J Clin Periodontol 2008; 35 (Suppl. 8): 216–240 doi: 10.1111/j.1600-051X.2008.01272.x
A systematic review of the success
of sinus floor elevation and survival
of implants inserted in combination
with sinus floor elevation
Part I: Lateral approach
Bjarni E. Pjetursson1,2, Wah Ching
Tan3, Marcel Zwahlen4 and
Niklaus P. Lang2,5
1
Faculty of Odontology, University of Iceland,
Reykjavik, Iceland; 2School of Dental
Medicine, University of Berne, Berne,
Switzerland; 3Department of Restorative
Dentistry, National Dental Center, Singapore;
4
Research Support Unit, Department of
Social and Preventive Medicine, University of
Berne, Berne, Switzerland; 5University of
Hong Kong, Prince Philip Dental Hospital,
Hong Kong SAR
Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of
sinus floor elevation and survival of implants inserted in combination with sinus floor
elevation. Part I: Lateral approach. J Clin Periodontol 2008; 35 (Suppl. 8): 216–240.
doi: 10.1111/j.1600-051X.2008.01272.x.
Abstract
Objectives: The objectives of this systematic review were to assess the survival rate
of grafts and implants placed with sinus floor elevation.
Material and Methods: An electronic search was conducted to identify studies on sinus
floor elevation, with a mean follow-up time of at least 1 year after functional loading.
Results: The search provided 839 titles. Full-text analysis was performed for 175 articles
resulting in 48 studies that met the inclusion criteria, reporting on 12,020 implants. Metaanalysis indicated an estimated annual failure rate of 3.48% [95% confidence interval
(CI): 2.48%–4.88%] translating into a 3-year implant survival of 90.1% (95% CI: 86.4%–
92.8%). However, when failure rates was analyzed on the subject level, the estimated
annual failure was 6.04% (95% CI: 3.87%–9.43%) translating into 16.6% (95% CI:
10.9%–24.6%) of the subjects experiencing implant loss over 3 years.
Conclusion: The insertion of dental implants in combination with maxillary sinus
floor elevation is a predictable treatment method showing high implant survival rates
and low incidences of surgical complications.
The best results (98.3% implant survival after 3 years) were obtained using rough
surface implants with membrane coverage of the lateral window.
Conflict of interest and source of
funding statement
The authors declare that they do not have
any conflict of interests.
The study was self-funded by the authors
and their institutions and the Clinical
Research Foundation (CRF) for the Promotion of Oral Health, University of Berne,
Switzerland. Dr. Wah Ching Tan was an ITI
Scholar for the year 2006/2007 (ITI Foundation, Basel, Switzerland, Educational grant).
The 6th European Workshop on Periodontology was supported by an unrestricted
educational grant from Straumann AG.
216
Elevation of the maxillary sinus floor
was first reported by Boyne in the
1960s. Fifteen years later, Boyne &
James (1980) reported on elevation of
the maxillary sinus floor in patients with
large, pneumatized sinus cavities in
preparation for the placement of blade
implants. The authors described a twostage procedure, where the maxillary
sinus was grafted using autogenous particulate iliac bone at the first stage of
surgery. After approximately 3 months,
a second stage surgery was performed in
which blade implants were placed and
Key words: biological complications; bone
augmentation; bone grafting; complications;
dental implants; failures; lateral approach;
longitudinal; meta-analysis; peri-implantitis;
sinus augmentation; sinus floor elevation;
sinus grafting; success; survival; systematic
review
Accepted for publication 20 May 2008
later used to support fixed or removable
reconstructions (Boyne & James 1980).
It is evident that the reduced vertical
bone height in the posterior maxillary
region often limited standard implant
placement. An elevation of the maxillary sinus floor is an option in solving
this problem. Various surgical techniques have been presented to enter the
sinus cavity elevating the sinus membrane and placing bone grafts.
To date, two main techniques of sinus
floor elevation for dental implant placement are in use: a two-stage technique
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
with a lateral window approach, followed by implant placement after a
healing period, and a one-stage technique using either a lateral or transalveolar
approach. The decision to apply the oneor the two-stage techniques is based on
the amount of residual bone available
and the possibility of achieving primary
stability for the inserted implants.
In cases where bone grafts are favored,
autogenous bone grafts are considered the
gold standard due to their maintenance of
cellular viability and presumptive osteogenic capacity. The use of autogenous
grafts in sinus floor elevation was first
reported by Boyne & James (1980) and
Tatum (1986).
Grafts may be harvested intra-orally
or extra-orally. Common intra-oral
donor sites include the maxillary tuberosity, the zygomatico-maxillary buttress, the zygoma, the mandibular
symphysis as well as the body and
ramus of the mandible. The harvested
bone may be used as block sections or
particulate grafts.
The extra-oral donor sites include the
anterior or posterior iliac crest, the tibial
plateau, the rib and the calvaria.
Autologous bone grafts contain bone
morphogenic proteins (BMPs) capable
of attracting osteogenic cells from the
surrounding tissues. They also contain
other growth factors essential for the
process of graft incorporation.
Tricalcium phosphate was the first
bone substitute to be applied successfully for sinus floor elevation (Tatum
1986). Over the years, allografts, alloplasts and xenografts of various types
have been used alone or in combination
with autografts.
One indication for using bone substitutes is to reduce the volume of autogenous bone to be harvested. When a
large sinus cavity is grafted with autogenous bone alone, 5–6 ml of bone may
by necessary. The amount of autogenous
bone to be harvested is greatly reduced
when bone substitutes are applied alone
or in combination with autografts.
In a clinical study (Ellegaard et al.
