgery to apose rhe implant at sit£ 25, ax uJucted
gingiva to be reduced before flap closure, preserving the 11 weeks after p/acemem. PapiUa-spo.ring indsions were used. During the sue around implant 25 was closed with a 4-0 resorbable
t issue and positioning it anteriorly so that interproximal same visit a reverse-t«que test at 35 fkm was wccessfiJNy compfered. chromic gut suture. The radiographic assessment confir-
papillae were present immediately after the procedure . med fi naJ bone healing. A waiting pe riod of 3 to 4 weeks
Prior to suturing, the lengths were reduced by approx- would permit adequate soft tissue heating for the fi nal
imately half to establish a bun joint with the palatal flap impressions.
(Figs 27 and 28). Bottle·shaped healing abutments 4 mm
in height were inserted at sites 14 and 15. Postoperative
medications were similar to t he fi rst surgical visit, except Prost het ic Phase
that amoxicillin was given. The patient returned to her restorative dentist 4 weeks
after the second·st age procedure . This visit was used fo r
fi nal impressions using a dosed tray technique. Subse-
quently the labor.ltory-customized st ock abutments fo r
25 and 26 plus the waxed 27 were scanned fo r custom
Fig 27 A palatal CT graft was haM!Sted from the bottom surlOce ofthe
abutments using CAD/CAM technology (Figs 31 to 33).
Fig 30 After cm«hing on RC conical healing obutmem (6 x 6 mm) to the The case was inserted as single crowns and cemented
palatal flap and was poskioned over the coltage_n membrane and under
implant at site 15, the tissue tt'llS sutured. Jnvvessioo·taking M-OS schedufed
the flops. lnterproximal papil ae ~"'re created from the scalloping of lhe for 3-4 week.s later. with permanent cement (Figs 34 to 39).
buccalflap.

Fig 31 Scanned /abofa.

tory wax.up ofcustomized
milled abutment for Z7
(fd:on; Stroumann, Basel
Switzerland}.
Fig 32 Ptosthetic abutments: 2.S and 16 were customized stock RC abut·
mencs; 27 M1S a custom aOOtmenr based mj(fed on the bosn of a wax.up
Fig 28 Final Sllttlrine. {/Or rigtl t) which was fabricated (&lwn; Stroumom AG. Base.l Switzer/QJld}.

ITI Treatment Guide · Volume S 11 s 116 ITI Treatment Guide- . Volume S


Fig 33 Good restorative posirion of the final aburmern:s; nOtHdJective
sarn paste was applied tc all abutments for scannffw of the final case
(Etkon; Stroumonn.. Basel, Sl>t·iuerland).
Fig 35 Final design with zirccnio copings at sites 24, 25, 26 and 28. C".e-
romic m>een were to be odde.d in the loboratoty. The restotarion at site 27
was CUWJm-miBed after being designed as noted above.
F1g 37 Final dinicotvk wofthesingfe O'Ol'11S m sites Z4. 25, 26, Zl. ond Z8.
R. A.. levi.ni?
Fig 34 A resrorativrtlydtivm surdca/guide IOOJitated the establishme.nr d
appropriate emergence p<ofiles and impkmt depdls.
Ftg 36 Fmal restorotions in the maxillary posrerior segnents.
Fe 38 Ocdusol view ofthe final ourCQ'J'le.
m Treatment Guide· Volume S 117
6 Oinical Case Presentations
Fig 40 Final case at 12 months..
FJg 42 Completed case oneyear aft.er bone ougmemation using titarUum
mesh in the mondibufar anU?tior sextant TM> N0t1Z mm implants wete
placed to suppon a >unit fixed bridge using CAOCAM technology ond
custom zirconium abutments. Single aowns l>t'M' placed on 34 and 44..
Compare with Fig 1.
Treatment Outcome
The esthetic treatment outcome is shown in Fig 40. Hor·
izontal and lateral ridge augmentation had been com·
pleted 4 months previously using titanium mesh and
bone grafting. A fixed provisional 34 to 44 was placed
prior to GBR (Fig 41 ). The final restoration consisted of
single crowns on 34 and 44 plus a FOP from 33 to 43
supported by two NCx12 mm implants (Figs 42 and 43).
Onfy 5 teeth are present on the FOP due to a tooth arch-
size discrepancy.
Maintenance Phase
After completion of the maxillary case, an alternating
3-month protocol was instituted wjth the patient's re·
storative dentist and the patient's compliance history to
preventive care has been excellent.
118 fTI Treatment Guide • Volume S
Fig 41 Final rodiogro.ph ar 1Z monchs.
Fig 43 Fma/ rodiograph upon cas-e compJttion 1Z moMJrs atler mandibu-
lar ant.e.rior ridge nxonst1uction OJ'ld 19 mot1dts after completion of the
maxiliary kit: reconsf1UCtion.
Conclusion
A team approach to complex surgical-restorative cases
encourages proper sequencing of care based on a restor·
atively driven approach . This will facilitate appropriate
lhree·dimensionat surgical positioning of implants for
the desired esthetic outcome. The use of "new tech-
nologies» such as the ones applied in SLActive surfaces,
bone-level implants, piezoelectric bone surgery, pJasma-
rich growth factors (PRGF) and CAD/CAM-assisted pros·
thetics will ensure improved patient esthetics, morbidity
and patient outcomes.
Acknowledgments
Restorative Procedures
Or. Zola Makrauer - Private practice in advanced restora-
tive dentistry, Huntingdon Valley, Pennsylvania, USA; Fel·
low of the International Team for lmplantology (ITI)
laborat ory Procedures
Robert Burns, MOT - Benchmark Dental Studio,
Southampton. Pennsylvania, USA

6.8 SFE with C mp ~ite Graft
using a S~d Approach
P. Casentin i
A 58-year-old ma.n with missing teeth distal of 24 and 35
wa.s referred for treatment.
He reported a history of recurrent caries and endodontic
compliations as the reason for previous t ooth extrac-
tions. The patient's dental history showed no evidence of
periodontaJ disease and bruxism. He complained about
inadequate chewing ability and was dissatisfied with the
esthetics of his smile. His desire was to have the eden-
tulous areas rehabilitated in a st:able a.nd comfortable
fashion.
The patient did not have any systemic diseases. was not
on any medication, and did not smoke. An extraoral in-
spection revealed an edentulous area in the left dist.al
aspect of his smile. lntraoraJly, partial edentulism was
noted in the maxillary left posterior segment distal to
tooth 24. The left mandibular molars were also missing.
lntermaxillary relations were normal in the edentulous
areas, as was the interarch distance (Fig 1). Also, the
edentulous ridges were foun d to have a favorable shape
with a rounded profile.
P. Casentini
Tooth 35 had been restored previously with a me-take--
ramie crown, which was inadequate in terms of esthetics
and fit. While the residual dentition presented some ves-
tibular gingival recessions in both jaws, the periodont:al
tissues were healthy. There were no signs of inflamma-
tion or pathology on probing. Occlusion was normal in
the right side of the mouth, with the dentition extending
to the second molar.
Oral hygiene was considered adequate, even though a
slight modification of the brushing technique was sug-
gested to arrest progression of the bucc.;il recessions. No
pathology of the oral mucosa could be diagnosed. The
patient was considered to have realistic esthetic expec·
rations.
Preliminary periapical radiographs dis.closed adequate
bone height in the left distal mandible, the presence of a
pneumatized sinus, and inadequate bone volume in the
left dis1<1I maxilla (Fig 2).
Fig 2 Prefiminory rodiogroph bdxe aearmenr. The reiiduol bone volume
m
dKI nOl attcw fOr implant placement the posterior maxilla.
m Treatment Guide· Volume S 119
6 Oinical Case Presentations
F-igs 3 and 4 ~c tadiopaque sttnts M'IE' obtained from a wax-up.
Treatment Planning A computed tomography (CT) scan was prescribed to ver-
ify the bone volumes and the condition of the maxillary
In accordance with the patient's request, an implant- sinus. During the scanning procedure, the patient was
supported fixed rehabilitation was planned to replace asked to wear diagnostic stents. The CT scan confirmed
the missing teeth in the maxi lla and mandible. It was both that the bone volume was inadequate for implant
decided that a rehabilitation extending to the first molar placement and that the maxillary sinus was healthy. The
would offer adequate esthetics and occlusal function. residual bone was considered insufficient to achieve pri-
mary implant stability (Figs Sa·b and 6a-c).
A wax-up of the planned rehabilitation was obtained
from mounted casts, and a stent including radiopaque
teeth (barium sulfate) was fabricated (Figs 3 and 4).
F-igs Sa-b A CTscan yielded useful detaits about the sinus an~.
I,, -
FJgS 6o< CTscans confirming that the sinus was heaftJry and ptcNiding a basis to simulate implantploce.ment aim sinus floor elevation with dedicated
computer software (Simplanr; Materialise., Uuvm, Belgium).
120 fTI Treatment Guide • Volume 5

Figs 7a-b A scroper was used to obtakl some atttotogous bone chips from the distal area ofrhe mandibular impkult site.
Based on the clinical and radiographic situation, the fol-
lowing treatment plan was proposed to the patient:
Placement of a single implant at the site of the
mandibular left first molar_
Sinus floor elevation in the posterior left maxilla,
fo llowed by delayed placement of two implants at
the sites of the second premolar and first molar.
Prosthetic rehabiliuition using a two-unit restoration
in the posterior maxilla and a single implant-sup-
ported restoration at site 36 associated with a s ingle
crown on tooth 35.
P. Casentini
The patient accepted the treatment plan and gave his
informed consent.
First surgical stage. local anesthesia was administ ered
and. since implant surgery in the mandible was expected
to be uncomplicated. sinus floor e levation was carried
out during in the same session. In this way. aut ologous
bone chips could be haivested with bone scraper distal
to the mandibular site (Figs 7a-b). Mandibular implant
surgery was completed by insening an implant (Strau-
mann SLActive Wide Neck 6.S mm, 0 4.8 mm, length
10 mm) (Figs 8a-b).
m Treatment Guide · Volume S 121
6 Oinical Case Presentations
A crestal incision, including venical releasing incisions, The sinus membrane was then gently elevated with hand
was extended to the tuberosity area in order to access instruments reaching the medial wall. and as the lateral
the lateral sinus wall. Since the periodontal status of the window was extended mesially to allow for better conttol
adjacent premolar was optimal, a para-marginal incision in that area (Fig 11 ). No perforation of the membrane
not involving the gingival sulcus was selected. Prior to was identified, cind the membrane continued to exhibit
establishing access to the sinus, the same scraper was normal movements during breathing.
applied once again to collect more autologous bone
chips from the lateral wall of the maxilla (Fig 9). The
lateral window was outlined with a round di-amond bur
(0 3 mm) mounted on a right-angled handpiece at a
spe<!d of 20,000 rpm (Fig 10).
Fig 10 Desf:n of the lateral window arowJ in Che maxmoty sinus wall.
Fig 11 Eleva.tion of the membrane ofter mesial extension d me mesial
window.
122 fTI Treatment Guide • Volume S

A composite graft including autologous bone chips and
DBBM (Bio-Oss; Geistlich Pharma, Wolhusen, Swiuer-
land) was prep.ared and then inserted into the sinus (Figs
12a·b and 13a). Autologous bone chips were considered
an imponant part of the mixture, as they are expected to
accelerate bone regeneration and the osseointegration
ofDBBM granules in widely pneumatised sinuses.
The lateral window of the treated sinus was sealed with
a coll,agen membrane (Bio-Gide; Geistlich Pharma. Wol·
husen, Swiuerland) (Fig 13b). Moreover, tension-free clo·
sure of the flap was obtained through s ingle interrupted
5-0 polyamide sutures (Fig 14).
Figs 11a-b The ffltft was inserted into the sinus andproceaed with o o:>llQHEn membtane.
Fig 14 A cens.io(Hree suture was obmined.
P. Casentini
A periapical radiograph confirmed adequate elevation of
t he sinus floor and a uniform radiopaque aspect of the
graft (Fig 1 S). The patient was prescribed antibiotics (for
6 days postoperatively), non-steroidal anti-inflammatory
drugs and chlorhexjdine mouth rinses for 10 days. He
was also instructed to avoid blowing his nose for the fi rst
few weeks after surgery.
When the sutures were removed after 10 days, t he pa·
tient reported no significant symptoms other than mod·
erate swelling.
ITI Treatment Guide · Volume S tB
6 O in ical Case Presentations
Second surgical stage. The maxillary implants were
scheduled fo r placement after a 6-month period of un-
eventful healing (Fig 16). The same surgical access was
selected, although flap reflection was reduced compared
to the first procedure. A restoratively driven approach
was take-n to prepare the implantosteotomies, using the
same radiopaque guide that had been used for diagno-
sis and obtained by the d iagnostic wax-up. One standard
implant (Straumann Regul.ar Neck 4.8 mm. 0 4.1 mm.
length 10 mm) and one wide-neck implant (Straumann
5LActive Wide Neck 6.5 mm, Iii 4.8 mm, length 10 mm),
Fig 16 Ginicof view aftEY' 6 months ofuncompficated heating.
were selected to obtain appropriate emergence profiles
for premolar and molar units (Figs 17a·c).
Implants featuring a (highly osteoconductive and rap-
idly osseointegrating) SLActive surface were selected
because there was a need to expedite osseointegration
and to minimize the risk of failure. These requirements
are considered particularly important in t ime-consuming
rehabilitations involving multiple treatment steps. Both
implants achieved good primary stabillty.
Polyamide sutures (6-0) were used to bring about accu·
rate adaptation of the soft tissue structures to the ma-
chined implant collars for transmucosal healing (Fig 18).
FJC 18 ~ completion of ucmsmucosal impklm plocE'ment 6-0 poJy-
omkle sutures wen:> used for soft tissue adaptation.
124 ITI Treatment Guide- . Volume S
 P. Casentini 6 O in ical Case Presentations

Restorative procedures. The clinical appearance after

8 weeks indicated healing of the s.oft tissue and os.-
seointegration of the implants (Fig 19). Now the final re-
habilitation was initiated by attaching snap-on Synocta
transfers and taking a closed-tray polyether impression
(Figs 20a-b). The same visit Y1as used to check the pa-
tient's occlusion and to obtain a bite record with the op-
posing arch. Bite registration devices relined with a self-
curing resin were used to record the opposing arch at
implant sites (Figs 21a-b).

Fig 19 Clinia:N view after 8 weeks. indiarting healing ofthe perJ.implanr

softris:sues.

Figs 2'0a-b Impress.ion-taking with Synocta sn~ rransfm and a polytther maten·a1 in a dosed troy. FJES Z3a-b Final restorotions on the master cast before deiiwry.

lnteratch bite registmtion.

The dental laboratory selected appropriate implant abut- Subsequently, the case was sent back to the dental labo-
ments (straight Synocta abutments for cemented restora- ratory fo r ceramic veneering of the final gold-ceramic
tions) and prepared the metaJ frameworks for the defini- restorations (Figs 23 a-b).
tive rehabilitation. An intraoral try-in was performed to
obtain clinical and radiographic verification of both preci-
sion and passivity, and another bite record was obtained
with a small amount of self-curing resin (Figs 22a-b).

ITI Treatment Guide · Volume S 125 126 ITI Treatment Guide- . Volume S
 P. Casentini 6 O in ical Case Presentations

The patient's smile did not display any black triangles

and was considered adequate (Fig 26).

Follow-up visits and professional maintenance sessions

were scheduled every 6 months. Radiographic follow-up
examinations took place once a year.

After 2 years. the peri-implant areas revealed neither

signs of soft tissue inflammation nor signs of bone re-
sorption {Figs 27a·b). The patient was perfectly satisfied
with the esthetics and function provided by his implant·
Figs 24a-d lnttaoraloppeara.nce of the final testorutions after delivery. Fig 26 Exttoorol w'ew ofthe patient's smile.
supported rehabilitation.

Acknowledgments

laboratory Procedures
Carlo Pedrinazzi, Roberto Colli - Milan, lt.aly

FJZS 27a-b GirikaJ and radiogrophjc follow.up after 2 years.

At delivery of the final rehabilitation, precision and occlu-

sion were checked again, titanium abutments were tight·
ened to a 35 Nern torque, and the implant-supported
restorations were cemented with a non-euge-nol cement
based on an acrylic-urethane polymer (lmplacem; Oen-
talica, Milan, Italy) (Figs 24;rd). The crown on the natural
abutment 35 was cemented with a glass-ionomer defi ni-
tive cement. A final periapical radiograph confirmed cor-
rect adaptation of the definitive restoration (Fig 25).