2006), 131 implants were placed using
the lateral approach. The sinus membrane was elevated, implants were
inserted and left to protrude into the
sinus cavity. The sinus membrane was
allowed to settle onto the apices of the
implants, thus creating a space to be
filled with blood coagulum. After a
mean follow-up time of 5 years, the
survival rate of these implants was
90%. It must be kept in mind, however,
that the residual bone height in this study
was at least 3 mm.
Of the 900 patient records that were
screened for the Sinus Consensus Conference in 1996 (Jensen et al. 1998), only
100 had radiographs of adequate quality
for analysis of the residual bone height.
In total, only 145 grafted sinuses in 100
patients, with 349 implants were analyzed. After a mean follow-up period of
3.2 years, 20 implants were lost. Of the
implants lost, 13 were initially placed in
residual bone with a height 44 mm,
seven were placed in residual bone
with a height of 5–8 mm. None of the
implants placed in residual bone height
of more than 8 mm was lost. There was a
statistically significant difference in
implant loss when residual bone height
was 4 mm or less, as compared with
5 mm or greater (Geurs et al. 2001).
Several treatment options have been
utilized in posterior maxillae to overcome the problem of inadequate bone
quantity. The most conservative treatment is the insertion of short implants to
avoid the need for entering the sinus
cavity. However, for placement of short
implants, at least 6 mm of residual bone
height is still required. Another way of
avoiding grafting the maxillary sinus
would be the placement of tilted
implants in a position mesial or distal
to the sinus cavity if these areas yield
adequate bone quantity. However, in
patients with appropriate residual bone
height, minor augmentation of the sinus
floor may be accomplished via the
transalveolar technique using osteotomes (Summers 1994, Rosen et al.
1999, Ferrigno et al. 2006).
Of the various options, the most invasive treatment for sites with inadequate
residual bone height for implant placement is the one- or two-staged sinus
floor elevation via lateral approach. By
mastering these different methods, most
edentulous areas in the maxilla may by
restored with implant-supported reconstructions. The concept of a shortened
dental arch must also be considered. The
work of Käyser (1981) showed that
patients maintain adequate chewing
capacity of 50–80% with a premolar
occlusion (Fontijn-Tekamp et al. 2000).
A review prepared for the Consensus
Meeting of the European Association of
Osseointegration (EAO) (Renouard &
Nisand 2006) concluded on the basis
of 12 studies on machined surface
implants and 22 studies on rough textured implants that the survival and
success rates of short (410 mm)
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
217
implants were comparable to those
obtained with longer implants.
In 2003, Wallace and Froum published a systematic review on the effect
of maxillary sinus floor elevations and
the survival of dental implants. The
criteria for review included human studies with a minimum of 20 interventions,
a follow-up time of one year of functional loading and with an outcome variable of implant survival being reported.
The main results indicated:
i. A survival rate of implants placed
in conjunction with sinus floor
elevation with the lateral approach
varied between 61.7% and 100%,
with an average of 91.8%.
ii. Implant survival rates compared
favorably with reported survival
rates for implants placed in the
non-grafted maxillae.
iii. Rough surfaced implants yielded
higher survival rates than did
machined surface implants when
placed in grafted sinuses.
iv. Implants placed into sinuses elevated with particulate autografts
showed higher survival rates than
those placed in sinuses that had
been augmented with block grafts.
v. Implant survival rates were higher when barrier membranes were
placed over the lateral window.
vi. The utilization of grafts consisting of 100% autogenous bone or
the inclusion of autogenous bone
as a component of composite
grafts did not affect implant
survival.
Unfortunately, the factor of the residual height affecting the survival rate of
implants in sinus-grafted sites was not
examined in the review. Hence, it is of
great interest to review the survival of
implants placed in grafted sinus sites
with residual bone height of 6 mm
or less.
The objectives of this systematic
review were to assess the survival rates
of grafts and implants placed in sites
with sinus augmentation via the lateral
approach, with a mean residual bone
height of 6 mm or less, and to evaluate
the incidence of surgical complications.
218
Pjetursson et al.
Material and Methods
First electronic search:
839 titles
Search strategy and study selection
A MEDLINE (PubMed) search from
1965 up to November 2007 was conducted for articles published in the
dental literature, and limited to human
trials, using the search terms ‘‘sinus
lift’’, ‘‘sinus augmentation’’, ‘‘sinus
grafting’’, ‘‘sinus floor elevation’’.
Manual searches of the bibliographies
of all full text articles and related
reviews selected from the electronic
search were also performed.
Independently selected by 2 reviewers:
160 titles
Abstracts obtained
Discussion
Agreed on 143 abstracts
Full text obtained
Hand search added:
32 titles
Inclusion criteria
Because of the absence of appropriate
RCTs, this systematic review included
prospective and retrospective cohort studies. The additional inclusion criteria
for study selection were:
publications in the dental literature,
based on human subjects, without
language restriction,
studies with a mean follow-up time
of at least 1 year or more after
functional loading,
mean residual bone height at the site
of implant placement of up to 6 mm,
studies reporting on implant survival
rates,
case series with a minimum of 10
patients,
studies without multiple interventions (like simultaneous ridge augmentations), and
studies with clearly defined survival
or success criteria.
Studies on sinus augmentation via the
transalveolar approach were excluded in
this review and will be separately analyzed (Tan et al. 2008).
Selection of studies
Titles and abstracts of the searches were
initially screened by two independent
reviewers (B. E. P. & W. C. T.) for
possible inclusion in the review. The
full text of all studies of possible
relevance was then obtained for independent assessment by the reviewers.
Any disagreement was resolved by discussion. The k values were 0.76 and
0.53 at the title and abstract levels,
respectively.
Figure 1 describes the process of
identifying the 48 studies selected from
an initial yield of 839 titles. Data were
extracted independently by the two
Total full text articles.
175
Exclusions:
2: not reporting on sinus floor elevation
29: reporting on the transalveolar technique.