ITI Treatment Guide · Volume S 127 128 ITI Treatment Guide- . Volume S

6.9 CQmbined SFE andlJorizontal Rid~
Augmentation with Autologous Block
(}rafts,,_ BCP.:. and (~BR usin_g a Stag.eel
Ap_proach
L. Cordaro
Various patterns of alveolar bone resorption are known
to occur in the posterior maxilla. Follo\Ying tooth loss,
resorpt1on may take a buccopalatal direction. resulting
in a narrow ridge displaced toward the palate. Resorp-
tion may also proceed vertically in an apical direction,
reducing the vertical dimension of the ridge and increas-
ing the interocclusal space. Another common pattern of
atrophy is caused by volume increases of the maxillary
sinus, which will reduce the residual bone volume in an
o-cclusal direction due to downward displacement of the
sinus floor. Most cases are characterized by combined
defects, leading to a variety of atrophy configurations.
Whenever t here is a grea.ter need for augmentation than
elevating the sinus floor with an inlay bone graft, hori-
zontal and vertical augmentation of the residual ridge
may be accomplished by intraoral harvesting of autolo-
gous onlay block grafts in the same surgical procedure.
We refer to this procedure as 1'inlay-onlay" grafting of the
posterior maxilla.
With this approach, the reconstruction is carried out 4 to
6 months before implant placement. During the recon-
su-uctive phase, the posterior maxilla is approached with
a wide mucoperiosteal flap designed through a crestal
incision and two vertical releasing incisions.
The same technique of elevating the sinus membrane
is used a.s in any sinus floor elevation . Either the trap-
door technique may be adopted, or a window may be
designed to remove the lateral sinus wall. Bone harvest-
ing is not commenced before the sinus mucosa has been
elevated and the clinician has confirmed the need for a
horizontal or vertical onlay graft.
LCordaro 6 O in ical Case Presentations
The occlusal and lateral views (Figs 2 and 3) demon-
strated the horizontal deficiency that was observed at
the firs t visit . The patient was informed and scheduled
for sinus floor elevation. He was also info rmed that an
onlay procedure might be necessary and that autologous
bone may be harvested from the mandible during the
procedure.
Fig 1 Orthopontomogram clearly illustratin£ tha:r the sinus was pneumo--
tized. Me9af to the residual second mo/ac verricai resorption of the al-
veolar ridge in an ocdusoapical direction was noticed. This radiographic
technique did not yield any intormation abocr! the horizontal dimension
Generally, the ram us is chosen as donor site, but t he man-
ofthe residual ridge.
dibular symphyseal region may be used when a need for
a large graft in the inlay procedure is anticipated. In this
event, screws are employed to secure the bone blocks to
t he recipient site, while part of the graft is milled and
used in particulate form to fill the space beneath the
elevated sinus membrane.
Depending on the clinical situation, bone substitutes
may be added and covered with a resorbable membrane.
In some situatjons, the clinician may choose to mix the
selected bone substitute with the milled autologous
bone for sinus grafting.
The flap is released and sutured. Implants may be placed
after 4 months if the inlay graft is made of particulate
autologous bone, or after 6 months if a bone substitute
was added to the autologous bone. Implant loading \viii
usually take place 8 weeks after implant placement.
A clinical ca.se is presented to illustrate t he surgical pro-
cedures. A 41-year-old man was referred for treatment
of his partially edentulous right maxilla. He wa.s a non-
smoker. Teeth 17 and 13 were present. Teeth 14. 15 and
16 were missing. The canine was intact. and the second
molar had an amalgam filling. Oral hygiene was inade- Fig 2 Ocdusol view ofthe edentulous area. A horizomol bone dd'ect was- Fie 3 Lateral view confirming the horiZ«ltal defecr and reveaf'ifle a srig1n
quate. A panoramic radiograph \vas obtained and clearly 011tkipated. verrio:zl de.ficiency. Soft tissue conditions (quafity ond quarttity) were ideal
revealed a vertical bone deficiency at the molar and and expected to be beneficiol fot the planned surgicaf procedures.
premolar sites :(Fig 1). The sinus floor required elevating
and grafting fo r implants t o be placed. The clinical situ-
ation suggested that a horizontal deficiency was present
in the area of the first and second premolar.
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 LCordaro 6 O in ical Case Presentations

Surgery ·Nas carried out in an outpatient setting under Part of the graft was milled and insened below the sinus Bone substitute cons1st1ng of biphasic calcium phos·
local anesthesia. Continuous sedation was not planned. membrane (Fig 7). The remainder was divided, securing phate (Straumann BoneCer.;imic; Straumann, Basel, Swit·
as the patient was very cooperative. The procedure start· two block grafts to the recipient site to achieve horizon· zerland) was added at the periphery of the block grafts
ed by elevating a wide flap. A cre.stal incision line was tal augmentation (Fig 8). On ly one lag screw 1.5 mm in (Fig 9) and covered with two layers of collagen mem-
used and continued into the gingival sulcus of adjacent diameter was used for each piece. brane (Bio-Gide; Geisdich Pharma, ~"t'ol husen, Switzer-
teeth. Mesial and distal vertical releasing incisions were land) (Fig 10). The flap was then mobilized with the aid
performed; the me-sial incision was placed immediately of periosteal horizontal releasing incisions and closed
distal to the canine to reduce visibility of the resulting with interrupted sutures (Fig 11).
scar. The lateral surface of the maxilla was exposed, and a
bony window was opened with a round bur {Fig 4). Once-
the access osteotomy had been completed, the bony
window was removed, bringing t o light an intact mucosa Fig 4 Acress ro die edentulous area was go.ined tfl1'oueh a fuN-thickness
of the maxillary sinus (Fig 5). flap with mesia/ and 6stal verrkaf releasing fucision:s and a mitJ.crestal
;ndskJn. The residual aes:. ~With was between 2 and 3 mm.
The sinus membrane was carefully elevated. At this point.
it was confirmed that a three-dimensional re-construe·
tion was needed, including horizontal ridge augmenta·
tion and sinus floor elevation. Bone was therefo re har·
vested fro m the right mandibular ram us using a standard
technique (Fig 6).

Fig S Access co che sinus nJembtane was established ofter remo!IOI of the Fii! 8 The block was divkled in two and grafted co ac/lin-e horizontal and
bony window. The mtaa sinus mJJC(l$(1 is clearly visible. ~rticol augmentation (onlay if!UftJ. The blocks it't'te stabilized <Ner tlle
residual ridge with titnnit1m screws 1. S mm in diameter.

Fig 6 Harvestine ofa bone block from the mandlwlar romus. The cortical Fig 9 The bone substitute was rhen added at the periphery ofthe. block Fie 10 Two layers of a col.lagen membrane were used to cover rhe com-
block ts outlined and is ovr·froaured. A«ess to the mandible was achieved grafts. posite reconstrucrion.
throCJBh o mucosoJ incision 3-4 mm away tiom the mucogingivo.f line.

Fig f 1 ~iosteaJ releasing incisjons allowed for repositioning ofChe buc·

col flap, l'lflich was stab;JUOO with interrupted sutures.

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After 4 mont hs of uneventful healing, the case was ready
fo r the second-stage surgery, including removal of the lag
screws and implant insertion (F"ig 1 2). A panoramic radio--
graph was obtained to evaluate the outcome of the graft-
ing procedure (Fig 13). The vertical-in lay bone graft was
Fig 13 Radiog-aph obt:a"1ed befOfe the second-stage ;nretVeJJtion. E/..
mttion of the sinus floor is et.'ident and the venicol bone reconstruction
achievr:d in a coronal direction is clearly visible.
LCordaro
visible, and the block grafts with t he stabilizing screws
were found to have remained in place. The clinical views
indicated t he amount of bone reconstruction achieved
at this stage (Figs 13 and 14).
Fig 12 Clinicot view 4 months after reconstruction and immediately prior
to implant Sl.ltgety (stfJCe 2).
ITI Treatment Guide · Volume S
6 O in ical Case Presentations
Fig 15 A flap was ra.ised to expose lhe smws and the reccnsuucted ridge. Fie 16 After retr.owt ofthe sctews, the implant sites M-'t'feprepared Direc-
Suffkie.nt wickh was miaifab/e to ploce one Standard implant and one Wide tion indianors !Or me 2.2-mm pilot drill were used here to demonstrate
Ned< implant ridge width.
Fig 17 A stJJndard implant (itraumann Reppktr Neck 4.8 mm, 04.1 mm..
length 14 mm) i.m placed at the site of the first premolar. and o "'*le-neck
impfant <Strotimann Wide Neck. 6.5 mm. 0 4.8 mm. length 10 mm) ~'Q'S
rltSl
plottd at the sit.e ofthe. molar.
Second-stage surgery (Figs 15 to 18) included a smaller The hole of the removed Jag screw was clearly v;sible,
flap, with only a smalJ vertical distal releasing incision, and the grafts were excellently incorporated in the recipi-
to expose the reconstructed alveolar crest. The amount ent bone. A transmucos.aJ technique was employed, and
of horizontal bone augmentation was clearly visible at the mucosa was adapted to the implant healing caps and
this stage. There was minimal graft resorption, as dem- sutured.
onstrated by the level of the lag screws in relation to the
bone surface. One wide-diameter implant (Straumann
Wide Neck 6.5 mm, 0 4.8 mm. length 10 mm) was posi-
tioned at the site of the first molar. One standard implant
(Straumann Regular Ne~k 4.8 mm, 0 4.1 mm, length
14 mm) was placed at the site of the first premolar.
1H 134 ITI Treatment Guide- . Volume S

Fig 19 Rodiogfaphk view ofrhe final t estomticn ;n pface.
A three-unit fixed partial denture was delivered 8 weeks
later. Both the occlusal view of the abutments and a
panoramic radiograph demonst rat ed the success of the
three-dimensional reconstruction (Figs 19 to 21).
LCordaro 6 O in ical Case Presentations
6.10 Sf'f' with Particulated Aut rafts
(,ombined with Vertical Ridge
Augmentation using_ Onlay Block Grafts
and Stag..ed Approach
W. D. Polido, E. Marini
Fig 20 Fmal restororion. ~nit fixed partial denture on two implants
and nicely suppotted by the. surrounding hard and soft Ussue struaures..
The crowns exti;bited a normal vertical dimension.
A 44-year-old man presented mainly because his com-
plete denture in the maxilla was unstable and to get an
opinion on a previous surg:ical reconstruction. He had
worn a complete denture since he was 20 years old, fol-
lowing extraction of his entjre dentition . His desire for
treatment had led him to undergo bone grafting from
the iliac crest, performed in a d ifferent oral surgery clinic
around 1 year previously. Unfortunately, this treatment
had failed because numerous technical issues involved
in a surgical procedure as complex as this one had not
been adequately observed.
Acknowledgments
Fig 2 CTSC'lll'I before tile firstgrafting treatment failute.
Restorative Procedures
Dr. Vincenzo Mirisola - Torresanto, lt<lly
Laboratory Procedures
Massi mo Corona, CDT - Eastman Dent.al Center,
Rome. Italy
Aristide Ficuciello, CDT - Eastman Dental Center,
Rome. Italy
ITI Treatment Guide · Volume S 13S 136 ITI Treatment Guide- . Volume S

Despite this experience. the patient was determined to
wear a maxillary fixed denture and therefore sought fur-
ther treatment. He \vas in good health and did not smoke.
Pretreatment panoramic radiographs and CT scans had
been obtained before the previous surgical procedure.
The panoramic radiograph obtained at baseline showed
complete pneumatization of the sinuses and a lveolar at·
rophy in both maxillary posterior segments (Fig 1 ). A CT
scan obtained prior to the first treatment fai lure aimed
at bilateral sinus floor elevation and anterior onlay graft-
ing had confirmed this pretreatment situation (Figs 2 to
5). Clinical views from that time were not available.
Fig 4 CT scan before the first grafting ueatment failure (maxillary left
posterior segment} showing .m-ere atrophy.
W. 0 . Polido. E. Marini
Fig. 3 CT scan befOre the first grafting trea".ment failure (axial view}.
Fig. 5 CT scan before the firs: grafting ueatment f(Jjture (max.iilary dght
posterior se.gmentJ.
ITI Treatment Guide · Volume S
6 O in ical Case Presentations
Fig 10 Ocdusal view at baseline. Nore the \'Ol!N71e d'bone placed during
the failed grafting ott.empL
A clinical examination was performed, revealing a com·
plete denture in the maxilla that was relined with a soft
tissue conditioner and offered a poor fit and poor oc-
clus.al stability. The residual dentition in the mandible
(48145 and 43- 34) presented with old restorations (Fig 6).
137 138 ITI Treatment Guide- . Volume S
Fie 7 Anterior viiew with the maxiNary denture 1emowtd.
F11 9 ldt lateral \liew. A prevkius attempt at bone f7tl/tinc had fiJiled. A
Chiapasco dass H three-dimensional frnerardl relatiooship was obsm-e.d.
On removing the denture, the a lveolar crest was found
to involve irregularities due to incorrect positioning of
the bone graft in the previous procedure. Occlusal and
frontal views were obtained, revealing that the bulk of
the graft had an excessively apical position toward the
buccaJ vestibule. A scar \vas observed in the alveolar
sulcus. possibly resulting from a sukular incision with
flap elevation performed from the apical to the alveolar,
which may have limited the surgical field and led to poor
adaptation of the graft (Figs 7 to 10).
 W. 0 . Polido. E. Marini 6 O in ical Case Presentations

A large interarch distlnce was noted. compounded by the A new surgical intervention was proposed. aiming to re·
absence of teet h in the posterior mandible. The case was construct the atrophic maxilla with a special focus on
clossified as Chioposco Class H (Chiopasco et ol. 2008). the sinus grafts. Difficult ies were anticipated. consider·
ing that these areas had been subjected to surgery previ·
New panoramic ra.diograp hs and CT scans were ordered. ously.As it was expected that the sinus membrane would
A fe\v issues were noted at this point (around 12 months rupture. coverage with a resorbable membrane was
after the previous grafting attempt). The panoramic view planned in conjunction with autologous corticocancel·
revealed that fixation screws were placed in an aITT:nge- lous bone (blo<k ond ponicles) horvested from the iliac
ment that would not allow for rigid stabilization of the crest.
grafts. Filling of the sinus areas with the bone graft was
less than opt imal, including areas of low-density bone Under genera l anesthesia, corticocancellous bone \vas
(Fig 11). harvested from t he anterior iliac crest in the form of a
Fig 16 Ocdusa/ surgjco/ view. Note that the fixation SCl't'M IKl'Stfy protrlJd.
ed from the bone. The incision line M'OS locatedpalatal to the allledar crest. block and curetted cancellous chips.
The CT scan of the posterior maxilla revealed that bone
w;as irregularly distributed in the sinus cavity (Figs 12 In the meantime, the maxilla was exposed by extend·
to 14). As a possible explanation, the sinus membrane ing a palatally shifted crestal incision from tuberosity
may have been elevated inadequat ely and, t hus remain- to tuberosity, including a midli ne releasing incision. This
ing a ttached to the palatal wall. Another common cause configuration allows for better vascularization of the
of irregular bone formation is failure to deliver enough flap (according to anatomical studies by Kleinheinz et
bone and to compact it against the anterior and palatal al. 2005) and optimizes vision of the alveolar crest in
walls, thus causing problems with implant placement in both the anterior and posterior segments. The flap \vas
the grafted sites at a later stage. reflected from the crest al toward t he apical, extending it
Fig 12 CT scan after fhe first. grafting treorment bilure. as far apical as possible to the subperiosteal level with·
Jn the anterior region, the bone block completely lacked out damaging the infraorbital nerves. This maneuver will
adaptation, giving rise to interposition of soft tissue be- render the flap more amenable to mobilization and re·
tween t he graft and the maxillary anterior wall (Fig 1 S). positioning, t hus eliminating t he need for extended pe·
Fig 17 Anterior surgical view. Note the lack ofcontaa between the block
on the left side ond the bufk ofbone ma/positioned on the rif/lt side. riosteal releasing incisions in achieving wound closure.

Exposing the anterior maxilla revealed that the anterior

grafts hod been completely molodop1ed (Figs 16 ond 17).
After perforating and rupturing the sinus membrane
(Figs 18 and 19), • round #6 diomond bur wos used to
open a large window for bener evaluation of the sinus
defec-t. The membrane had already been perforated, and
the remaining portion was carefully released and efev;at·
ed on bot h the vestibular and palatal aspects to open the
site for the new graft. A communication of the alveolar
Fig 13 CT sarn after the first grafting treatment failure (axial view). Nore area with the sinus was noticed on the left side (Fig 20).
the posterior horizontal defic.iency.

Fig 18 Anterior \.'few to/lowing removal ofthe screi.s and loose bone frog.
ments. Note the sinus window openinc on the left

Fig 14 CT scan of the maxiNary right postaior se,sment. Not€ the poor Fig 15 CT sam of the maxiNary felt posf.erior ~t. Inadequate gfaft
ado.pt.arion of the bone graft inside the sinus, possibly due to ;nad€quate positioning on me sinus. Fig 19 Window crear€dto the left mus. Note the elevated sinus mucosa. FJC 20 Window to the felt sinus, whjch comm!lnf.
elevation ofthe sinus membrane or ;nadeqoote compaction ofbone. lttlich had been perforated in o distal and upwwd direction. cat«J with the oral cavity on the pafatal side of the
alveolar bone.