26: no survival data or no distinction of survival data between
implants inserted in sites with various grafting techniques
10: mean follow-up < 1 year in function or no loading time
8: mean residual bone height > 6 mm or majority of implants
inserted in sites with residual bone height > 6 mm
24: no information on residual bone height
7: combination of grafting techniques
10: sample size of less than 10 patients
11: multiple publications on the same patient cohorts
Final number of studies included:
48
Fig. 1. Search strategy.
reviewers using a data extraction form.
Disagreement regarding data extraction
was resolved in consensus.
Excluded studies
Of the 175 full-text articles examined,
127 were excluded from the final analysis (see reference list).
The main reasons for exclusion were
(Fig. 1):
not reporting on sinus floor elevation,
no survival data or no distinction of
survival data between implants
placed in sites with various grafting
techniques,
mean follow-upo1 year in function
or no loading time,
no information on residual bone
height or mean residual bone height
46 mm or majority of implants
placed in sites with residual bone
height 46 mm,
combination of grafting techniques,
sample size of o10 patients,
multiple publications on the same
patient cohorts, and
studies applying the transalveolar
technique
Data extraction
The data was analyzed separately for
sinus floor elevation with the lateral or
the transalveolar techniques.
Of the 48 studies included, information on the survival of the sinus grafts
and implants were retrieved. Survival
was defined as implants remaining in
situ at the follow-up, irrespective of
their conditions. Failure was defined as
implants that were lost, before or after
functional loading.
Complications included Schneiderian
membrane perforation, infection and
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
total graft loss, resulting in inability of
implant installation.
Statistical analysis
Failure rates were calculated by dividing
the number of events (failures or complications) in the numerator by the total
exposure time (implant-time) in the
denominator.
The numerator was usually extracted
directly from the publication. The total
exposure time was calculated by taking
the sum of
(1) The exposure time of implants that
could be followed for the whole
observation time.
(2) The exposure time up to a failure of
implants that were lost during the
observation time.
(3) The exposure time up to the end of
observation time for implants that
did not complete the observation
period due to reasons such as death,
change of address, refusal to participate in the follow-up, chronic illnesses, missed appointments and
work commitments.
For each study, event rates for
implants were calculated by dividing
the total number of events by the total
implant exposure time in years. For
further analysis, the total number of
events was considered to be Poisson
distributed for a given sum of implant
exposure years and Poisson regression
with a logarithmic link-function and
total exposure time per study as an
offset variable were used (Kirkwood &
Sterne 2003a).
Robust standard errors were calculated to obtain 95% confidence intervals
(CIs) of the summary estimates of the
event rates. The Spearman goodness-offit statistics and associated p-values
were calculated to assess heterogeneity
of the study specific event rates. If the
goodness-of-fit p-value was below 0.05,
indicating
heterogeneity,
randomeffects Poisson regression (with Gamma-distributed random-effects) was
used to obtain a summary estimate of
the event rates. One-year survival proportions were calculated via the relationship between event rates and
survival function S, S(T) 5 exp( T event rate), by assuming constant event
rates (Kirkwood & Sterne 2003b). The
95% CI for the survival proportions
were calculated by using the 95% confidence limits of the event rates.
Multivariable Poisson regression was
used to investigate formally whether
event rates varied by grafting material,
surgical approach, implant surfaces,
membrane coverage of the lateral window, smoking status, bone availability
and study design.
All analyses were performed using
Statas, version 8.2 (Stata Corp., College Station, TX, USA).
Results
Included studies
A total of 48 studies on implants
inserted in combination with sinus floor
elevation utilizing the lateral approach
were included in the analysis. The characteristics of the selected studies are
shown in Table 1.
The first study was published in 1996.
The median year of publication was
2002. Twenty-six of the studies were
prospective and the remaining 22 were
retrospective studies (Table 1).
The 48 studies included around 4,000
patients between 15 and 86 years of age.
Information on patient drop-out was
retrieved from 17 of the 48 studies and
ranged from 0% to 20% (Table 1). The
studies were mainly conducted in an
institutional environment such as
universities or in specialist’s clinics
(Table 1).
Surgical approach
Two different surgical techniques to
access the sinus cavity were utilized in
the 48 studies. The most frequently used
technique (28 studies) was the ‘‘trapdoor technique’’ or in-fracturing of the
cortical bony plate like a trap-door and
using it as the superior border of the
sinus compartment leaving it attached to
the underlying Schneiderian membrane.
The second surgical technique reported
was the preparation of an access hole by
removing the entire buccal bone plate
before the elevation of the sinus membrane. This method was used in 12 of
the studies. The remainder of the studies
did not report any details on the surgical
techniques used (Table 1).
Fourteen studies reported on sinus
floor elevations where the implants
were placed simultaneously (one-stage)
and 16 studies reported on sinus floor
elevation with delayed (two-stage) implant
installation at 3 to 12 months after sinus
grafting. Seventeen of the studies
reported on both one- or two-stage tech-
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
219
niques (Table 1). One study even randomized the patients into two groups
utilizing one- or two-stage techniques
(Wannfors et al. 2000). This RCT, however, included only 20 patients per treatment group and yielded insufficient
statistical power to make any definitive
conclusion regarding the result of the
surgical approach.
The decision to use the one- or the
two-stage technique was mainly based
on the amount of residual bone available
and the possibility of achieving primary
stability for the inserted implants.
Grafting material
Autogenous bone grafts which are considered the gold standard of grafting due
to their maintenance of cellular viability
and presumptive osteogenic capacity
were used in 23 out of the 48 studies.
In the older studies, published between
1996 and 2001, autogenous block grafts,
harvested from the iliac crest or intraorally were frequently used. Since 2001
no studies reported on sinus floor elevation using solely this grafting material.
In nine studies, particulate autogenous
bone harvested extra-orally from the
iliac crest and the calvaria (1 study) or
intra-orally were used as grafting materials. In 19 studies, a combination of
particulate autogenous bone and various
bone substitutes were used as grafting
material to reduce the volume of bone
that must be harvested. In these combination grafts, the ratio of autogenous
bone ranged between 20% and 70%. In
12 studies, various bone substitutes were
used alone without using additional
autogenous bone as grafting material.
Three out of the 48 studies did not report on the grafting materials utilized
(Table 1).
After inserting the grafting material, a
resorbable or non-resorbable membrane
was always used to cover the lateral
window in 11 out of the 48 studies. In
18 studies, no membrane coverage of
the lateral window was performed. Four
studies included both patients with and
without membrane coverage (Table 1).
A vast majority of the authors prescribed antibiotic prophylaxis in combination with sinus floor elevation
procedures. Twenty-five authors prescribed both pre- and post- surgical use
of antibiotics. In 2 studies, only presurgical antibiotics were prescribed and
in another nine studies, only post-surgical intake was prescribed. Moreover, in
two studies (Zitzmann & Schärer 1998,
Retrosp.
Retrosp.
Prosp.
2005
2005
2004
2004
Papa et al.
Weingart
et al.
Hallman &
Nordin
Hallman &
Zetterqvist
Prosp.
Retrosp.
2005
Retrosp.
Retrosp.
Ewers
2006a
Peleg et al.
Retrosp.
2005
2006
Lindenmüller
& Lambrecht
Prosp.
Baccar et al.
2006
Prosp.
2007
Karabuda
et al.
Retrosp.
2007
Krennmair
et al.
Marchetti
et al.
Prosp.
2007
GalindoMoreno et al.
Prosp.
Study
design
2008
Year of
publication
Bornstein
et al.
Study
Institution
Private
Institution
Institution
Institution
Institution
Private
Institution
Private
Institution
Institution
Institution
Institution
Institution
Institution
Setting
20
50
57
50
118
44
731
80
91
30
12
70
56
No. of
patients
48–69
23–82
20–69
35–60
NR
24–68
42–81
18–82
29–74
23–67
42–66
NR
19–74
Age
range
62
61
55
48
NR
43
53
57
46
48.8
53.8
NR
53.9
Mean
age
2 stage
(5 months)
1 stage
2.5
o5
o5
4
4–6
3.6
3
2 stage
(6 months)
2 stage
(8 months)
2 stage
(6 months)
2 stage
(6 months)
2 stage
(4–12
months)
2 stage
(6 months)
2 stage
(6–12
months)
1 stage
2.4
1–7
2 stage
1 stage
o5
4.5
X5
1 stage
Pre
Pre, post
Pre, post
Post
NR
Pre, post
Pre, post
Post
Pre, post
Pre, post
NR
Pre, post
(7.8 months)
1 stage
2 stage
(6–8 months)
2 stage
Pre
antibiotic
prophylaxis
2 stage
1 or 2
stage
5.3
3.5
o5
X5
o4
Residual
bone
height
(mm)
Table 1. Study and patient characteristics of the reviewed studies for implants in sinus graft (lateral approach)
Trap door
NR
Trap door
Trap door
Access hole
Access hole
Trap door
NR
Trap door
Trap door
Access hole
Access hole
Access hole
Trap door
surgical
approach
No
Yes
Resorbable
NR
NR
Yes
Resorbable
Nonresorbable
No
Yes
Resorbable
Resorbable
NR
Yes
Yes
Resorbable
No
Resorbable
Resorbable
Yes
Yes
membrane
coverage
Surgical procedure
DBBM1fibrin
glue
80% DBBM: 20%
ABG 1fibrin glue
90% AlgiPore/C
Graft/AlgOss
AlgOss110%
ABG1Blood or
PRP
ABG
DBBM
Coral HA
ABG particulate
50% ABG150%
DBBM/DFDBA/
bone cement
ABG1DBBM
ABG
ABG
Ceros 82
Algipore
DBBM1fully
synthetic
ceramic graft
70% ABG130%
DBBM
ABG1DBBM
ABG1DBBM1
PRP
ABG1DBBM
or -TCP
graft materials
0
NR
Brånemark
ITI
20
0
NR
NR
NR
ITI
NR
1.8
NR
7.7
NR
NR
NR
10.7
Spline Sulzer
Dental
Zimmer
ITI
Frialit
Camlog
Xive
MIS
Brånemark
Frialit-2
Camlog
Frialit
Microdent
Astra Tech
ITI
implant
types
Dropout (in
percent)
220
Pjetursson et al.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Retrosp.
2004
2004
2003
2003
Peleg et al.
Velich et al.
Mangano
et al.
McCarthy
et al.
2002
2002
2002
2001
2001
2001
2001
Engelke et al.
Hallman et al.
Kan et al.
Cordioli et al.
Geurs et al.
Hising et al.
Kahnberg
et al.
Prosp.
Retrosp.
Retrosp.
Prosp.
Retrosp.
Prosp.
Prosp.
Retrosp.
Prosp.
2003
2003
Prosp.
Retrosp.
Prosp.
Retrosp
2003
Valentini &
Abensur
Rodriguez
et al.
Stricker et al.
Prosp.
2004
Mazor et al.
Prosp.
2004
Iturriaga &
Ruiz
Prosp.
2004
Hatano et al.