ITI Treatment Guide · Volume S 139 140 ITI Treatment Guide- . Volume S

Fig 11 Window co the r~t sinus. The resorbable membrane was used
ro pror.«t the petforated mucosa. On the lower aspect. an overhang wm
left to the outside ofthe sinus window. Cancellovs chips had already been
positioned on the anterior aspect..
Fig 23 Latem! and ver6ca/ ausmemation with a cortkoconcelfous fll«t
over the left: sjde. The sinus ..us already filled l'lith cnncellous bone and
protected with a resorbable membrane o~ the apic:JI. distal. and palatal
aspectt_ An l ·shoped block was adapt.ed. with canttllous bone toward the
iidge and cortical bcne to the bu«a/ aspect.
After removal of the anterior screws and loose fragments
of the remaining bone. the anterior maxilla was cleaned
until it was free of debris. Decorticalization of the ante-
rior bone was performed with a #1/4 round bur under
copious saline irri~tion .
A resorbable membrane (Ossix; Biomet 3i, Palm Beach
Gardens, Florida, USA) was placed to contain the grafted
bone in the posterior segment. In addition, a piece of the
membrane was placed against the bone on the palatal
aspect and covered by the local periosteum at the s it e
of communication between the oral cavity and the sinus.
The corticocancellous part iculated graft from the iliac
crest was prepared and packed into the maxillary sinus
cavity. A cesorbable membrane was used to cover the
graft apically and palatally, thus preventing particles
from dislodging into the sinus cavity.
W. 0 . Polido. E. Marini 6 O in ical Case Presentations
Fig 12 Sinus • ·indow, compltteJy fitled Bone was positioned level with Fig 2S 8vcrol \'Jew 6 months aftet graftif'/£.
the anterior block lateral to the w.indow. Both groft:s were covered with a
resorbabie membrane.
The patient remained without a restorat ion for 4 weeks. A clinical examination performed after 6 months re-
After removing the suture, an impression was aken and vealed an excellent contour of the reconstructed ridge in
a new temporary complete denture fabricated. Adhesive the vertical and horizontal planes (Figs 25 and 26). A new
paste was nee<led to stabilize t he denture. Healing was CT scan was ordered, using a radiopaque- stent to identify
uneventful. No graft exposure or infection was observed. the most appropriate sites for implant placement.
Every 4 \Veek.s. the patient was seen to monitor the
progress of mucosal/bone healing and t o adjust the den-
t ure as needed to avoid compression of the graft.
Fig Z4 Final view ofthe lateral and horizontal leftgraft after stablization
with fixation settM. Note the low position of the .screws to st.abilize the
block over the sinus window in the residual afveolat bone.
A corticocancellous block was us.eel to gain vertical and
horizontal bone volume in the anterior maxillary seg-
ment. The block was sculpted to the shape of an L. adapt·
ed. and stabilized with titanium screws. Another piece
of t he corticocancellous bone block was placed laterally
and vertically over the sinus window. fo llowed by s"tabi-
lization with screws in the most anterior region (Fig 19).
On the right side, a corticocancellous particulated graft
was placed horizontally and verticalty outside of the
filled sinus window, and a resorbable membrane (Ossix;
Biomet 3i, Palm Beach Gardens, Florida, USA) was used
fo r protection (Figs 21 to 24).
Closure of the wound was achieved \\lith 4-0 vicry-1 for
interrupted mattress sutures, also using a periosteal re-
leasing incision.
ITI Treatment Guide · Volume S 141 142 ITI Treatment Guide- . Volume S
 W. 0 . Polido. E. Marini 6 O in ical Case Presentations

Fig 28 CT scan 6 months after grafting and prior to implant placement.

fie 33 Anterior view during ;mp1anr surgery. Nole rhe membtane frag-
ment on the riQ:t side.

.~~.•.~j.~·
•M
. 'ij...:~:t.J':~i.....:;1'; ~-
I

~10
'

• tO
.

•io ~
~

•. 1..••• f •• 1..• •, • .. 1..... . .. 1..•••~

):. :~·~ l :~· •• . ~ .. :,.\. J~

·~ V· ~at> y -~ ~ ·• \:'
,,. t . I

l-10
•

~ to
Fig 34 Ocdusal view du.line implant surgetJC Note the comprehensiw atJ.- Fii! 35 Gose-up vkw ofthe grafted window ;n the right sinus. Fragments
Fig 29 CT scnn after grafting (axial view). Note the lateral ougmentation Fig 30 CTSCOl'I 6 months aftet ' (maxillary kft posr.erior
grofting
' segmend.
apcarion of rhe grafts. L.ow mnodeling oflhe gait (as determined by the
distance from the fixation screw head) was obsenW.
ofthe membrone ate still visible.
in the posterior maxilla. Note the excetlent adapwtion with bone flit in the sinus-floor area and
good bone density.

The CT scan showed excellent bone healing and 30

volume, allowing for optimal positioning of the im-
plants {Figs 27 to 31 ). Implants were planned at sites
1611411 311 1/21/23124/26 to allow rehabi litation with •
fixed dental prosthesis, to be delivered as four segments,
each spanning t hree units.

Fig 36 Close-up view of the grafted window and the horizorttol/verrk1JI

block flult in the left sinus.

Fig 31 CT scan 6 months after gral'tiJw (mari/lary right posterior set·
ment). N«e the exce!fent adclptation •·ith bone fill in the sinus-floor area
and good bone densfty.
The following implant type was selected: Straumann Ta-
pered Effect, Regular Neck 4.8 mm, 0 4.1 mm, length
10 mm, featuring an SLA surface. Different implants
were only used at sites 16 and 26: Straumann Wide Neck
TE, Regular Neck 6.5 mm, 0 4.8 mm, length 10 mm.
Surgery for implant placement was conducted with lo-
cal anest hesia and inuave-nous sedat ion. A restorat ively
driven surgical guide was used (Fig 32). A palatally shift-
ed crestal incision W<lS made to place thick mucosa to
the buccal aspect of the implants during wound closure.
Ocdusal and buccal views showed adequate bone height
and width, wit h minimal resorption obse rved along the
distance from the bone to the fixation screws, Fragments
of the resorbab!e membrane were visible on the left side
(Figs 33 to 36).

ITI Treatment Guide · Volume S ,.. ITI Treatment Guide- . Volume S


Fig 37 Ocdusal viewofthe maxilla with the implant sites. Note rhe vitality
ofthe bone.
Standard protocols we-re used to conduct the osteoto-
mies and subsequent impl.ant procedures. Excellent bone
density with good primary was noted and was improved
by the shape of the (Straumann Tapered Effect) implants
used. Complete closure of the implants was performed
(Figs 37 and 38).
The implants were exposed under local anesthesia 70
days after placement. Th is was followed by t.aking im·
press ions (2 weeks 1.ater) and delivering a provisional seg·
mented prosthesis (another 2 weeks later) (Fig 39).
W. 0 . Polido. E. Marini
Fig 38 Ocdusal view during implam surgery. Imp/ants were placed at sites
16114113111121113124126.
Fig 40 View ofthe patient's smile Mith the final restorations 2 years after
lood;ng.
Fig 42 Ocdusa/ view ofthe final restororions 2 years ofter loading.
After 60 days of using the provisional prosthesis to al·
low for bone and soft tissue remodeling and occlus.al ad·
justments, the fin.al metal-ceramic restoration of a fixed
dental prosthesis in four segments spann ing three units
e.ach, was cemented to solid abutments.
Different views of the fina l restoration are provided here,
including the patient's smile line (Fig 40), a buccal view
(Fig 41 ), and an occlusal view (Fig 42) taken 24 months
.after loading. Figure 43 displays a panoramic !'<ldiograph
obtained during the same time.
ITI Treatment Guide · Volume S 145
6 O in ical Case Presentations
Figures 44 and 45 represent a panoramic radiograph and
a buccal view obtained 5 years after loading. Note the
discrete bone remodeling in the cervical implant regions
and the small vertical bone loss between the implants at
sites 23 and 24.
In discus.sing the outcome achieved. vie suggest that a
number of factors may influence the outcome of large
bone grafts in severe bone atrophy.
Correct incision design and flap management will im·
prove visualization. closure, and vascularization.
The need for a resorbable membrane to cover the
sinus window and the anterior blocks will promote
healing of the graft. If the sinus membr.ane gets per·
forated, it is used to protect the graft internally.
Perfect adaptation of the block graft is needed be-
cause it will improve healing with Jess resorption.
Complete filling of the sinus fl oor with good compac·
cion of the conicocancellous chips may also improve
healing and result in gre.ater bone density.
Tapered implants (Straumann Tapered Effect) will
optimize primary stability. However. the large cervi·
c.al surface may enhance bone resorption in that
region . Today we suggest the use of Bone level
implants for this indication, as they offer a primary
stability th.at is sim ilarly excellent to Tapered Ef·
feet implants while featu ring a more bone-friendly
interface at the implant neck. which m.ay result in
less resorption and better bone stability .around the
cervical region.
Acknowledgments
Prosthetic Procedures
Joao Emilio Roehe Neto - Porte Alegre, Br.azil
146 ITI Treatment Guide- . Volume S
 S. Umanjec·Korac 6 O in ical Case Presentations

6.11 Bilat ral SFE iI1 th_g f!:dentulous Maxilla

witl1 DBBM using a Staged Approach
S. Umanjec-Korac

Fig 2 Anterior view ofmaximum interws.pation. Note the moxilkJry den--

ture and the shortened occtusaJ line in the mandible with ptOtJOunced out·
growth of the lower indsars.
A heafthy 56-year-old woman was referred to our Depart·
ment of Oral lmplantology for complete rehabilitation of
both jaws. She was a non·smoker and requested being
treat ed with fixed restorations. The patient was d issatis·
fied with her appearance. particularly with the excessive
length of her mandibular dentition.

Her dental history was e.xtensive. Over the previous 20

years. she had undergone periodontaJ and onhodontic
ueatment but also onhognathic surgery to advance the
mandible.
Fig 1 Baselinepanoramic nxfjograph. Note the endodorrtiatllytreated ca- F1g 4 Baseline latetal view (1dt side).
Clinical examination revealed good oral hygiene. The pa· nfrle.S. the y,WJe sinuses. and the inadequate vetticol dimension for imp/am
tient wore a maxillary denture" and the roots of t eeth placement distal to the atnines.
13 and 23 were endodontically treated. Panoramic ra-
diographs were obtained, indicating pneumatization of
the sinuses and an inadequate vertical dimension of the
alveolar process distal to both maxillary canines {Fig 1).

Fig 5 Ocdusal view ofthe maxi/kl ar initial presentation.

The mandibular dentition showed pronounced hyper-
eruption. Only one-third of the periodontal attachment
remained. The anterior teeth had been splinted to re·
duce their mobility (Figs 2 to 5).
Several factors need to be considered and evaluated
before implant·supponed fixed rehabilitations in the
edentulous m~xilla can be proposed. A diagnostic wax-
up is useful in evaluating the smile line, lip suppon, and
interarch space.

ITI Treatment Guide · Volume S 147 148 ITI Treatment Guide- . Volume S
 S. Umanjec·Korac 6 O in ical Case Presentations

Three phases of treatment were planned: DBBM (Bio·Oss; Geistlich Pharma, Wolhusen, Switzer-
land) was used to fill the cavity (Figs 13 and 20). The
1. Bilateral sinus floor elevation. Including extraction conical windo~Y was replaced (Figs 14 and 15).
of all residual teeth in the mandible, followed by im-
mediate delivery of a removable denture.
2. Implant surgery after 4 months. Six implants in the
maxilla (four in the posterior segments and two in
extraction sockets 13 and 23 by wa.y of immediate
placement) and another six implants in the mandible.
Figs 10 to 12 A k.tterol wi>dow
3. Restorative phase. Delivery of the final maxillary was aeated and the Sc.hneiderian
and mandibular fixed dental prostheses (FOP). Fig 6 lnci'Sion fine on me right membrane F:Jevated with a fJar
sideofrhe maxilla. Cutette.

Two alternative implant protocols are available in corr

junction with sinus lift procedures: simultaneous or
delayed placement . Which of both should be selected
depends on 1he vertical dimension of the residual crest.
which in turn influences the chances of primary implant
stability. Attaining optimal mechan ical stability in ridges
less than 4 mm high is well known to be a challenge.

In the diagnostic phase of the treatment, cone-beam

computed tomography (CBCT) was used to evaluate the
three-dimensional arch itecture of the maxillary bone,
the anatomical characteristics of the maxillary sinuses,
and the height of the alveolar processes. At the sit e of Fig$ 7 and 8 A mucoperiosteal
the first molar. the residual alveolar process was found to flap was elevated.
b-e 4 mm high. Considering tha1 primary implant stabi l-
ity might be compromised by pursuing the simultaneous
implant protocol, it was decided to use the staged proto-
col on both sides.

A modified lateral window technique was used to aug-

ment the maxillary sinuses (Boyne and James 1980).
The procedure was started via a crestal incisi-on (Fig 6).
Vertical releasing incisions were placed anteriorly and
posteriorly (Fig 7). A mucoperiosteal flap was prepared
and elevated, thus exposing the lateral sinus wall (Fig 8).
A bone scraper was used to collect autologous conical
bone chips from the lateral sinus wall (Fig 9). A piezo-
electric window osteotomy was performed to open the Fig 13 The maxillary sinus was filled with DBBM.
sinus window (Figs 17 to 19). An outline was drawn us·
ing insert OTS of a kit specially designed for sinus floor
elevations (Mectron Piezosurgery; Mectron, Carasco,
Italy). The cortical plate was removed and a flat curette
applied t o elevate the Schneideria.n membrane (Fig 10).
The membrane was dissected from the antral lateral wall,
floo r, and medial wall (Figs 11 and 12). Care was taken
not to perforate the sinus membrane.

Fig 9 Bone chips f/lllefe harwsted

from the lama/ sinus wall.

ITI Treatment Guide · Volume S 149 1SO ITI Treatment Guide- . Volume S
 S. Umanjec·Korac 6 O in ical Case Presentations

The defect of the lateral sinus wall was covered with a Postoperative Healing
resorbable collagen membrane {Bio-Gide; Geistlich Phar-
ma, Wolhusen, Switzerland} (Fig 16). The mucoperiosteal The patient received 3 g amoxicilli n 1 hour before sur-
flap was repositioned and sutured. A panoramic radio- gery and 500 mg every 8 hours fo r 5 days after surgery.
graph was obtained im mediately after su rgery, display- The patient was instructed to rinse twice daily •Nith a
ing adequate bone height distal to the maxillary canines chlorhexidine solution (0.2%) for 2 weeks. Postoperative
(Fig 21). wound healing was uneventful. No complications oc-
curred.

Fig 22 Teeth ewocted from the mandible. Note the loss ofperiodcnml
attachment.
Implant Surgery
After 8 weeks, the patient was scheduled for complete
extraction of her mandibular dentition. An immediate
complete denture was delivered (Figs 22 and 23).

A CBCT scan was obtained 4 months after bilateral sinus

Fig 17 Preparing the Jarerol window with a piezosurgical device (ldt sid;:J.
augmentation, indicating sufficient height of the a lveo-
lar bone in both maxill-ary posterior segments (Fig 24).
The ensuing implant procedure included placement of
four implants (Biomet 3i Osseotite implants, Florida,
USA; sites 16 and 26: prosthetic platform 4 mm, endos-
seous 0 4 mm, length 13 mm; sites 15 and 25: prosthetic
platform 4 mm, endosseous 0 3.75 mm, lengih 13 mm)
in the areas previously treated by sinus floor elevation
(Figs 25 and 26). Good prim>ry stabi lity was obtained in
Fig 23 Anterior view of me mo:rilfary and mandibular umporory den-
all cases. Once the implants were in place. healing abut·
"""'- ments were attached and torqued to 15 Nern. The ca-
nines ware carefully exuacted with periotomes to avoid
damage of bone and soft tjssue. Two implants (Biomet
3i O,sseotite implants, Florida, USA; prosthetic platform
4 mm, endosseous 0 4 mm, length 13 mm) were placed
in a correct three-dimensional position, and t he facial
gap between the implants and the bony socket walls
were augmented with DBBM {Bio-Oss; Geistlich Pharma,
Wolhusen, Switzerland). Subsequently the grafted are;1s
were covered with a resorbable collagen membrane and
sutured (Fig 27}.

Figs 18 and 19 Outlining the lateml window. Fig 24 CBCT satn obtained befi>re implam surgery, iodkming suffidem
bone heightfor implant pk.Jament in the post.erior ma.xitlarysegmmts and
insuffic.ient bone "idth and height in rfle maxNJary antetior segment.

Fig 20 GrofWe the nlaXiilary

sinus with DBBM.
Fig 21 Panoramic radiograph obtained after bilateral sinus augmenta-
tion. demonstrating that the vu6c1Jf dimension had improved distaf to
both ma.:rillary canines.

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 S. Umanjec·Korac 6 O in ical Case Presentations

Fig 2S lmpfants at sites 1S and 16. Fie 30 Anrer'ior view d models mount.ed in an articulator a«ordint: ro
ment. the JOttbow regi.stlution.

Fig 31 ™1x try-in illustratitlfmandibular tooth lenetfJ (cervical crown seg~

ments to ridge). Pink ceramic mate.rial was requiml to mask tooth length.