Institution
Institution
Institution
Institution
Private
Institution
Institution
Institution
Institution
Institution
Institution
Institution
Private
Institution
Institution
Private
Private
Institution
Private
Institution
26
100
30
12
60
21
83
59
41
15
18
12
624
NR
105
58
191
40–72
NR
24–84
35–63
41–84
19–80
27–86
NR
38–73
NR
18–75
42–67
NR
NR
25–69
NR
26–76
56
NR
60
48
64.6
54
55.6
NR
55
NR
43.7
54
50
NR
51
NR
55.5
2 stage
(6 months)
1 stage
2 stage
(6 months)
2 stage
(6–9 months)
2.5
Post
NR
Pre, post
Post
Pre, post
Post &
in graft
No
NR
Post
NR
NR
NR
NR
2 stage
Pre, post
(11.9 months)
1 stage
Pre, post
2 stage
1 stage
44
3–5
5
o4
1 stage
44
o5
5.8
X5
o5
1 stage
o5
1 stage
2 stage
(4.9 months)
1 stage
2 stage
(6 months)
o4
Min 5
1 stage
X4
4.5
1 stage
2 stage
(6.5 months)
1 stage
1 stage
o5
2–6
1 stage
o5
Pre, post
2 stage
NR
(3–11 months)
o5
NR
1 stage
4–6
Trap door
Access hole
NR
Access hole
Trap door
Trap door
NR
Access hole
Trap door
Trap door
Trap door
Trap door
Trap door
NR
NR
Access hole
NR
Access hole
No
NR
No
Yes
Resorbable
Yes
Resorbable
No
NR
NR
No
No
Resorbable
Nonresorbable
No
No
Yes
No
NR
Yes
Resorbable
NR
NR
No
HA surface
Ti surface
Brånemark
ABG block (iliac)
Brånemark
11.5
NR
NR
0
NR
0
NR
1.7
IMZ
Brånemark
Various
0
0
NR
16.7
NR
NR
NR
NR
NR
ITI
NR
Brånemark
Brånemark
SIS
ITI Protetim
Mac system
Zimmer
Astra
3i Osseotite
Calcitek
Corevent
Semados
Zimmer
Brånemark
3i
20–30% ABG
particulate1
70–80% Biogran
Various
NR
ABG (i/o)1DBBM Various
80% DBBM:
20% ABG or
DBBM or ABG
ABG1DFDBA
DBBM1DFDBA
ABG1-TCP
50% DFDBA:
50% DBBM
DBBM
ABG (iliac)
DBBM1PRP
ABG block/
particulate 50%
ABG150%DBBM
HA
ABG1DBBM1
PRP
ABG alone
50% DBBM: 50%
ABG
Various
combinations
66% ABG: 33%
DBBM
ABG (calvarium)
Systematic review of sinus floor elevation
221
Retrosp.
Prosp.
Retrosp.
1999
1999
1998
1998
1998
Khoury
Kaptein et al.
Van den
Bergh et al.
Watzek et al.
Retrosp.
Prosp.
Prosp.
Retrosp.
Retrosp.
1998
1997
1997
1997
1997
1996
Zitzmann &
Schärer
Daelemans
et al.
Lundgren
et al.
Raghoebar
et al.
Schliephake
et al.
Blomqvist
et al.
Prosp.
Retrosp.
Retrosp.
Prosp.
Prosp.
2000
1999
Prosp.
Prosp.
2001
2000
Prosp.
Study
design
2001
Year of
publication
Johansson
et al.
Keller et al.
Van den
Bergh et al.
Wannfors
et al.
Raghoebar
et al.
Tawil &
Mawla
Study
Table 1. (Contd.)
Institution
Institution
Institution
Institution
Institution
Institution
Institution
Institution
Institution
Private
Institution
Institution
Institution
Institution
Institution
Institution
Institution
Setting
49
NR
43
20
33
10
20
42
77
216
37
NR
15–78
18–65
46–70
27–75
36–75
43–76
22–64
36–76
22–69
18–73
40–77
39–78
20
39
31–72
32–65
38–75
17–73
Age
range
20
24
29
99
No. of
patients
55
51.4
44
57
51.8
58
53.2
44
51
NR
56
56
57
54
50
56
48
Mean
age
1 or 2
stage
2 stage
(4 months)
2 stage
(4 months)
2 stage
(3–8 months)
o5
o4
2 stage
o5
2–4
o5
1 stage
2 stage
2 stage
(3–4 months)
1 stage
2 stage
1 stage
44
o5
4.4
1 stage
4–6
2.1
1–5
1 stage
2 stage
1 stage
2–4
o5
2 stage
(6 months)
1 stage
X5
1 stage
o5 (3) 2 stage
5.7 1 stage
2 stage
(6–9 months)
4–8
2 stage
(6 months)
2–7
1 stage
Residual
bone
height
(mm)
Pre, post
Pre, post
Post
Pre, post
Post
Pre, post &
in graft
Pre, post
Pre, post
Pre, post
Pre, post
NR
Pre, post
Pre, post
Trap door
NR
Trap door
Trap door
NR
Trap door
Trap door
Trap door
Trap door
Trap door
Access hole
Access hole
NR
Trap door
Trap door
Pre, post
Pre, post
Trap door
surgical
approach
Post
antibiotic
prophylaxis
NR
NR
No
NR
Resorbable
NR
Yes
No
No
Yes Nonresorbable
No
No
No
No
NR
Yes
Resorbable
No
No
No
membrane
coverage
Surgical procedure
ABG block
(iliac or i/o)
ABG block
(iliac)
ABG block1
particulate (iliac)
ABG (iliac)
ABG block
ABG block
(iliac)1ABG
particulate1HA
ABG particulate
(iliac)
ABG (iliac)
ABG (iliac)1HA
or DBBM
HA ABG (i/o)
1DBBM
DBBM block
ABG block
(iliac or i/o)
ABG block
(iliac or i/o)
ABG blocks1/
various fillers
ABG block (iliac)
ABG particulate
(iliac)
DFDBA
DBBM
ABG (iliac or i/o)
graft materials
Brånemark
Brånemark
Brånemark
Brånemark
Brånemark
NR
NR
NR
NR
NR
0
NR
IMZ
Frialen
Brånemark
0
NR
NR
NR
NR
0
0
NR
NR
ITI
IMZ
Brånemark
Frialit-2
IMZ
Brånemark
Brånemark
Brånemark
ITI
Brånemark
Brånemark
implant
types
Dropout (in
percent)
222
Pjetursson et al.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
o5
NR
30–71
50
Institution
Prosp.