Implant surgery was performed in the mandible. Six The wax try·in indicated adequate facial and lip support.
Prosthetic Phase
implants were placed (Biomed 3i Osseotite implants, Also, the requirements fo r pink resin to mask the length
FL. USA; sites 31/33/41/43: restorative platform 4 mm. The restora:tive procedures were initiat ed 4 months af· of the mandibular teeth (cervical crown segments to
endosseous "13.75 mm. length 11 mm; sites 36/46: re- ter implant placement (Fig 29). Using screw-on impre:s· ridge) were identified on m is basis (Fig 31). The angula-
storative platform 4 mm, endosseous f213.75 mm, length sion copings, the fi nal upper and lower impressions were tions of implants at sites 13 and 23 posed an esthetic
8.5 mm). Good primary stability was obtained in all taken at the implant level. Facebow registratjon was used challenge with regard to the original plan of delivering
cases (Fig 28). Healing abutments were positioned, and to record the interarch relationship, and the patient was a conventional screw·retained implant prosthesis, as the
the denrure was adjusted and relined with a soft lining re-scheduled for a wax try-in 2 weeks later (Fig 30). screw access holes on the facial aspect were anticipat·
material. ed to compromise esthetics. Keeping that in mind, the
most viable solution was to fabricate two mesostructures
(splinting implants 16-15-13 and 23-25-26) and to use
Fig 18 Panoromic radiograph obt.amed after implonr placemet1t mthe palatal screws for fixation (Figs 32 to 34). The maxillary
maxif!a and mandible. and mandibular FDPs were delivered and checked for
proper occlusion (Fig 37).

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 S. Umanjec·Korac 6 O in ical Case Presentations

The milled mesostructures {Fig 32) and retaining screws

of the final mandibular FOP were tightened to 35 Ncm.
The maxillary prosthesis was retained on a mesostruc-
ture with palatal screws. Wax was used to cover the screw
heads of the mandibular FOP, and the screw access chan-
nels were sealed with light-curing composite. The occlu-
sion was carefully checked and adjusted (Figs 35 and
36). The FOPs were contoured to aJlow for adequate s.elf-
performed hygiene. The patient received maintenance
instructions and was recalled for follo1A•-up visits every 6
months during the first year. After 1 year of function, the
Fig 33 Final max'ilfary FOP. Fig 34 FmaJ maxillary FOP with p<datal screw access holes. Fig 38 Anterior view obtained after 1 year.
patient continued to be very satisfied with the function
and esthetics of his FDPs (Figs 38 to 40). Another pano-
ramic radiograph was obt.ained (Fig 41).

Acknowledgments

Laboratory Procedures
Arnold Ngariman - K & J Tandtechniek, Haarlem,
Netherlands

Fig 35 Anterior view cfthe final prostheses in rrmfun;m inttrcuspatioo.

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 T. W. Head 6 O in ical Case Presentations

6.12 SFE witl Particulated AJJto afts

Combined with Ve1tical Ridg
Allgmentation t1sing_Onla Grafts
and a Stag_ed A__pproach
T. W. Head
A 61 -year·old woman was referred for asse.ssment of the
possibility of bone grafts for implant placement to recon-
struct her severely auophic maxilla. She was a healthy
non-smoker. Since her thirties she had worn a complete
upper denture against a natural lower dentition. Ten
years prior to the consultatjon, five implants had been
placed in the maxilla for a fixed prosthesis. One implant
fa iled immediately, and others failed over the ensuing
10 ye.lrs. In t he previous 2 years, she had been wearing
a complete denture without retentive elements over the
last two implants (Fig 1). Her primary concern was the
Fig S Harvesting of a cortk«anceJlous blocJc graft and Fie 6 Corricoconce/fous block to be shaped to the anterior max·
PS,CM (pankulate bone and canrenous marrow}. The po- ilia. and PBCM (patticuklte bone and cancelious marrow} to be
tienr's head was oriented to the left and her I~ ro the packed into the sinuses and atound the anterior block uaft.
right. The stro.iffe fine indiattes the midline ofthe lumbar
instability of her denture. She had great difficulty with
spine a:?d sacrum.
mastication and felt insecure when speaking. Her desire
was to have a fixed prosthesis.
At the consultation appointment, one implant remained
in the anterior maxilla. (Fig 2). Clinical and radiographic
examination revealed that the maxillary alveolar ridge
was completely resorbed from site 15 to site 25. The pos-
terior maxilla had maint.ained its form, but due to the
presence of pneumatized sinuses, it exh ibited no bone
mass (Figs 3 and 4).

Fig 7 View ofthe exposed maxilTa aftet eleKlting bu«al Fil 8 \lj·ew after pkJcing the anterior corococance11ous block. and
and palatal flaps. Note the absence of anrerior alveolar creating the right la!eral sfrws--wa» osteotanies.
bone. Also apparent are the site of the removed implant
and the l'IOIH'eSorbed bur pneumatized posterior segments.

Fig 1 Ainoramk radiograph 1 year prjor ro con.sutrari<Jn.
Based on the clinical and radiographic evaluation, this
case was classrfied as complex (SAC classification), in-
volving a high risk of complications and graft or implant
fai lure. Risk factors associated with surgery included:
limited soft tissue for graft coverage in the anterior max-
illa; the need to obtain horizontal and vertical augmen-
Fig 2 lntraoral ~w at rhe consultation oppoinrment.
tation in jaw segment 15 to 25 and vertical augmenta-
tion in the posterior maxilla.; and complete absence of
residual alveolar bone to conuibute to implant stability
,., - / ... , r .. \ and osseointegration .
\J-.\;.\J.' I
. ..........
( ',(1' ( '
~
Under general anesthesia, the patient was placed in
prone position. A6-cm incision was created for bone har-
vesting (Fig 5). The gr.tft consisted of a corticocancellous
block, to be shaped for the onlay gr>ft of the anterior
maxilla, and PBCM to be densely packed around the an-
terior block graft and into the maxillary sinuses (Fig 6).
Subsequently the patient wa.s turned into a supine posi-
tion. An incision was created in the ke-ratinized mucosa,
extending from the right to the left tuberosity, to expose
the maxilla (Fig 7). The corticocancellous block graft was

(
In consult.ation with the prosthodontist, it was decided
that eight implants (at sites 11121, 13123, 16117, and
26/27) to support a fixed prosthesis should be planned
for. The surgical plan included an autologous corticocan-
cellous block onlay graft to the anterior maxilla and bi·
shaped to the desired curvature of the anterior max-
illa and fixed in position with 1.7-mm titanium screws
(Fig 8). Then the maxillary sinuses were entered by cre-
ating osteotomies in the lateral sinus walls (Fig9) and
elevatjng the Schneideri.an membrane with the lateral-

Fig 4 CT scan demonstrating
sawe atrophy and sinus pne1.1-
matization. The tronsW'!Se cua
Fig 3 CT scm demons1101illg 13·16 cetr£SPOOd ro tooth sifts-
severe anterior ma'tiHary atro- 15 ond 14, and cutt 9-11 cotre-
phy in sarfttal \.iews. spondto tooth sites 17and16.
\.~
lateral sinus floor elevation with particulate bone and
.\,r-. \.r . 1,.._ cancellous marrow (PBCM) grafts. The volume of bone
required indicated harvesting from the posterior illium.
Implants would be placed in a second-stage procedure 4
,,_ - . Al(. l.J).<".:
to 6 months later.
wall segment (Fig 10). The space created in the inferior
aspect of the sinus \vas filled by densely packing PBCM
into it. P6CM was also densely packed around the ante-
rior corticocancellous block on lay graft (Fig 11). Continu-
ous chromic gut sutures were used to close the mucope·
riosteal flaps (Fig 12).

ITI Treatment Guide · Volume S 157 158 ITI Treatment Guide- . Volume S

Fig 9 The Scflne.;cfetian memtmme and the ktterol siflfJS flt'<lH seg.-
nJent were elevated to place the s.inus floor at a more superior
position.
Fig 11 Cantt»ous bone f!O~ nw a.lsc packed around the ante-
riot block graft.
T. W. Head
Fig 10 View ofrhe elevated left siflfJS floor. A space 15 mm in
hejght was cmit£'d for the c:nnre/lous bone graft.
F1.g 13 FJSW!oe dew/oped 2.S months after grafting.
ITI Treatment Guide· Volume S 159
6 O in ical Case Presentations
Initial healing was very good, although two fistulae de·
veloped in the anterior maxilla 2.5 months after graft·
ing (Fig 1 3). These areas were explored and found to
contain necrotic bone and granulation tissue, which was
removed by curettage. This left large void areas in the
anterior block graft (Fig 14). A CT scan was obtained,
demonstrating the extent of the defects in the anterior
maxill• (Figs 15 •nd 16) but •lso indica1ing good he•l-
ing progress of the sinus grafts (Fig 17). Another inter·
vention was performed to graft the voids in the anterior
maxilla with PBCM from the proximal tibia 1 month later.
.
( \r
( .··
~ ~~ ·~
Fig 16 Sagitral CT 11iews af the amerior maxilla. demomtratins voids 'in FJC 17 Transverse CT views of the posterior maxiFfa, demonsmnin,g the
rhe onlay gndt bone mass aeated by the cancellous graft insKle the sinus.
160 ITI Treatment Guide- . Volume S
 T. W. Head 6 O in ical Case Presentations

The surgical plan of placing eight implants was imple-

mented 4 months after the second grafting procedure
in the anterior maxilla. Following a crestal incision from
the right to the left tuberosity, a buccal mucoperiosteal
flap was raised to expose the maxilla. Abundant viable
bone was found at both the anterior onlay graft and the
posterior sinus grafts (Fig 18). A surgical guide provided
by the prostho-dontist was used to position the implants
(Fig 19). Four implants (Straumann Bone Level. Regular
Cross Fit. 0 4.1 mm, lengths 10 and 12 mm) were placed
in the anterior maxilla, and fou r im·pl.ants (Straumann
Wide Ne<k, SLActive, 0 4.8 mm, length 12 mm) were Fig 18 Four months after rhe second grafting procedure in the anterior Fie 24 Panoramic rodiograph 3 months after implant placement. The pa-
placed in the posterior maxiUa (Fig 20). Plain 4-0 gut su· maxilla. lhe reconstruaed alveolar ridge was exposed Wo a crest incision tient was referred back to the prosthodont& at thjs time.
tures were used to close the mucoperiosteum, obt.aining and elevarjon ofa buccal n'ucoperiosteol flap.
primary closure over the anterior implants and open clo-
sure around the posterior implants.

The patient's conventional denture was relined with a

soft material 2 weeks after implant placement. Because
of the lack of keratinized mucosa on the labial aspect of
the four anterior implants, free gingival grafts from the
palate were placed labial to these implants while chang·
ing to longer abutments (Figs 21 and 22). The denture
was again relined with soft reline material.

Fig 19 A surgical guide was used to place the implants at the sites re-
quited by the prosthodontisr..

I ..

Fig 10 Eijfrl implants wereplaced.kK:luding 10-mmdesierJsatsites 11121,

12-mm designs at sites 13123, and12-rnm designs at sites 16117126127.

Afte-r 6 weeks of soft tissue healing, the patient was re·

ferred back to the prosthodontist fo r fabriation of the
prosthesis (Figs 23 and 24).

The final pr.osthesis was de.livered 4 months after im-

plant placement (Figs 25 to 28).

Radiographic follow-up examinations were performed

after 6 months (Fig 29) and 1 year (Fig 30) after delivery.

Fig 21 V-JeW obtained 6 i.'ed:s after implanc placement Note the

FJC 28 The smile ofrhe patient.
non-keratinized mucosa at the aai cf the max'illary antetiot ridge.

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 T. W. Head 6 O in ical Case Presentations

Acknowledgments
6.13 .fil'f' with a.ConJ..P-osite raft C.Q__rn_bmed
Restorative Procedures
Dr. Robert Valiquette - Greenfield Park, Quebec, with Ve1tical Ridge Augn1entation usmg
Canada
()nlay (~rafts and a Staged Approach
Laboratory Procedures
Eric Fortin. CDT - l e Groupe Dentachrome,
Montreal, Quebec. Canada M. Chiapasco

Fig 29 A:umamic radiograph 6 months after defwery.

A 40-year·old woman •Nith partial edentulism in both The patient reported a previous history of periodontal
maxillary posterior segments was referred fo r consulta· disease as the main cause of t ooth los.s in the posterior
tion and treatment (Figs 1 to 4). Her ma.in concern was maxilla . She was in good general health, did not take any
the missing postedor teeth, which compromised mastj- medications, and did not smoke.
cation and were detrimental to her facial esthetjcs. She
requested to have her appearance improved with a fixed
prosthesis supported by oral implants.

Fig 30 Panoramic radiograph 1 )"E?ar after delivery.

FJCS 1 and 2 Initial dinkal and rodiof}Tlphic situation. The patient had prei.iously undergone ueaunem fix periodontal disease.

Figs 3 and 4 Ede.nrut;sm in the maxitlary posreriot segmems,. associattd wih intennaxiikJry discrepandes in the horizonttJI and 'oErticol planes.

ITI Treatment Guide · Volume S 163 164 ITI Treatment Guide- . Volume S

An intQoral examination was conducted. indicating eden-
ru lism in the maxilla distal t o the cuspids. Horizontal and
vertical resorption of the alveolar ridge was present and
associated with an increased interarch distance (notably
on the left side). GingiV<ll re-cessions resulting from peri·
odontal disease were noticed on teeth 12, 13, 22 and 23
(Figs 1, 3 and 4). A panoramic radiograph and CT scans
were obtained, demonstrating that bone availability at
the premolar and molar sites was bilaterally reduced,
as the maxillary sinuses had expanded in conj unction
with alveolar ridge resorpt ion. Nor did the bone volume
in these areas seem to be adequate for implants with
reduced dimensions (Figs S to 8). A ,11simple 11 procedure
of sinus floor elevation was also excluded, as th is would
not have included grafting of the vertical and horizontal
ridge resorption.
M.. ( h iapasco
Figs Sand 6 CT scans indkmjng rhat the max1Jlary sinuses were sevo-ely
expanded in C011junction with the wttkaJ and horizonta( ridge attophy.
ITI Treatment Guide · Volume S 165
6 O in ical Case Presentations
tt was decided to proceed with an <tugme-ntation proce·
dure that included sinus floor elevation in association
with vertical and horizontal autologous bone grafts. This
procedure would not only adequately reconstruct the
bone volume for implant placement but would also es·
tablish favorable intermaxillary relationships. In this way,
a restoratjvefy driven approach with ideal implant place·
ment coukl be pursued. It was also planned to insert the
implants after consolidation of the grafts in a second·
stage procedure.
Figs 9 to 11 A corticocancellous bone block MrS hatVested from rhe an--
Due its complexity and duration, the reconstructive pro-
tetior iliac crest cedure was conducted under general anesthesia with
nasotracheal intubation. The first step was to harvest a
conicocancellous bone block from the medial s ide of the
anterior iliac crest (Figs 9 to 11).
The next ph<tse was to elevate a mucoperiosteal flap to
expose the posterior maxilla. A bony window was created
so that the sinus membrane could be elev.lted (Figs 12
and 13).
Figs 12 and 13 The latetal vrindow (with the a/W:olar Cll'ltral artery1 was prepared and the sinus nlembrane ekvated.
166 ITI Treatment Guide- . Volume S

The cancellous component of the iliac graft was partic-
ulated, mixed with biphasic calcium phosphate (Strau-
mann BoneCeramic; Straumann, Basel, Switzerland),
and used to fi ll the cavity created after sinus floor el-
evation. At the same time, iliac bone blocks were fix-
ated with titanium microscrews to g~ft the vertjcal and
horizontal defici t of the left maxilla (Figs 14 to 16). Af-
ter creating adequate releasing incisions, the flap was
eventually sutured for non-permeable and tension-free
closure {Fig 17). The same procedure W<lS repeated on
the right side, again including s inus floor elevation in
conj unction \\lith vertic<ll and horizontal bone grafting
(Figs 18 and 19).
Figs 18 and 19 The same proadure MlS used on the rit}1t side. including
w'ith horimntal and verrkal aurologous grafts from the ;/iac crest.
M.. ( h iapasco
Fig 14 A composite graft induding autoloe-ous bone (particukrted chips}
and a bone substitute Wl1S used ta fill rhe cavity created ofter elevation of
rhe sinus metnbrone
Fig 17 E'Ventually rhe mucoperiOSleal flap was adequately released and
rhe surgical field closed with a non-permeabk suture.
J
mus floor elevation with pankulated bone and a bone substitute in conjunction
ITI Treatment Guide· Volume S 167
6 O in ical Case Presentations
After surgery, a panoramic radiograph W<lS obtained
<llong with inmoral clinica.1views. These images demon-
strated the increase in bone volume obt<lined (Figs 20
to 22).
A waiting period of 4 months was observed to allow for
undisturbed healing. No removable prosthesis was al-
lowed to c ircumvent any risk of wound dehiscence, infec-
tion. inadequate graft incorporation, or graft resorption .
After this period had elapsed, the patient was ready to
receive implants.
Fig lO A panoramk rodiograph was obtained afterreconstructive surge~
demonstrating its outcome in tenns ofbone ca.in and reconstf1.jefion ofthe The fl<lp on the left s.ide was elevated, revealing that the
irltemtch relation. gldft was excellently integrated in the absence of res.orp-
tion (Fig 23).
Thre-e implants (Straum<lnn Bone- Level, Regu lar Cross Fit
4.1mm,0 4. 1 mm. length 10 mm) were placed as dic-
tated by the surgical guide provided. The implants were-
left to heal in a submerged fash ion (Figs 24 to 27).
FJgS 21 and 21 Cfinkat views 4 months aft.er reronstroctive SJJIF,E'Tf. Its otttoome (din'ltnsional changes of rhe edentulous areas and correction of the
initial deficit1 is ckarly vis;ble. The patient showed an adequate bone vokime and a favorable interorch relarion. thus allowing Nnplants to be pkKed in a
resr.orati1re/y dr'ivM approach.
168 ITI Treatment Guide- . Volume S
 M.. ( h iapasco 6 Oin ical Case Presentations

......
.. ~
After 2 months of healing, the implants were uncovered
with a partial-thickness fl ap, using palatal incisions on
... _ ·,.