1996
Zinner &
Small
ABG, autogenous bone graft; BG, Bioglass; CS, collagen sponge; DBBM, deproteinized bovine bone mineral; DFDBA, demineralized freeze-dried bone allograft; FDBA, freeze-dried bone allograft; HA,
Hydroxyapatite; -TCP, beta-tri-calcium phosphate; PRP, platelet-rich plasma; PTFE, poly-tetra-fluoro-ethylene; SLA, sandblasted, large-grit, acid-etched; Ti, Titanium; TPS, Titanium plasma-sprayed surface;
i/o, intra-oral; Min, minimum; NG, no graft; NR, not reported; Pre, pre-operative; Post, post-operative; Prosp., Prospective; Retrosp., Retrospective.
NR
Yes
Resorbable
Trap door
Pre, post
NR
1996
Wheeler et al.
Retrosp.
Private
24
18–74
57
o6
1 stage
2 stage
1 stage
NR
Trap door
Various
IMZ
3i Brånemark
ABG1
HA
DFDBA1coral HA coated TRS
NR
Systematic review of sinus floor elevation
Rodriguez et al. 2003) antibiotic powder
was also added to the grafting material.
In conclusion, only one author did not
prescribe prophylactic antibiotics after
sinus grafting. The information on the
use of antibiotics was not available in 11
of the studies (Table 1).
Survival of grafts
Eighteen of the 48 studies reported on
graft failure, defined as excessive graft
loss resulting in inability of implant
insertion at second stage surgery 3–12
months after sinus grafting. The incidence of graft failure ranged from 0% to
17.9%. From the original 2140 sinuses
that were grafted, 41 had total graft
failure, translating into a mean graft
failure of 1.9% (Table 2).
Surgical complications
When performing sinus floor elevation,
the risk of complications must be considered and the appropriate treatment
foreseen. The most common intraoperative complication was the perforation of the sinus membrane. This was
reported in 20 studies and ranged from
0–58.3%. The mean prevalence of membrane perforation was 19.5% (Table 2).
There is still a controversy whether this
complication influenced the survival
rate of the implants. Some authors
(Khoury 1999) reported a correlation
between membrane perforation and
implant failure while other studies
reported no correlation.
Smaller perforations (o5 mm) were
usually closed by using tissue fibrin
glue, suturing or by covering them
with a resorbable barrier membrane. In
conditions of larger perforations, larger
barrier membranes, lamellar bone plates
or suturing was used either alone or in
combination with tissue fibrin glue to
provide a superior border for the grafting material.
Infection of the grafted sinuses was a
rare complication. This was reported in
24 studies and the mean incidence was
2.9%, ranging from 0–7.4% (Table 2).
The risk for infection seemed to increase
with membrane perforation. Infection of
the grafted sinuses was usually seen 3 to
7 days post-surgically.
Other complications like excessive
bleeding from the bony window or the
sinus membrane, haematoma, wound
dehiscences, injury of the infraorbital
neurovascular bundle, implant migra-
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
223
tion into the sinus cavity were also
reported occasionally.
Survival of implants
Survival was defined as the implant
remaining in situ during the entire
observation period.
For implants inserted in combination
with sinus floor elevation, 48 studies
provided data on the survival of a total
of 12,020 implants after a mean followup time of 2.8 years (Table 3). 679
implants were reported to be lost. In
meta-analysis, the estimated annual failure rate was 3.48% (95% CI: 2.48%–
4.88%) translating into a 3-year implant
survival of 90.1% (95% CI: 86.4%–
92.8%) (Table 3). Furthermore, 2.6%
of the implants that were investigated
in these studies were lost during the
healing phase or before the implants
had been functionally loaded (Table 3).
None of the included studies had a
follow-up time of more than 10 years.
The longest mean observation period
(6.1 years) was reported by Valentini
& Abensur (2003).
However, when failure rate was analyzed based on subject level, the estimated annual failure was 6.04% (95%
CI: 3.87%–9.43%) translating into
16.6% (95% CI: 10.9%–24.6%) of the
subjects experiencing implant loss over
3 years (Table 4).
In a separate analysis, a group of 18
studies with a total of 2307 machined
surface implants and a group of 25
studies with a total of 6399 rough surface implants were analyzed. For the
former, the annual failure rate was
6.86%, translating into a survival of
only 81.4% after 3 years (Table 5) and
for the latter group the annual failure
rate was 1.19%, translating into a survival of 96.5% after 3 years (Table 6).
Moreover, 8.1% of the machined surface
implants were lost already during the
healing phase compared with only 1.1%
of the rough surface implants (Tables 5
and 6). Investigating the difference in
events rates in a Poisson regression analysis showed that the difference was
highly significant (po0.0001) (Table 15).
The relative failure rates of different
types of grafting materials were analyzed with multivariable random-effect
Poisson regression using bone substitutes alone as the reference, and including all implants (Table 7). The
combination of autogenous bone and
bone substitutes showed significantly
224
Pjetursson et al.
Table 2. Incidence of surgical complications with sinus floor elevation
Study
Bornstein et al.
Marchetti et al.
Galindo-Moreno et al.
Krennmair et al.
Lindenmüller & Lambrecht
Weingart et al.
Ewers
Papa et al.
Baccar et al.