-...- ,\
,, both sides, in order not to expose the underlying bone
and to "transpose" the keratinized tissue toward t he buc-

-~
...
---.:-·a
.-4!.. !--
... e>I s ide (Figs 31 and 32).

After 2 months, impressions were taken for final reha-

bilitation, using a polyether material and an open-tray
• technique (Figs 33 and 34).

'.J ....
Figs 24 and 25 Three bone.Jevef impkmts M?re ;nsened as d'iaared by a previocmy fabricated svrpjcal ten)p/are in !he kft maxilla 4 months after re~ Figs 31 a.7d 32 To gr:iin keratinized tissue around the Nnplants, a par·
Subsequently the case was sent to the dent.al laboratory
where customi-zed titanium abutments and the final
metal-ceramic FPOs were fabricated (Figs 35 to 37).
structive surgery. Dal-thickness flap with a palatal incision was elevated and uonsposaJ to
the buccal side at tM time ofimplant reopening. Ptosthttk tehabititution
commenced 2 months later.

Figs 26 and 27 A submetged healing protJXol was Weaed,, such that the grofttd area remained prot.ected dtJrinc osseointegµition ofthe implants.

Figs 33 and 34 Impressions were token for defmitive rehabilitation, using a polyether material and an open-tray technique.

Figs 28 and 19 The same procedure was followed on the rig/It side. Three bone-1~-el Unplants of the same dimensions were placed in the grafted areas,_

The same procedure was repeated on the right side.

A.gain, no resorption of the graft was observed at the
time of implant surgery. The implants could be placed
in restoratively driven ideal positions and were com-
pletely surround<?<! by healthy and vital bone (Figs 28 to
30). Bone-level implants were favored over tissue-level
designs to allow for submerged healing and to promote
continued undisturbed and "protected" healing of the
bone grafts with integration/revascularization.

Fig 30 A panoramic ratfi.ouaph Ml'S obtakled after placiog the frnplant:s Fie 37 CJ.Jstomized tftanium abutments and final metaf-a:romk FPDs
in a restoratively drive.n tashi0tt. showing axrect alignment ofthe implants. before delillety.

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 M.. ( h iapasco 6 O in ical Case Presentations

The prostheses were delivered to the patient. Thanks

to the previous bilateral reconstruction of the alveolar
ridge, the ceramic crowns appeared well integrated with
the rest of t he dentition, including appropriate d imen-
s ions and good emergence profiles {Figs 38 to 41). The
patient was satisfied with the esthetic and functional
outcome (Fig 42). A panoramic radiograph obtained im-
mediately after completion of the prosthetic re:storation
demonstrated excellent integration of the implants in
the grafted areas (Fig 43).

Fig 38 Clinicat verification after compfetjon ofthe restoration. Figs 46 to 48 Radiographs 3 yecm after loading, Na rescrpiion of the
perHmplant bone *W" detectable compared to the pnvious rodicgraphs.

Figs 39 and 40 Ocdusat Wew ofthe rehabilitation and extmoraJ ¥.iew ofthe patjent's smile.

Figs 41 and 42 lntJttorol lateml views ofthe final resroratJOns in the rigf1! and Jett posterior maxilla..

Since restorative treatment was completed, the patient Acknowledgments

has returned for annual periodic recalls. Radiogr.-.phic
follow-up examinations performed after 2 years (FigS- 43 Restorative Procedures
to 45) and 3 years (Figs 46 to 48) demonstrated a stable Dr. Claudio Gani - Milan, Italy
outcome without relevant peri-implant bone loss.
laboratory Procedures
Sandro Bertoglio, MOT, Gianni Zibetti, MOT -
Busto Arsizio, Varese, Italy

ITI Treatment Guide · Volume S 172 ITI Treatment Guide- . Volume S

 7 (omplicatiions \\·ilh Sinus Floor Elevation Procedures

Sinus floor elevation {SFE) using the 1.ateral window tech·

nique is a predictable procedure involving a low compli-
cation rate and high implant survival rat es (Jensen and
Terheyden 2009). Though considered predictable. com·

7 Complications with Sinus Floor plications and failures do occur with these procedures
01.nd are generally difficult to manage. This chapter will
discuss the etiology and management of intraoperative
Elevation Procedures •nd postoperative complications.

H. Katsuyama

m Treatment Guid~ •Volume S m 174 rn Treatment Guide . Volume S

 H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures

Donor sites mentation. Table 2 gives an overview of intraoperative

7.1 Intraoperative Complicatio11s
In treatment cases involving autogenous bone grafts,
complications may also occur at the donor site. Potential
intraoperative complications of intraoral harvesting in-
clude neurovascular damage or exposure. Extraoral bone
harvesting is indicated whenever major reconstructions
of the maxilla are required to compensate for adverse in-
termaxillary relations and to perform major vertical aug·
complications at extraoral donor sites. lntraoral donor
sites include the maxillarytuberosity and the mandibular
symphysis and ramus. The most common intraoperative
complication at donor sites is damage to neurovascular
structures, which could be minimized by careful and
accurate preoperative evaluation of the site anatomy
using 30 imaging.

lateral window technique
Tables 1 and 2 provide an overview of potential compli-
cations affecting the intraoperative donor and recipient
sites in SFE. Uneventful healing of the augmented site
occurs in the vast majority of cases after lateral window
SFE (Chiapasco et al. 2009). Perforation of the sinus
membrane is repo1ted to occur in approximately 10% of
cases (range: 4.8% to 56%), the most common intraoper-
ative complication (Chiap.asco et al. 2009). Usually these
perforations are repaired with collagen sponges, various
membranes, or allograft sheets. Only in less than 1% of
patients did the grafting procedure have to be discontin·
ued due to extensive membrane ruptures (Chiapasco et
al. 2009).
However, it should be noted that membrane perfora-
tions are not always detected intraoperatively due to the
difficult access to some areas of the sinus cavity (e.g.
superomesial or posterodistal regions). Perforations of
this type may be detected in postoperative radiographs.
They should be suspected whenever the e levated si-
nus floor has an indistinct border or when some of the
grafting material is found to have spread. The clinical
management of membrane perforations is shown in sec-
tion 7.3.1. Some studies have described a correlation
between membrane perforations and implant survival
rates (Hernandez-Alfaro et al. 2008), while others re-
ported no such correlation (Nkenke and Stelzle 2009).
Potential intraoperative complications als.o include
bleeding due to engagement of t he superior posterior
alveolar artery (Pjetursson et al. 2008). nerve damage
or exposure (Engelke et al. 2003), inadequate primary
stability of the implant when a simultaneous approach
is utilized (Lee et al. 2008), and migration of grafting
material due to membrane perforation (Nkenke et a l.
2009). Lateral window SFE has been reported to involve
a 2%-~% intidence of bleeding (Zijderveld et al. 200&;
Kim et al. 2009). The incidence of neurovascular damage
is not well documented. Inadequate primary stability of
the implant will heavily depend on bone density.. bone
Table 1 lnrraoperative complications at (lateraf window and rransaestol) SFE recipjem sires.
quantity, implant bed preparation. and implant design.
It was reported in a case serie-s to affect 3.9% of cases lntraoperative complicati_ons. Reponed rates of occurrence
(Schwartz-Arad et al. 2004). Finally, dislodgement of the
1. Membrane perforation 10% (4.8%-S6%)
implant into the sinus cavity is seen in less than 0.5% 2. Poor primary stability of implant 3.9%
of cases (Schwartz-Arad et al. 2004; Velich et al. 2004). 3. Bleeding from injured vessels 2%-3%
While the precise indications for repair of membrane Lateral window SFE 4. Implant migration within the sinus 0.27%--0-47%
perforations have not been well defined, such re.pair S. Graft migration wit hin the sinus -
would be indicated when collagen sponges, various types
of membranes, or fibrin gel can be used to preserve the
6. Nerve exposure or injuries
- .- _
grafting materia l. 1. Sinus membrane perforation 3.8% (0%-26%)
Transcrestal SFE
2. Bleeding caused by blood vessel injuries -
3. Poor primary stability of implants -
Transcrestal technique 4. Migration of bone graft within the sinus -
lntraoperative complications of transcrestal SFE are also
shown in Table 1. These procedures are usually less in-
vasive than the lateral window technique. Quite similar
complications have been documented, however, includ- Table 2 tntroopera!ive complications at donor sites (used for bone h~
ing membrane perforation (Pjetursson et al. 2009a,
Donor site-s lntraoperative complications
2009b), bleeding (Nkenke et al. 2002; Tan et al. 2008),
a.nd inadequate primary stability of the implants (Fer- 1. Nerve exposure or injury (inferi-or alveolar nerve or mental nerve)
merg3rd and Astrand 2008). The most common intra- 2. Bleeding caused by injury to the
operative complication of transcrestal SFE is membrane - inferior alveolar artery
Chin
perforation, whose presence can be confirmed by a Val- - mental artery
salva test (Pjerursson et al. 2009a, 2009b). This verifi- - submental anery
cation technique is, however, not successful in all clini- lntraoraJ Mandible 3. Sensory dist urbance of mandibular anterior teeth
cal situations. Another option to confirm the results of
1. Nerve exposure or injury (infe rior alveolar nerve)
transcrestal SFE would be to employ a. fib.er endoscope, 2. Bleeding caused by injury to the inferior alveolar artery or
although some unnoticed perforations have even been Ramus-
sublingua.I artery
reported with these devices (Nkenke et al. 2002). An 3. Mandibular fracture
a.cknowledged complication of membrane perforation
is migration of grafting material (Nkenke et al. 2002). 1. Injury to lateral femo~l cutaneous nerve
Membrane perforations should be expected to occur ap· 2. Injury to superior gtuteal nerve
Ilium Iliac crest
proximately as often with transcrestal SFE as with lateral 3. Injury to sciatic nerve
window SFE {Gabbert et al. 2009). They are considerably 4. Injury to superior gluteal artery
underreported. however, perhaps due to the "closed" 1. Injury to diplofc and emissary veins
E.xtraora1
nature of transcrestal SFE. The increased risk of perfora- 2 . Injury to median meningeal artery
tions due to the shape of the sinus cavity and the exist- Parietal 3. Dural tear
ence of sepia has been discussed in preceding chapters Calvarium
bone 4. lntracranial hemorrhage
a.nd related to the selection of surgical procedures: no S. Air embolism
correlation between complications and implant survival 6. Death
rate has been identified (Pjetursson et al 2009a.).

ITI Treatment Guide· Volume S 175 176 ITI Treatment Guide-. Volume S

7.2 Postoner tive Compl1cati
Postoperative complications at SFE donor and recipient
sites are summarized in Table 3.
A definition of what constitutes an early or late compli-
cation has been provided by Pikos (Pikos 20-06). Early
complications occur within 7 to 10 days of surgery and
commonly include bleeding from the incision line, nasaJ
bleeding, paresthesia, infection, wound dehiscence, he-
matoma, and swelling. late complications are rare. The
incidence of dehiscence at surgical sites ranges from 2.7
to 8.4% (van den Bergh et al. 2000b; Raghoebar et al.
2001 b; Chiapasco et a l. 2008). Postope rative infections
occur in 2.7% of cases (Pjetursson et al. 2008), bleed-
ing has been obseived in 0.46% (Khoury 1999) to 16.6%
(2ijderveld et al. 2005). Different defin itions of bleed-
ing may account for this vast difference in postoperative
bleeding reported. The incidence of hematoma is not
well documented.
Late complications of SFE may include loss of the im-
plant and (acute or chronic) sinusitis, the latter being
reported as occurring in 2.5% of cases (Chiapasco et al.
2009). Correlations have been reported with pre-surgi-
cal chronic sinusitis, membrane hypertrophy, and post-
extraction timing of the surgical procedure (Timmenga
et al. 1997). Graft loss or failure due to membrane per-
foration has been reported to occur at an incidence of
1.9% (0- 17.9%; Pjetursson et al. 2008) or 1% (0-20%;
Chiapasco et al. 2009) and m ight be the cause of post-
operative sinusitjs. Although one might speculate that
the use of resorbable grafting materials (e.g. autografts)
would minim ize the risk of long-term complications in
the presence of membrane perforation, this assump-
tion has never been scientifically documented. Poten-
tial complications after SFE procedures include sinusi-
tjs and infection. While both eventualities are primarily
caused by membrane perforation, sinusitis may even
occur fo llowing uneventful surgical procedures. Infec-
tion and sinusitis may occur soon after surgery or may
H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures
Table 3 Postoperotiw compikations ar SFE recipient sites
Postoperative complication.s Reported rates of occurrence
1. Implant loss 2.3%-12.1%
2. Wound dehiscence 2.7%-8.4%
3. Infection 2.7%
4. Maxillary sinusitis 2.5%
5. TotaVpanial graft loss 1%(0%-20%)
6. Bleeding 1.9% (0%- 17.9%)
Lateral window SFE
7. Hematoma 0.46%. 16.6%
8. Necrosis of the bone graft -
9. Inadequate bone volume -
10. Cyst formatjon -
11. Air embolism -
12. Pain {temporary or protracted) -
only show after several months. It is sometimes diffi-
1. Implant loss 4% (0%-17%, 64 months)
cult to diagnose sinusitis exuaorally, as the symptoms
are similar to the ones observed in nasal conditions.
Transcrestal SFE 2. Maxillary sinusitis -
3. Infection -
Several follow-up examinations with CT scanning may
be required.
Another possible sequela of SFE is insufficie-nt bone aug-
mentation. \Vhile outcomes of this type are not strictly
regarded as a complication, they do have implications
for subsequent implant placement. A transcrestal tech-
nique combined with implant placement could be con-
sidered if sufficient bone augmentation is not attained,
but the clinical para.m eters for this approach are as yet
unclear.
lateral window SFE is a reliable technique to place im-
Given the relative weakness of the elevated bone area, plants of ideal length in the atrophic posterior maxilla.
realizing an adequate bone gain is an essential goal of Nevertheless, implant fa ilures do occur. The mean im-
surgery. If primary implant stability cannot be achieved plant survival rate i.s 94.2% after approximately 3 years.
with staged or simultaneous SFE, an extended healing Rough-surfaced implants have a mean survival of97.7%,
period may be indicated. Prolonged healing will, how- compared to 87.9% for implants with machined surfaces.
ever, offer no benefit in regaining stability if implant mo-
bility becomes apparent in the follow-up period. What is Rep.air of a membrane perforation is indicated if it is
indicated in th is situation is to remove the implant and small (under 10 mm) and the grafting mate-rial can be
to consider replacement once the site has been carefully preserved in the site. Possible materials for repair in-
re-examined. clude resorbable (e.g. collagen) membranes. fibrin glue
or allograft sheets. An autogenous bone graft or resorb-
Donor sites used for bone harvesting may include postop- able grafting material may be indicated to minim ize the
erative infections, paresthesia, and hematoma (Table 2). risk of infection associated with any dispers.al of grafting
Paresthesia is a frequent complication in the mandibular material into the sinus cavity. However, scientific evi-
symphysis and has been reported to occur in 10 to 50% of dence to support this assumption remains scarce.
cases postoperatively (Chiapasco et al. 1999; Clavero and
Lundgren 2003; Nkenke et al. 2001, 2002; Raghoebar et
al. 2001a, 2007; Misch 1997). In 8%of cases, the sensory
disturbances associated with this complication may last
for up to 1 year. In the mandibular ramus. paresthesia
may occur in up to 5% of cases. with 0.5% being affected
by persistent sensory disturbances for over 1 year (Chia-
pa.sco et al. 2ooa, 2009). Curremly, the intraoral donor
site of choice is the mandibular ramus.
ITI Treatment Guide · Volume S 177 178 ITI Treatment Guide- . Volume S
 H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures

Figs Za-b Sott rim.le dehiscena after simultaneous and staged sinus floor devotion using a larerol Mndow technique. One implant M'OS placrtd in the
premoklr area using a simultaneous approach; atthe distal implant site. a staged approach •·as sefeaed using PRP (platekt-rich pk1sma) and a resotbabJe
membrane. Sott tissue dehis«nces and edema were noted early into the healint phase. In the majoriry ofcases, healing arid soft tissue c/OSJ(e can be
achieved with addmonal antibiotics and regu(ar cleansing of the. site.