Iturriaga & Ruiz
Peleg et al.
Hallman & Zetterqvist
Mazor et al.
Hallman & Nordin
Velich et al.
McCarthy et al.
Stricker et al.
Engelke et al.
Rodriguez et al.
Mangano et al.
Valentini & Abensur
Raghoebar et al.
Kahnberg et al.
Tawil & Mawla
Van den Bergh et al.
Khoury
Van den Bergh et al.
Kaptein et al.
Zitzmann & Schärer
Watzek et al.
Daelemans et al.
Raghoebar et al.
Zinner & Small
Year of
publication
2008
2007
2007
2007
2006
2005
2005
2005
2005
2004
2004
2004
2004
2004
2004
2003
2003
2003
2003
2003
2003
2001
2001
2001
2000
1999
1998
1998
1998
1998
1997
1997
1996
Range
(po0.001) lower annual failure rates
(1.47%) than bone substitutes used alone
as grafting material with an annual failure
rate of 2.59% (Table 7). Both particulated
autogenous bone and autogenous bone
blocks as grafting materials showed higher failure rates than bone substitutes used
alone, with annual failure rates of 5.69%
and 7.41%, respectively. This difference
however, did not reach statistical significance (p 5 0.077; 0.090) (Table 7).
When the same analysis was repeated
using bone substitutes alone as the reference with only rough surface implants
and excluding machined surface
implants, the results changed dramatically (Table 8). Bone substitutes, combination of autogenous bone and bone
substitutes and autogenous bone blocks
all showed similar annual failure rates of
1.13%, 1.10% and 1.27%, respectively.
The particulated autogenous bone graft
showed significantly (p 5 0.008) lower
annual failure rates of 0.06%. It must,
Total no.
of grafts
59
48
98
12
98
114
209
76
45
79
194
30
105
71
810
27
66
118
24
12
78
182
39
30
30
216
62
88
10
40
44
81
57
3252
Membrane
perforation
Post operative
infection
Total graft
failure
no.
%
no.
%
no.
%
18
0
0
7
11
NR
43
8
6
NR
NR
9
NR
10
NR
NR
25
28
NR
NR
NR
47
NR
5
6
52
3
14
NR
4
NR
28
NR
30.5
0
0
58.3
11.2
NR
20.6
10.5
13.3
NR
NR
30
NR
14.1
NR
NR
37.9
23.7
NR
NR
NR
25.8
NR
16.7
20
24.1
4.8
15.9
NR
10
NR
34.6
NR
19.5%
0–58.3%
1
1
0
NR
3
NR
25
2
1
2
0
2
3
2
NR
2
NR
1
0
0
1
7
NR
0
2
NR
2
2
NR
NR
NR
2
2
1.7
2.1
0
NR
3.1
NR
12.0
2.6
2.2
2.5
0
6.7
2.9
2.8
NR
7.4
NR
0.8
0
0
1.3
3.8
NR
0
6.7
NR
3.2
2.3
NR
NR
NR
2.5
3.5
2.9%
0–12.0%
1
0
0
NR
0
3
1
3
NR
2
0
NR
NR
NR
22
1
NR
1
0
0
NR
NR
7
NR
NR
NR
NR
NR
0
NR
0
0
NR
1.7
0
0
NR
0
2.6
0.5
3.9
NR
2.5
0
NR
NR
NR
2.7
3.7
NR
0.8
0
0
NR
NR
17.9
NR
NR
NR
NR
NR
0
NR
0
0
NR
1.9%
0–17.9%
however, be kept in mind that all types
of grafting materials had high survival
rates ranging between 96.3% and 99.8%
after 3 years (Table 8).
Furthermore, the implants were
grouped according to the surgical technique utilized. Twenty-four studies with
a total of 5672 implants inserted at time
of sinus grafting (one-stage technique)
and 25 studies with a total of 3560
implants inserted 3–12 months after
sinus grafting (two-stage technique).
The implants inserted with the one-stage
technique had a slightly higher annual
failure rate (4.07%) (Table 9), than
implants inserted with the two-stage
technique with a annual failure rate of
3.19% (Table 10), translating into a 3year survival of 88.5% and 90.9%,
respectively. This difference, however,
did not reach statistical significance
(p 5 0.461) (Table 15).
Furthermore, the studies were separated according to the surgical approach
utilized in relation to membrane placement over the lateral window. Thirteen
studies with a total of 4285 implants had
membranes placed over the lateral window after sinus grafting and 21 studies
with a total of 2990 implants had no
membrane used. For the membrane
group, the annual failure rate was
0.72%, translating into a survival of
97.9% after 3 years (Table 11) and for
the non-membrane group, the annual
failure rate was 4.04%, translating into
a survival of 88.6% after 3 years (Table
12). Investigating the difference in event
rates in a Poisson regression analysis
showed that this difference was highly
significant (p 5 0.001) (Table 15).
In addition, the nine studies that
utilized both rough surface implants
and membrane coverage of the lateral
window were analyzed separately. From
a total of 3579 implants included in
these studies, the incidence of implant
loss before functional loading was only
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
225
Systematic review of sinus floor elevation
Table 3. Annual failure rates and survival of implants inserted in combination with sinus floor elevation grouped by grafting materials
Study
Year of
publication
Total
no. of
implants
Mean
follow-up
time (years)
Autogenous bone block
McCarthy et al.
2003
29
Raghoebar et al.
2001
392
Kahnberg et al.
2001
91
Wannfors et al.
2000
76
Khoury
1999
467
Keller et al.
1999
139
Johansson et al.
1999
131
Watzek et al.
1998
53
Daelemans et al.
1997
121
Raghoebar et al.
1997
171
Schliephake et al.
1997
85
Blomqvist et al.