FJES 40:-d Subcutaneous bleedine (hemorrhage) aft.er bone harvesting from the ramus (O<)andchiri (d). Hequentty, theprocedure used for bone ha/vest·
ing will be mote invasive than the SFE procedure itself. Pastoperative pain and swelling occurs in most cases. The informed consent obtained needs to
include posrcperotive symptoms.

a
Fig Sa Graftirw matelial retained on the ffnplant surface.

Implant instability or mobility may occur as a resuh of

unsuccessful osseointegration. As mobile implants will
rarely reach the point of successful osseoint egration, re-
moval and re-treatment is required in these cases. Figure
Sa shows an implant with grafting material retained on
its surface. Implant mobility may be caused by exces-
sive loading in the healing phase, poor mal\Jration of the
augment ed s it e, infection. or inadequate primary stabil-
Figs 3o-d Subcutaneous biee.dirlg (hemorrhage) may occur not only at the surgical site followinc SFE but also ar other sites due ro the tendency of acJ.- ity. In most cases of implant removal, bleeding will be
ditional SJ.Jrgko/ trauma. Bang very diffKult to ptedkt, this complication shou.fd be included in the informed consent obtained prior to SUtgt!Jy. minimal and he.aling uneventful (Fig Sb).

ITI Treatment Guide · Volume S 179 180 ITI Treatment Guide- . Volume S
 H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures

After obtaining the patient's consent, the procedure was

7.3 Case Presentations of Failures performed under local anesthesia on an outpatient basis.
A midline crestal incision was made with a posterior and
and Complications anterior vertical release of the mucosa of the left poste·
rior maxilla, followed by elevating a full--thickness muco·
periosteal flap to expose the lateral v1all of the left maxilla.
A vertical defect was noted in the buccal plate at site 26,
probably being the outcome of a large buccal plate frac·
ture in the pa.st, and was filled with fibrous tissue.

Fig 4 Ocdusa/ view ofthe mW:kres:al mdsion with anterior and posterior
«leases.

The following cases are presented to demonstrate the

range and potential severity of <omplications associated
with SFE.

7.3.1 Membrane Perforation

E. Lewis
This is a case of a 70-year-old man who presented with
an edentulous left posterior maxilla, pre<eded by a com-
plicated exttaction. He was an otherwise healthy non·
smoker and denied having any current symptoms in the Fig 1 lnt1aoral photograph with the patiMrs left posrerjor de.ntition in Fig S Elewnion of the mucopericsteal flap exposing the latetal wall of
area. occlusion. the maxilla. which indf.Jded a pcevious frocwre line in its pa;.t.erior buccal
ritJJ;e.
A clinical exam ination revealed that he was partially
dentate. Teeth 25. 26, 27. 28 were mis.sing in the left
maxilla. His residual posterior dentition was heavily re-
stored but well maint<!iined. A four-unit FPO was present
in the opposing arch. The pa:tient's oral hygiene was
satisfactory, with no signs of active periodontal disease.
The alveolar ridge in the left posterior ma:xilla was char·
acterized by adequate horizontal width and covered by
healthy mucosa.

A panoramic radiograph disclosed insufficient bone

height in the left posterior maxilla . Fig 2 Ocdusalviewofthe. kttposterior maxilla.

The following options were discussed with the patient:

(i) No treatment
(ii) Removable partial denture
(iii) Implant-supported FPO

After a detailed discussion with the patient. he elected

to proceed with surgical ueatment. A treatment plan
was developed as follows:

(i) SFE with allograft bone augmentation

(ii) Placement of implants at sites 25 and 27 after
6 months of healing
(iii) Delivery of a three-unit FPO

ITI Treatment Guide · Volume S 181 182 ITI Treatment Guide- . Volume S

The fibrous tissue was curened away from the defect,
and an oval-shaped osteotomy of the lateral wall Qf the
maxilla approximately 12 x 8 mm in size was performed
using the Piezosurgery@ system (Mectron SpA, Carasco.
Italy} with a tombination of osteotomy tips (OT1 and
OTS). Once the osteotomy was completed, a Piezosur·
gery elevation tjp (Ell) was employed to initiate separa·
tjon of the sinus membrane from the sinus floo r. Sinus
curenes were used to tomplete membrane elevation in
an inferior-to-superior direction . This time, however, a
large perforation developed as the membrane adhered
to the bu cc al plate defect. Upon completion of the eleva·
tion maneuver. a perforation of the membrane roughfy
1 cm in diameter Y/as noted. The oval-shaped bony win·
dow was rotated inside_the sinus to become the roof
of the graft site. Fi nally, a small resorbable collagen
membrane (Bio-Gide@; Geistlich Pharma AG, Wolhusen,
Switzerland) was trimmed and carefully placed over the
membrane defect.
H. Katsuyama
Fig 6 Viewofrhe lateral waHosteoromy with fibrous tissue at the prettist-
ing fracture site in the bu<.cot plate.
ITI Treatment Guide · Volume S 183
7 Complications with Sinus Floor Elevation Procedures
A 2-cc block of Regenaform® (Exatech, Gainsville, Flor-
ida, USA) demineralized freeze-<lried bone allograft
(DFDBA) was placed into a warming bath (43' C to 49' C)
for S minutes and was then uansferred to the surgical
site. Using curettes and pluggers, the allograft was gently
packed into the sinus cavity in a 1-ayered fashion, from in-
ferior to superior, ensuring that the collagen membrane
remained over the defect. Once an adequate height was
achieved (approximately 12 mm), the remaining bone
was placed over the sinus window. A large resorbable
collagen membrane (Bio-Gide®, Geistlich Pharma AG,
Wolhusen, Switzerland) was placed over the lateral as-
Fig 9 Pockin£ DFDBA Ntto the 'Sinus floor.
pect of the bone graft, tucking the medial edge under
the palatal edge of the mucos.a.
Fig 10 Df08A grafting compkf.ed.
Fig 11 Placing a col!agen membrane over the entire bone graft.
184 ITI Treatment Guide- . Volume S

After some careful irrigation with sterile s.aline. the mu-
coperiosteal flap was replaced and reapproximated us-
ing a 4-0 resorbable braided VicryJ suture material. Upon
completion of the procedure, a baseline postoperative
CBCT scan of the graft was obtained.
The patient was given general postoperat ive instructions
with a special emphasis on sinus precautjons. Prescrip-
tions were issued for a 1-week course of ora l antibiotics
(Amoxicillin 500 mg p.o. three times daily), for oral an-
algesics, and for rinsing with chlorhexidine digluconate
0.12%.
At the 1-week foll ow-up, the surgical site was examined
for incision closure and absence of infection . Following
removal of the remaining sutures, t he patient was in-
structed to continue with sinus precautions for another
week.
Six months after SFE, implants were placed under local
anesthesia at sites 25 and 27. A mid-crestal incision was
made wit h e levation of a m inimal mucoperiosteal flap.
Subsequently a standard drilling protocol was followed,
using a surgical template, for preparation of the implant
osteotomies. The Astra Tech Implant System™ (Astra
Tech Dental, Molndal, Sweden} was used. placing a 4.0S
13 mm and a 5.05 9 mm Osseo5peed implant at site-s 25
and 27, respectively, in a single-stage procedure without
complications. Immediately after implant placement, a
panoramic radiograph was obtained.
H. Katsuyama
Fig 12 Incision dosed primarify with resorbable inrerrupled sutures.
memarion.
Fig 15 Postoperative tangentio/
CBCTshowing vertical augmenro-
tJon ot site 27.
Fig 16 Panoramic rodiowaph obtained immediately after implant place-
ment.
ITI Treatment Guide · Volume S 185
7 Complications with Sinus Floor Elevation Procedures
Fig 17 lntraora/ viewofthe ldt posterior dentition 6 months after deliver-
ing the three-unit FPO.
Fig 19 CBCT range_nOal view 11
months after implant placement
at site 15.
186 ITI Treatment Guide- . Volume S
The patient was subsequently restored with a three·unit
FPO. Figures 17 to 20 illustrate the clinical and radio-
graphic find ings obtained 6 and 1 2 months after implant
placement.
In summary, this case illustrates how a significant perfo-
ration of the sinus membrane (occurring during SFE) was
managed. Perforations during SFE are not uncommon,
especially in the presence of anatomic.al anomalies like
the buccal plate fracture by which this case had presum-
ably been afflicted in the past and which resulted in scar-
ring and tethering of the sinus membrane to the fracture
line. The repon demonstrates that membrane perfora-
t ion can be successfully managed with a collagen mem-
brane as barrier. It was possible to complete the proce-
dure with careful postoperative follow-up in a standard
fashion. Also highlighted is the fact that t he presence of
a sinus membrane perforation did not comprom ise the
success of t he case.
Clinical Recommendations
ft is often difficu lt to predict the complication of sinus
membrane perforat ion in connection with SFE . While
bone anatomy and membrane thickness can be assessed
by obtaining a preoperative CBCT. the sinus cavity is a
complex shape. Sometimes these issues will not come to
light any earlier than during surgery.
• Perforations of the sinus membrane should be exam-
ined for size and locat ion. While small perforat ions can
~t .~
be managed without modifying the surgical plan, larger
perforations either should be repaired immediately with
resorbable sutures or should be isolated with a barrier
,.&....- ._ .... .._,
(e.g. a collagen membrane}. The patient s hould then be
followed closely in the earty postoperat ive period and be
given strict instructions to avoid increased sinus pres-
sure. If multiple perforations exist or if a perforation is
very l.arge, considerat ion should be given to aborting the
Fig '}(} CBCT rangential view 12
procedure, closing the incision and allowing the area to
months after implant placemem heal. Depending on the nature of the perforation, a sec-
otsite 27. ond attempt could be made later.
With the advent of the Piezosurgery system, the u ltra-
sonic cutting technique may be helpfu l in avoiding mem-
brane perforation at the time of conductjng the lateral
window osteotomy. A careful surgical technique using
various straight and angled curettes will also assist in
separating the intact sinus membrane from the bony
walls of the s inus cavity.
 H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures

7.3.2 Soft Tissue Dehiscence and

Correction after SFE with
Vertical and Horizontal Bone
Grafting
H. Katsuyama
A 42-year-old woman re<eived implant treatment in the
mandible and requested a fixed restoration in the maxil-
la. Surgery was postponed for treatment of sinusitis untjl
a healthy sinus was confirmed.
Fig 1 Preoperative view of the surpjco/ site. While the mucogfrrgival junc. Fig 4 A lateral window was prepated usine the toutine technique with Fie 5 A mixture ofaur0£m0US bone and ~TCP was grafttYJ into the sinus
The maxillary right posterior segment was edentulous tion is located near rhe aesi of the ridge. the mucosaJ stafUS appears rocationaf devices and ttaditional instruments. No membtane petforation aMry.
from the first premolar to the second molar (Fig 1). Also healthy. was obsem:d.
not ewonhy is the patient's history of bilateral hip-joint
replacement.

A CT scan of the site was obtained to investigate the

local anatomy and for pre-surgical treatment planning.
The bone at the sinus floor was found to be very thin.
In addition, SFE alone was not able to meet all clinical
requirements due to the presence of .ln intermaxillary
discrepancy. Whi le the sinus cavity itself showed no ab--
normalities, a damaged bone wall in the sinus floor was
confirmed (Fig 2). It was proposed to wait for the bone
waJI to heal and then to perform SFE in conjunction with Fig 2 CTscan disp/ay;ng the fimked vertical and horizontJJI bone wlume. Fig 6 Following hoiizontal and w.nkal plamnent ofthe grafting mate· Fie 7 Fixation ofthe titan;um mesh with SC'tews.
vertical and horizonta1 ridge augmentation. The patient Unfavorable intermax.iflary relations wete confirm&J. Vet6cof and hori- rial, a ritanitlm mesh was applied and ttimmedfor space prese!'IOiion and
was duly informed about the surgical procedure. She ac· zontal ridge auementation was planned in conjunction "'ith SFE. Surgery stab;Jization ofthe composite autogenous bone and ff-TCPgait
was petfomted under general anesthesia due to the large OJ710<lnt ofbone
ce-pted the risks involved and the need to harvest large
required.
amounts of autogenous bone. The iliac crest was ruled
out as donor site due to her history of bilateral hip-joint
replacement.

It was therefore decided to use the tibia for harvesting

(Fig 3). While the tibia is an ideal donor site for cancel·
lous bone, it will yield limited amounts of conical bone.
A mucoperiosteal flap was prepared for lateral window
SFE, using divergent relieving incisions (Fig 4). Routine
methods were used to prepare the window, grafting a
mixture of autogenous bone and fl·TCP into the sinus Fig 8 Primal)' WOU11d closure •w odlieved using a releasing fucision inro Fig 9 CBCT scan obtained after SFE and three-{/;mensiona/ bone oug.
cavity (Fig S). More grafting material was added to aug· the petiosteum and an appropriate flap design. Vkryl suture material was mentation. Thtee-dimensional conditions were found UJ be ideal at the
ment the vertical and horizontal space, followed by the used fol secure flap adaptarkxl. augmented site.
application of a titanium mesh (Fig 6). Several screws
were used for fixation of the titanium mesh to ensure
stability of the augmented site (Fig 7). Tension-free pri·
mary soft tissue closure was obtained by adapting the
flap carefully with a Vicryl*' suture (Johnson & Johnson
Medical, Cornelia, Georgia, USA), using a releasing in·
cision into the periosteum (Fig 8). Upon completion of
the procedure, a CT scan was obtained to confirm the
FJg 10 After 1 wee.t a soft £issue deh;scence 'lt'irh necrotic mucosa was
surgical outcome (Fig 9). The three-dimensional result of observed. Oral rinses were kxJJlly applied to prevent inti!ction. includ-
augrnentaiion was found 10 be ideal. The elevaied mem- ing Qrl o.ntif.epck {benz«hon;um chloride Q.Z~; N;ppon Shika Yukuhin.
brane was intact, as was the horizontal and vertical graft. YamQBUChl Japan) and an arrtibjotic geJ (gentamkin sulfate 0.1 ~; MSD
Fig 3 &rte harvesting from the tfbja. An adequate ~ume could be hor· KK, Tcl<yo, Japan}.
The sinus cavity was filled with bJood or exudate. veted. which, hoM-ever, consisted mosfo/ ofcancellous bone.

ITI Treatment Guide· Volume S 187 188 ITI Treatment Guide- . Volume S

Fig 11 Clinical view 2 mcmhs after surgery. Note the exposure both of
the titonjum mesh and ofthe fixation screws loaned buccally. Oral rinses
we.re applied, ;ndudiog an antiseptic fbenzethonium chloride 0.296; Njp--
pon Shika Yatuhil\ Yamaguchi, Japan) atid an an6biotk gel (gent:amkin
sul!iJte 0.196; MSD Kl<, Toiyo, Japan).
Fig 12 This vkw was obtained 1 mcnrh otter remcNO/ of the titanium
mesh, which 11r-ns removed 3 months after surgery. While soft tissue cover·
;ng the row svrface is apparttit under the Vtanium mesh, rbe scdt tissue
siwao·on at the site is subopdmal.
Fig 13 SQlt tissue correction and ;mpkmt placement was simultaneously
performed 5 months after initial swg.eryand 2 months otter remm'f.J/ ofthe
ritanj!lm mesh. A submerged healfne prot«cl was used.
A dehiscence of t he surgical wound, but without any
s igns of infection. was noted soon after the procedure
(Fig 10). There were no signs of infection, but the pa-
tient \\las instructed to exercise prophylaxis by applying
an antibiotic gel to the exposed titanium mesh. She was
also told to use oral rinses of an antiseptic twice daily
(benzethonium chloride 0.2%; Nippon Shika Yakuhin,
Yamaguchi. Japan) and an antibiotic gel (gentamicin sul-
fate 0.1%; MSD KK, Tokyo, Japan). The t itanium mesh
was left in si\\I for ma1ura1ion of the underlying tissue.
Periodic recall visits were scheduled to verify the con-
tjnued absence of infection. At the 2-month follow-up.
the center of the t itanium mesh and the fixation screw
H. Katsuyama
on the buccal aspect were exposed without showing any
signs of infection (Fig 11). At the 3-month follow-tJp, the
titanium mesh was removed. Ne\vly formed tissue was
present beneath the mesh. While the dehiscence wound
was surgically corrected to ideal tissue form at this time,
wound healing was less than ideal and the dehiscence re-
curred. Healing as such was uneventful (Fig 12). Another
2 months later, an implant was placed in the augmented
site, with soft tissue plastic surgery being performed si-
muhane<iusly. A submerged healing proiocol was used
(Fig 13). Due t o the repeated soft tissue surgery, the mu-
cosa was frag ile and soft t issue healing less than ideaJ
around the implants, particularly on the buccal aspect
ITI Treatment Guide· Volume S 189
7 Complications with Sinus Floor Elevation Procedures
Fig 15 Clinical view 2 months after im{ia:'ft placement An aberrant sott
tissue siwation is erjdent on the buccal aspea. Mn the shallow bucca/
vestiblllum.
Fig 16 Vestibuloplasry wirh a COJ laser was performed to correct the sott
rissue situation on the bucc1/ aspect
190 ITI Treatment Guide- . Volume S
F1g 14 Cfinical view 1 month afte.r impklnz placement of a Straumann
Standard Plus implant (Regular Neck. B <! 1 n>m, length 12 mm). Due to
rhe. frQgility of the sott tissue. the implant stioulders became exposed, attd
the cr.mtfition of the soft tissue conditions on the bucro/ as.pea was sub-
optimal.
where the vestibulum was shallow. The final step was to
enhance the soft tjssue s ituation by performing vestibu-
loplasty with a CD2 laser (Fig 16).
In summary, this case illustrates a significant complica-
tion that occurred in conjunction with a complex graft-
ing procedure. There was a need not only to elevate
the sinus floor but also to achieve lateral and venical
augmentation of the site. A titanium mesh was used for
space prese-ivation. Wound dehiscence occurred as a ma-
jor complication because the mucosa was overstressed
and the vascular supply t o the flap edge-s Y1as compro-
mised. Meticulous postoperati\!e care was the key to
managing this complication, which also highlights the
difficu lt soft tissue conditions that can arise from wound
dehiscences and the subsequent difficulty of soft tissue
management.
Clinical Recommendations
Th ree-dimensional bone augmentation in combination
with SFE is a complex procedure. not only to achieve
ideal bone augmentation but also in the surgical hand-
ling of the soft tissues. SFE with three-dimensional
hard·t issue augmentation requires the following criteria
to be observed:
- Healthy soft tissue conditions
- No inflammation around the surgical site
- Adequate blood supply (to be considered in flap
design, incision lines and flap management)
- Well-trained and experienced surgeon (capable of
managing any complications that may arise)
 H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures

7.3.3 Sinusitis after Undetected

.\. •
Membrane Perforation during .I
Surgery ; ~· ..,..... J
H. Katsuyama
A62-year-old woman visited our clinic to receive implant
treatment in the right post erior maxilla. SFE using a
staged approach was performed 2 months after extrac·
tion of the second molar (Fig 1). The pre-surgical CBCT
scan did not show any absolute or relative contrajndi·
'·"-" <'
Fie 4 Panoran1ic rodiograph 1 monrh after surgery. White the graft ap-
peared stable. the volume ofits posredor portion has been reduced by the
cations to SFE. After establishing access and elevating gruttlcss.
Fig 1 Ptesurgiall situation 2 monUts oftuexuaction ofthe mariJJaryridlt
the sinus membrane through a lateral window, a mixture second molar. A sraged opproadl was pkJnned for implant placement.
of ~-TCP and autogenous bone was grafted to the sinus
floor. Membrane perforation was not detected during
surgery. A postsurgical orthopantomograph revealed
that grafting material had been lost into t he sinus cavity
through a posteriorly located perforation of the mem·
brane that was unnoticed during surgery (Fig 2). A clear
image of the graft loss was obt ained by CBCT (Fig 3). A
postsurgical orthopantomograph obtained 1 month into
uneventful healing showed that the augmented site had
changed to a uniform clear round shape (Fig 4). The s ite
was left for furthe r maturation without applying any spe·
cific treat ment. After 4 months had e lapsed since sur·
gery, t he patient returned to the clinic because of symp- Figs S and 6 Sinvsitis was wspeaed based on dinkal symptoms and the patient complaining ofdiscomfort A CTscan confirmed lhe presence ofsinusitis
Fig 2 SFE itous uneventful. and a mixture offt-TCP and autogenous bone
toms related to the surgical site. Examination by CBCT was gafted. Panoroniic radiogroph showine an unclear siwation at the on the right (Fig S). Anribiotic rteatment ~us prescribed. Folkm·ing an ;,mial decrease ofsymproms. the patient reported bilaterol pain in both sinuses
clearly revealed the presence of infection in the right Ol@'Tlemed site and low density ofthe graft 2 months ofter antibi«k treatment. Upon confinnation by CT that sinusitis had developed io both calhries. another course ofantibiotic treatment was
sinus (Fig 5). Antibiotic treatment was therefore initi· prescribe.d.
a ted, using levofloxacin hydrate (Cravit 500 mg; Daiichi
Sankyo, Japan) in combination with L·carbocisteine (Mu-
codyne 500 mg, 3 times daily; Kyorin Pharmacuticals. Ja·
pan) and carried on for 2 weeks. Upon complet ion of t his
course, the patient's discomfort had disappeared. After
another 2 months, however. she returned with nasal
symptoms. A CBCT examination confirmed the presence
of bilateral s inusitis (Fig 6). Another course of antibiotic
treatment (fosfomycin calcium 500 mg, 3 t imes daily
over 14 days; Foxmicin, Meiji. Japan) was prescribed but
fa iled to resolve the infection. After concluding that anti· Fig 3 erscan showinc distinct loss ofgrafting material into the s.inus aw-
biotic treat ment alone would not bring about resolution, ity. The petforation •'OS not n«iced during surgery but coufd have been
it was decided to surgically debride the affected s inus due to fraajliry ofthe sinus membrOM or the e:ttraaion site.
under local anesthesia. A panoram ic radiograph was ob-
tained after debridement (Fig 7). While the bulk of the
graft had been e liminated, some radiopaque remnants
were still visible . The symptoms resolved after debride-
ment. Nevertheless, the unfavorable incision line and
flap elevat ion over the lateral window resulted in the
fo rmation of an oroantral fistula. Another surgical pro-
cedure was conducted to close the fistula (Fig 8). The
remainder of healing was uneventful. Complete resolu·
tion of the sinusitis was finally confirmed by the absence Fig 1 Panoramic rad'iogtaph after lkbridement of the right sinus. Vi'hile
of signs and symptoms of infection and by a CBCT·based mast of the grafting material has been retfl<?'o'f!d., some rodiopaque bone
substftute is still apporent in thecrestal Oll'O.
radiographic examination (Fig 9).

ITI Treatment Guide · Volume S 191 192 ITI Treatment Guide- . Volume S

Fig 8 The incision line for debridement was placed above the oripj.nat
lateral sinus window, km·ing a fistula. No discharge ofpus was confirmed
In summary, this case illustrates a. significant late com-
plication following SFE. The sinusitis was presumably
caused by loss of grafting material into the sinus cavity
through an undetected membrane perforation. Postsur-
gical assessment is therefore mandatory to confirm the
re-suits. Some cases of sinusitis can be difficult to treat
once they have developed. A decision must be made as
to whether antibiotic u-eatment will suffice or should be
combined with surgical debridement to resolve the in-
fection.
Clinical Recommendations
Clinicians should be aware that perforating the sinus
membrane will increase the infection risk. The sirua.tion
needs to be carefully assessed. A summary of clinical rec·
ommendations follows:
- If membrane perforation is confirmed during sur-
gery, a non-resorbab1e grafting material may not be
the treatment of choice. It may be better to select
resorbable materials like autogenous bone and/or
an appropriate bone substitute.
- It is strongly recommended to obtain a postsurgical
radiograph. If signs or symptoms of infettion are
present, additional d iagnostic tests such as CBCT
may be considered.
H. Katsuyama
Fig 9 CT SC1Jn confirming that lhe sinusitis had resolved.
- In the presence of sinusitis without any signs of
acute infection such as bleeding or pus discharge,
antibiotic treatment is the first choice.
- If antibiotic treatment alone does not solve the
problem, surgical debridement should be considered
the first treatment of choice.
- Clinicians who are not used to handl ing such
complications should consider prompt referral to a
specialist.
- While CBCT or MCT are useful and conven ient
techniques to examine the sinus cavity, any pros-
pect of conducting multiple examinations of this
type should be carefully considered and discussed
with the patient because of the radiation exposure
involved.
- If surgery for debridement of the sinus cavity is
planned to de.al with SFE-related complications, the
incision line should not be placed over the previous
window, as this position will carry a higher risk of
wound dehiscence due to compromised blood supply.
- SFE planned near post-extraction sites will require
a careful examination. as they involve a. risk of
communication into the sinus cavity via the healing
socket.
- The risk of perforation is increased in ~st-extrac·
tion sites, as the sinus floor will show an uneven
contour near the root sockets in this situation.
ITI Treatment Guide · Volume S 193
7 Complications with Sinus Floor Elevation Procedures
Fig 1 Baseline situation 2 months after exttoction of the maxillary left
premolars and mokJrs.
Fig 2 A panoramic radiograph obtainedafterbilateral implantplacement.
fflrst-premo/ar sites} Md bi!at.Yal SFE. An ertensive perforation ofrile sinus
men1brane occurredon the le.ft. Note that the graft in theposterior portion
of the fdt sinus show'ed irregularities. The differential radicpadt:y of the
felt and rifjlt gaits is due to different gaffing mareriols used (nBftt sinus:
autQgenous bone and HAl~TCP compound; felt sinus: OllfOCMCUS bone
a.ndp.TCPJ.
194 ITI Treatment Guide- . Volume S
7.3.4 Bilateral Sinus Infection after
Perforat ion due to Res idual
Non-resorbable Barrier
Fragments
H. Katsuyama
A 45-year-old man present ed at our center for fixed
implant restorations in both posterior segments of the
maxilla. He had received implant treatment in the left
mandible 10 years previously. The n.arural dentition of in
the maxillary left posterior segment had be-en extracted
3 months prior to this consultation. A clinical examina-
tion revealed that soft tissue healing was uneventful.
With regard to the planned SFE procedures, a panoramic
radiograph and CBCT scan did not reveal any evidence
for pathological or anatomic.al problems (Fig 1). lateral
window SFE was performed bilaterally with simultane-
ous implant placement at the premolar sites. While no
intraoperative membrane perforation was noticed in
the right sinus, a large perforation resulted in the left
sinus (Fig 2). A collagen sponge reinforced by a silicone
membrane (Olympus Terumo Biomate-rials. Tokyo, Ja-
pan) was used to repair the perforation. Full coverage
of the perforated sites wa.s confirmed by direct mirror
visualization through an operative microscope. A pano-
ramic radiograph obtained postoperatively showed that
the repair attempt had fa iled. There was loss of graft-
ing material in the posterior pan of the augmented s ite.
Autogenous bone and a composite bone substitute (HA
and ~-TCP) was grafted into the right sinus. In the left si-
nus, .autogenous bone and resorbable ~-TCP was used to
avoid adhesion of grafting material to the sinus wall. No
signs of infection were observed bilaterally in the early
postoperative period.

Fig. 3 View obtained 2 months after bilamol sinus augmentution. Thete
is e.'idence ofsinusitis in the left maxillary segment fiHing mote lhan halfof
the sinus cavity, possibly caused by membrane perforarion or hemorrhagic
effi.IDon. In the ritftt ma;ciJlary segment,. some hypertrophy cF the sinus
membrane is apporenL.
Two months after surgery, the patient returned to re·
port bleeding into the oral cavity. A CBCT was obtained
for proper diagnosis a.nd revealed membrane perfora·
tion in the left sinus (Fig 3). Antibiotic tre.atment was
initiated but d id not prevent sinusitis from developing
2 weeks there•fter (Fig 4). A CBCT sc•n reve•led th•t
sinusitis had developed bilaterally with a cobweb-l ike
appearance of the membrane hypertrophy. A second
course of antibiotic treatment was prescribed. The
symptoms then gradually abated, even though mild
bleed ing into the oral cavity persisted. Steps that foJ.
lowed included debridement of t he left sinus a.nd re·
moval of the si licone membrane, which had been used
H. Katsuyama
Fig 4 CBCT scans obtained 2 weeks latet {i.e. 10 weeks after SFE). Sinusi·
tis had de\-eloped bilateralfy by that time. w.th the patient compJa;ning of
left nasal bfeeding.. Nore the cobweb-like membrane hyperuophy.
to reinfo rce the collagen sponge. After this interven·
tion, the symptoms of infection appeared to have re·
solved in both sinuses (Fig 5). Another 6 weeks later,
however, the patient reported symptoms in the right
nostril and, once again, bleeding into the oral cavity.
A CT scan demonstrated recurrence of the infection in
the right sinus (Fig 6). This time the treatment deci·
sion involved a radical surgical approach with creation
of a lateral window to remove a ll infected membrane
tissue from the right sinus . After hospitalization for
radical sinus surgery, two implants alre.ady installed at
the fi rst premolar sites were used for locator attach·
ments to stabilize a partia l denture.
ITI Treatment Guide· Volume S 195
7 Complications with Sinus Floor Elevation Procedures
Fig 5 Fcllo"int antibiotic ueatmem. !he left sinus was debride.d. Any re-
sid1JOI fragments of the silicone m~ne ~w-e re1noved. Indications are
that the inflammaa·on has re.solved in b«h sinuses.
Fig 6 later oo, the patient v;pen"enced symptoms ftom the right nostril.
A CT sam reveafed some residuol fragments in the wan of the right sinus.
After recurrence ofsinusitis was diQgnost:d, taefK.al surge_ry was performed
an
to femolle 'infected membtane tissue from rhe right sinus.
196 ITI Treatment Guide- . Volume S
The case presented here can be summarized as follows:
for unknown reasons, sinusitis may develop not only in
the sinus where membrane perforation occurred but also
in the contra.lateral non-perforated sinus. Some cases of
sinusitis ca.n be difficult to treat by antibiotic treatment
alone, once they have developed .
Clinical Recommendations
A collagen sponge reinforced by a silicone membrane
was used to repair the sinus peiforation in the present
case, which involved a need for stronger support. How-
ever, any non·resorbable silicone that may be retained
after complete resorption of the collagen will potentially
increase the risk of sinusitis.
- Any confirmed perforation of the sinus membrane
should prefer•bly be m•n•ged with • resorb•ble
grafting material. Grafting should only take place
upon successful repair of the perforated sinus.
- Aggressive membrane repair may not be indicated
if the membrane perforation is too large to support
the grafting material and a barrier membrane. The
chances of successful repair will depend on the size
of the perforation and on the position/ configura·
tion of the sinus cavity. Once SFE has been aborted,
at le.ast 6 months shou1d be allowed for complete
healing of the membrane. In most cases, the second
attempt at SFE will be more complicated. An alter·
native treatment option may need to be considered.
- Recent extraction sites may carry a higher risk of
sinus membrane perforation, due to irregularities
of the sinus floor and to fibrous adhesions. An
adequate healing period will be required if a com·
munication between the exuaction site and the
sinus floor has been confirmed at the time of tooth
removal.
 H. Katsuyama 7 Complications with Sinus Floor Elevation Procedures

7.3.5 Implant Loss due to The treatment plan was to provide implant-supported
fixed restorations in the maxilla and mandible . A staged
Unsuccessful Osseointegration
I
'li:
.. .. ~
approach was taken in the maxilla due to the reduced
bone height, with bone augmentation followed by a sec-
H. Katsuyama
A60-year-old man, whose residual dentition was reduced ..
;·,~-
ond procedure to place the implants.

to a few teeth in the mandibular anterior segment, pre- -..

- ' ~'L
sented himself for treatment. His desire was to have
implant-supported fi xed restorations in both jaws. He ' ~ ,·.m. i
smoked more than 10 cigarenes/day, but did not have
\
•
any systemic health problems. Soft tissue conditions in •
the maxilla were less than ideal, including ulcers and a -
Fig J Soft tissue conditions jn the maxilla at injfjal present®on. Note the
flabby anterior ridge (Fig 1). Bone quantity was adequate mucosa/ ulceration and bltUsh hue.
in the mandible, but the maxjlla was extremely atrophic
(Figs 2 and 3). Treatment was planned for a fixed rehabil- (J \)
itation of the mandible and for a staged procedure with
Fig 4 CT scan used fOr infflal treatmentplannm;:. B«h sinuses rereafeda
SFE prior to implant placement in the maxilla. A CBCT thin layer ofrottJ·ca1 bone at the floor and wolfs. Membrane proliferatk>n
scan was obtained for careful evaluation of the maxillary Mias obsetved it! the right sinus.

anatomy. which revealed mild hypertrophy of t he right

sinus membrane and an extremely thin I.ayer of corti-
cal bone on both sides (Figs 4 and 5). Placing implants
simultaneously with SFE was not an option. Therefore a
staged approach was planned, starting with a mixture of
autogenous bone and bone substitute (HA granules) to
augment the bone volume at the sinus floor, and con-
tinuing with a separate procedure to place the implants. Fig 2 Sa•erefy resorbed mo:xilk1 ofan edentulous patient
The- buccal cortica_I bone w<ls so thin and fragile that it
fractured from the needle when administering local <ln-
esthesia. It was extremely difficult to prepare the win-
dow and elevate the sinus membrane. which resulted in
perforation of the membrane bilaterally even with infil-
tration anesthesia. Both perforations were successfully
repaired, and no indication of graft loss was evident on
t he postoperative orthopantomograph (Fig 6). After 6 FJg 5 Magnified image ofleft sinus. Only 1 to 2 mm ofo thin bone waft
months of healing, two implants were placed into each remained ot the floor and buccal aspect of the sinus cavity. No cancellous
component "'1S obsen-ed at rhe site.
of the elevated sinus sites. Ideal primary stability wa.s
not attained (less than 15 Nern) due to the Jew density
of the cortical layer and the augmented sites (Fig n. A
submerged healing protocol was used, and the complete
denture was relined with a soft tjssue conditioner. After Fig 3 PtmMlmic rad'io£raph displaying the severity of the resorption in
1 month. the right dist al implant was found to be mobile the maxilla.
and was removed {Fig 8). The next implant to be lost was
t he left mesial implant, and eventually all implants were
lost {Figs 9 and 10). We did not attempt to perform an-
other SFE but proceeded to deliver a complete denture.

Fig 6 A staged approach starting with lateral window SFE was- used ;n Fw 7 After a healing Pffiod of6 months, four in1plants were placed in a
both sinuses. The bu«ol won of the Wws cavity was e.rtremely th;n and flapless approach.. Whife stability .,.us obtained. the final insettion torque
sett andpelfi:llation ofthe buccal bone wan was confirmed durine surgery. was less than 15 Ncm for a}f four implams.
The staiJ!d approadl was performed successfu'1y.

ITI Treatment Guide · Volume S 197 198 ITI Treatment Guide- . Volume S

Fig 8 Aft.era healing pe.riod of1 month, rhe rit}lr <Mta/ implant was found
to be mobile and wns- removed.
In summary, a thin cortical layer is a risk factor for SFE.
Even if SFE is successful, the low potential for new bone
formation may compromise new bone maturation. In
situations of this type. extraoral bone harvesting may be
considered to obtain a sufficient amount of aut ogenous
bone grafts with a high osteogenic potential, compensat-
ing for the reduced potential of bone healing.
Smoking is a risk factor in any implant trea tment. Es-
pecially when it comes to SFE procedures, smoking is
the predominant risk factor for surgical complications
and poor implant survival. Age may be a risk facto r if
additional bone harvestjng or radical surgery becomes
necessary.
H. Katsuyama
Fig 9 The left mesial implanc was found co be mobile and was removed
8 weeks ofter implant placement
Clinical Recommendations
Two risk factors need to be considered in patients exhib·
iting a thin conical layer: a reduced potential for primary
implant stability, and a reduced capacity for bone for·
mation. Compromised situ.ltions such .lS these shouk:I
be managed with autogenous bone that has osteogenic
potenti.11.
- The severely resorbed maxilla is usually character-
ized by a thin cortical l.lyer. Three-dimensional
bone augmentation is often required in this type of
s ituation.
- Extra.oral bone harvesting m.ly be considered in the
severely resorbed maxilla to obtain a sufficient bone
volume which, in addition, will offer an increased
osteogenic potential.
- ControlJing functional loading forces during the
healjng period is critical in fully edentulous patients.
A submerged healing protocol for the implants is
recommended to reduce the risk of excessive loading.
Fig 10 EvenwaNy, 10 weds after implant pklceme11t all maxiikuy im-
plants were lost because ofmobility.
ITI Treatment Guide · Volume S 199
7 Complications with Sinus Floor Elevation Procedures
7.4 Conclusions
SFE is a predictable surgical procedure when performed Acknowledgments
following appropriate diagnosis and meticulous treat-
ment planning. However, some failures .lnd complica- Research Support
tions must still be anticipated even if these require- Or. Shinichiro Kuroshima - Hokkaido University,
ments are met. As a result of its anatomic features, the Sapporo, Japan
s inus cavity is susceptible to infection. The incidence of
complications is modified by the presurgicaJ st.ate of the Or. Yoji Kami ura - Center of Implant Dentistry,
s inus cavity and anatomical conditions. Risk facto rs in- Yokohama, Japan
clude parameters related to the sinus membrane, soft
tissue conditions, healing capacity of the surrounding Dr. Kazutoshi Nakajima - Center of Implant Dentistry,
bone, and not least the surgeon's experience. Clinicians Yokohama, Japan
performing SFE procedures need to understand the dif-
ficulties and morbidity arising in the event of complica- Or. Yasushi Nakajima - Center of Implant Dentistry,
tions. They must be able to correctly judge the individ- Yokohama, J.lpan
ual risk and the presence of modifying f.lctors that may
cause these complications. Surgical Procedures
Or. Masaharu Mitsugi - OMS, Takamatsu. Japan
200 ITI Treatment Guide- . Volume S
 8 References
8.1 Re£ rences fc r I iterat re Re ew
{Chapter 2.3)
8 References
To iniprove the readabiliry of the chapter itself, the exten-
sive reference lists for the literature review in Chapter 2.3
have been placed here. List numbers refer to the super-
script numbers in brackets in Chapter 2.3. For complete
bibliographic data, please consult Chapte.r 8.2, Literature/
References.
List 1 Lateral window technique; 85 studies
Kent and Block 1989; Tidwell et al. 1992 ; Block and
Kent 1993; Raghoebar et al. 1993; Small et al. 1993;
Chiapasco and Ronchi 1994; Blomqvist et a l. 1996;
HUrzeler et al. 1996; Lundgren et al. 1996; Triplett et
al. 1996; Wheeler et al. 1996; Block and Kent 1997;
Oaelema.ns et al. 1997; Lundgren et al. 1997; Raghoe-
bar et al. 1997; Valentini and Abensur 1997; Block et
a l. 1998; Blomqvist et al. 1998; Fugazzotto and Vias·
sis 1998; Peleg et a l. 1998; van den Bergh et al. 1998;
Watzek et al. 1 998; Zitzmann and Scharer 1998; De Le-
onardis and Pecora 1999; Johansson et al. 1999; Keller
et al. 1999; Khoury et al. 1999; Lekholm et al. 1999;
Mazor et al. 1999; Peleg et al. 1999a, 1999b; Kassolis
et al. 2000; Lorenzoni et a l. 2000; Olson et al. 2000;
Mazor et al. 2000; Valentini et al. 2000; van den Bergh
et al. 2000b; Wannfors et al. 2000; Cordioli et al. 2001:
Hallman et al. 2001 ; Kahn berg et al. 2001; Raghoebar
et al. 2001a; Tawil and Mawla 2001; Hallman et al.
2002a; Hallman et al. 2002b; Kan et al. 2002; Pej rone
et al. 2002; Engelke et al. 2003; Mangano et al. 2003;
McCanhy et al. 2003; Philippan et al. 2003; Pin holt
2003; Reinen et al. 2003; Rodriguez et al. 2003; Strick·
er et al. 2003; Valentini and Abensur 2003; Hallman
and Nordin 2004; Hallman and Zenerqvist 2004; Ha-
tano et al. 2-004; lturriaga and Ruiz 2004; Lundgren et
al. 2004; Shlomi et al. 2004; Simion et al. 2004; Velich
et al. 2004; Butz and Huys 2005; Hallman et al. 2005;
Rodoni et a l. 2005; Wiltfang et al. 2005; Zijderveld et al.
2005; Mangano et al. 2006; Orsini et al. 2006; Peleg et
al. 2006; Becktor et al. 2007; Chen et al. 2007; Galindo-
Moreno et al. 2007~ Krennmair et al. 2007; Mangano et
al. 2007; Marchetti et al. 2007; Mardinger et al. 2007;
Thor et al. 2007; Bornstein et al. 2006; Chiapasco et al.
2008; Kahnberg and Vannas-Lofqvist 2008; Chaushu et
al. 2009; Dasmah et al. 2009; Degidi et al. 2009; Fer·
reira et al. 2009.
m Treatment Guide ~ Volume S 201 202 ITI Treatment Guide- . Volume S
List 2 Bone substitute material only; 19 studies
Small et al. 1993; Valentini and Abensur 1997; Zitzmann
and Scharer 1998; Valentini et a.I. 2000; van den Bergh et
al. 2000b; Tawil and Mawla 2001; Hallman et al. 2002b;
Kan et a.I. 2002; Mangano et a.I. 2003; Valentini and
Abe.nsur 2003; Hallman and Nordin 2004; Rodoni et al.
2005; Mangano et al. 2006; Orsini et al. 2006; Mangano
et al. 2007; Ma.rdinger et al. 2007; Ferreira et al. 2009;
Dasmah et al. 2009; Chaushu et al. 2009.
list 3 Aut ograft material on ly or a combination of
autograft material and a bone substitute; 36 studies
Blomqvist et al. 1996; Lundgren et al. 1996; Daelemans
et al. 1997; Lundgren et al. 1997; Blomqvist et al. 1998;
Peleg et al. 1998; van den Bergh et al. 1998; Johansson
et al. 1999; Keller et al. 1999; Mazor et al. 1999; Pele.g
et al. 1999b; Wannfors et al. 2000; Hallman et a l. 2001;
Kahnberg et al. 2001 ; Raghoebar et al. 2001a; Hallman
et al. 2002a. 2002b; Kan et al. 2002; Pejrone et al. 2002;
Reinert et al. 2003; Stricker et al. 2003; Hallman and Zet-
terqvist 2004; Hatano et al. 2004; Shlomi et al. 2004;
Hallman et al. 2005; Wiltfang et al. 2005; Becktor et al.
2007; Chen et al. 2007; Krennmair et al. 2007; Marchetti
et al. 2007; Bornstein et al. 2008; Kahnberg and Vanna.s-
Lofqv ist 2008; Degidi et al. 2009.
List 4 DBBM only; 11 studies
Zitzmann and Scharer 1998; Valentini et al. 2000; Tawil
and Maw la 2001; Hallman et al. 2002b; Valentini and
Abensur 2003; Hallman and Nordin 2004; Rodoni et al.
2005; Orsini et al. 2006; Mangano et al. 2007; Mardinger
et al. 2007; Ferreira et al. 2009.
List 5 OBBM and particulated autograft material;
11 studies
Ha.ta.no et al. 2004; Shlomi et al. 2004; Hallman et al.
2005; Krennmair et al. 2007; Marchetti et al. 2007; Born-
stein et al. 2008; Degidi et al. 2009.
List 6 Autogenous block grafts; 10 studies
Daelemans et a l. 1997; Lundgren et al. 1997; Blomqvisi
et al. 1998; Johansson et al. 1999; Keller et al. 1999;
Wannfors et al. 2000; Kahnberg et a l. 2001: Raghoebar
et al. 2001 b; Pejrone et al. 2002; Becktor et al. 2007.

List 7 Particulated autografts from different donor
s ites; 7 studies
Lundgren et al. 1996; van den Bergh et al. 1998; Wan-
nfors et al. 2000; Hallman et al. 2002b; Stricker et al.
2003; Wi ltfang et al. 2005; Kahnberg and Vannas-
Lofqvist 2008.
List 8 Composite graft consisting of particulated
autograft and allograft; 4 studies
Peleg et al. 1998; Mazor et al. 1999; Peleg et al. 1999:
Kan et al. 2002
List 9 Alloplastic particulate in the form of
hydroxyapatite; 3 studies
Mangano et al. 2003; Mangano et al. 2006; Mangano et
al. 2007
List 10 DFDBA and DBBM; 3 studies
Valentini and Abensur 1997; Kan et al. 2002; Valentini
and Abensur 2003
List 11 No grafting material; 3 studies
Lundgren et al. 2004; Chen et al. 2007: Thor et al. 2007
List 12 Barrier membrane; 16 studies
Small et al. 1993; Peleg et a l. 1998; Zitzmann and Schar-
er 1998; Mazor et al. 1999; Valentini et al. 2000; Cordioli
et al. 2001: Hallman et al. 2002b; Shlomi et al. 2004;
Orsini et al. 2006; Krennmair et al. 2007; Mardinger et
al. 2007; Bornstein et al. 2008; Chaushu et al. 2009; Das-
mah et al. 2009; Ferreira et al. 2009.
List 13 No membrane; 28 studies
Blomqvist et al. 1996; Lundgren et al. 1996; Daelemans
et a l. 1997; Lundgren et al. 1997; Valentini and Aben-
sur 1997; Blomqvist et a l. 1998; van den Bergh et al.
References 8
1998; Peleg et al. 1999a; van den Bergh et al. 2000b;
Hallman et al. 2001; Kahnberg et a l. 2001 ; Raghoebar et
al. 2001b; Hallman et al. 2002a, 2002b; Mangano et al.
2003; Reinert et al. 2003; Stricker et at 2003; Valentini
and Abensur 2003; Hallman and Zetterqvist 2004; Ha-
tano et al. 2004; Lundgren et al. 2004; Mangano et al.
2006; Becktor et al. 2007; Chen et al. 2007; Mangano et
al. 2007; Marchetti et al. 2007; Thor et al. 2007; Kahn-
berg and Vannas-lofqvist 2008.
List 14 Transcrestal e levation; 18 studies
Zitzmann and Scharer 1998; Fugazzotto and De Paoli
2002; Winter et al. 2002; B r~gger et al. 2004; Deporter
et al. 200S; Leblebicioglu et al. 200S; Rodoni et al. 2005;
Ferrigno et al. 2006; Stavropoulos et al. 2007; Krennmair
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List 1 S Subantral bone height; 14 studies
Stavropoulos et al. 2007
List 16 No grafting material; 8 studies
Winter et al. 2002; Leblebicioglu et a l. 2005; FermergArd
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List 17 DBBM only; 4 studies
Zitzmann and Scharer 1998; Deporter et al. 2005; Ro-
doni et al. 2005; Krennmair et al. 2007
List 18 Autologous bone; 2 studies
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m ITI
Implant Therapy in the Esthetic
Zone -Single-Tooth Replacements
268 pages• 833 images • hardcover • ISBN 978-3-938947- 10-4
Languages: English, German, Italian, Ponuguese, Japanese, Chinese, Russian
In Treatment Guide Vol. I focuses on implant therapy for single-
tooth edentulous spaces in the esthetic zone. It takes its readers
through the entire process, starting with the assessment of the
patient's individual esthetic risk profile and proceeding to ideal three-
dimensional implant placement and proven prosthetic management
options. The various aspects are illustrated using patient case studies.
Detailed illustrations serve to clarify any potential ambiguities. An
analysis of the potential complications in esthetic implant dentistry
completes this first volume.
D. Wistneije;, D. Buser. U. Bel""r (EdiL)
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ITI Treatment Guide Vol. 2:
fl'I
Loading Protocols in Implant
Dentistry - Partially Dentate Patients
184 pages• 420 images • hardcover • ISBN 978-3-938947-1 2-8
Languages: English, German Italian, Portuguese, Japanese, Chinese, Russian
In Ireatment Guide Vol. 2 is devoted to the restoration of partially
dentate patients Central to this volume of the ITI Treatment Guide
are loading protocols available to the clinician and the patient and
how they relate to various treatment indications. including both sin-
gle and multiple missing teeth in the posterior and anterior regions
of the mouth.
For further infor mation, please visit www.quintessenz.de/iti
9 QUINTESSENCE f I Ii' I l'.l IH ,, '
FOR YOUR LIBRARY
D. Buser, D. Wisrneiier; U. Belser (EdiL)
ITI Treatment Guide Vol. 3:
Implant Placement in Post-Extraction
Sites - Treatment Options
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2 16 pages • 553 images • hardcover • ISBN 978-3-938947- 14-2
Languages: English. German, Japanese, C hinese
In Treatment Guide Vol. 3 was created to provide clinicians with
practice-oriented infoomation about implants inserted in post-
extraction sites. It aims at supporting clinicians not only in their
evidence-based choice ofthe appropriate implant placement protocol
but also in their detailed treatment planning and execution.
D. Wismeiier. D. Buser. U. Belser (EdiL)
ITI Treatment Guide Vol. 4:
ITI
Loading Protocols in Implant
Dentistry - Edentulous Patients
248 pages • 746 images • hardcover • ISBN 978-3-938947- 16-6
Languages: English. German. Italian, French. Spanish. Portuguese, Japanese.
Chinese
I n Treatment Guide Vol. 'I presents implant therapy approaches and
procedures in the edentulous jaw with a special focus on loading
protocols.After discussing the current evidence base in the literature
and a summary of the most recent relevant I n Consensus State-
ments it proceeds to guide readers through the entire treatment
process. 13 detailed case studies and illustrations clarify potential
ambiguities and complications to help clinicians master the most
common challenges in clinical practice.
For further information, please visit www.quintessenz.de!iti
~QUINTESSENCE - I ·t·.
Dental implants are used routinely throughout the world to replace missing teeth. With the broad-
ening of treatment options and an increasing numbers of clinicians that provide implant therapy,
it is important to ensure that the treatment methods used meet the highest clinical standards.

The ITI Treatment Guide series is a compendium of evidence-based implant-therapy techniques

in daily practice. Written by renowned clinicians and supported by contributions from expert
practitioners, the ITI Treatment Guides provide a comprehensive overview of various therapeutic
options. The management of different clinical situations is discussed with an emphasis on sound
diagnostics, evidence-based treatment concepts, and predictable treatment outcomes with mini-
mal risk to the patient.

Volume S of the ITI Treatment Guide series provides clinicians with evidence-based data and prac-
tical information relating to sinus floor elevation procedures. Strong emphasis has been placed on
proper case selection, based on a comprehensive clinical and radiological examination of the pa-
tient. Detailed case studies and illustrations support the clinical recommendations and highlight
the challenges associated with the management of complications of these surgical procedures.

The forthcoming Volume 6 of the ITI Treatment Guide series will address the implant-based reha-
bilitation of patients with extended edentulous spaces in the anterior zones.

ISBN : 978-3-9 38947-18·0

• For Sound Diagnostics

• For Evidence-Based Treatment Concepts
• For Predictable Outcomes