1996
171
Autogenous particulated bone
Weingart et al.
2005
284
Iturriaga & Ruiz
2004
223
Peleg et al.
2004
218
McCarthy et al.
2003
47
Stricker et al.
2003
183
Hallman et al.
2002
33
Wannfors et al.
2000
74
Van den Bergh et al.
1998
161
Lundgren et al.
1997
46
Combination of autogenous bone and bone substitutes
Bornstein et al.
2008
111
Marchetti et al.
2007
140
Galindo-Moreno et al.
2007
263
Peleg et al.
2006a
2132
Krennmair et al.
2007
12
Ewers
2005
614
Hatano et al.
2004
361
Peleg et al.
2004
218
Hallman & Zetterqvist
2004
79
Mazor et al.
2004
276
Engelke et al.
2003
211
McCarthy et al.
2003
5
Kan et al.
2002
26
Hising et al.
2001
104
Cordioli et al.
2001
27
Kaptein et al.
1998
357
Watzek et al.
1998
85
Zinner & Small
1996
215
Solely bone substitutes
Karabuda et al.
2006
259
Hallman & Nordin
2004
196
Rodriguez et al.
2003
70
Mangano et al.
2003
28
Valentini & Abensur
2003
187
Kan et al.
2002
202
Hallman et al.
2002
43
Tawil & Mawla
2001
61
Van den Bergh et al.
2000
69
Watzek et al.
1998
16
Zitzmann & Schärer
1998
20
Mixture of various combinations
Lindenmüller & Lambrecht
2006
201
Papa et al.
2005
228
Baccar et al.
2005
112
Velich et al.
2004
1482
Geurs et al.
2001
349
Wheeler et al.
1996
66
12020
Summary estimate (95% CI)n
n
Estimated
failure rate
(per 100
implant years)
Estimated
survival after
3 years (%)
71
1840
293
68
1611
578
316
236
384
275
210
241
12.68
1.74
11.95
23.53
1.18
3.46
10.13
1.27
2.08
3.27
9.52
12.45
68.4
94.9
69.9
49.4
96.5
90.1
73.8
96.3
93.9
90.6
75.1
68.8
0
0
0
0
0
NR
1
0
4
556
223
216
114
416
32
68
447
57
0
0
0.93
6.14
0.24
18.75
11.76
0
15.79
100
100
97.3
83.2
99.3
57.0
70.3
100
62.3
0
6
2
15
0
0
4
1
NR
0
9
0
0
NR
1
NR
1
0
2
1
0
29
0
27
17
0
NR
2
2
0
0
NR
0
NR
3
3
502
322
552
7620
45
3070
1047
217
309
502
404
12
90
475
26
1586
218
645
0.40
2.17
0.36
0.58
0
0.88
2.01
0.46
2.91
0.40
2.72
0
0
3.79
3.85
2.77
1.83
0.47
98.8
93.7
98.9
98.3
100
97.4
94.2
98.6
91.6
98.8
92.2
100
100
89.3
89.1
92.0
94.6
98.6
11
12
5
0
10
23
2
9
0
0
0
3
6
0
0
7
NR
NR
NR
0
0
0
8
6
5
0
3
NR
NR
NR
0
0
0
752
322
115
84
1134
678
43
101
171
27
28
1.46
3.73
4.35
0
0.88
3.39
4.65
8.91
0
0
0
95.7
89.4
87.8
100
97.4
90.3
87.0
76.5
100
100
100
20
17
2
81
20
5
679
10
17
NR
NR
NR
4
239
2.6%
10
0
NR
NR
NR
1
206
764
1055
335
1482
860
132
33,977
2.62
1.61
0.60
5.47
2.33
3.79
92.4
95.3
98.2
84.9
93.3
89.3
3.48 (2.48–4.88)
90.1 (86.4–92.8)
No. of
failure
Before
loading
After
loading
2.4
4.7
3
1
2.8
4.2
3
4.5
3.2
1.6
3.2
1.4
9
32
35
16
19
20
32
3
8
9
20
30
9
18
20
11
0
14
21
3
5
7
NR
23
0
14
15
5
19
6
11
0
3
2
NR
7
2
1
1
2.4
2.3
1
1
2.7
1.2
0
0
2
7
1
6
8
0
9
0
0
2
7
1
NR
7
0
5
5
2.3
2
3.5
3.7
5
3
1
5
1.8
2
2.4
3.5
4.6
1
4.4
2.6
3
2
7
2
44
0
27
21
1
9
2
11
0
0
18
1
44
4
3
3
1.6
1.6
3
6.1
3.4
1
1.7
2.5
1.7
1.4
3.8
5
3
1
2.5
2
2.8
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Total
implant
exposure
time
226
Pjetursson et al.
Table 4. Subject-based annual failure rates and percentage of patients without implant failures
Study
Year of
publication
Total
no. of
subjects
Mean
follow-up
time (years)
Total
no. of
implants
No. of
failure
Total
subject
exposure
time
Estimated
failure rate
(per 100
subject years)
Estimated
success after
3 years (%)
2008
2007
2007
2006
2005
2005
2004
2004
2004
2004
2003
2003
2002
2003
2003
2002
2001
2001
2001
2000
2000
1999
1999
1998
1998
1998
1997
1996
1996
1996
56
70
12
80
57
44
58
20
105
50
18
41
83
15
12
60
99
30
12
24
40
37
39
42
10
20
43
50
49
24
1300
5
2
3.7
3.8
2
3
1
5
1.8
1.6
2.4
2.3
2
1.6
3
3.4
4.7
4.6
1
2.5
1
4.2
3
2.7
1.4
3.1
1.6
3
1.4
2
2.7
111
263
12
201
284
112
223
79
276
196
81
183
211
70
28
228
392
104
27
69
150
139
131
161
20
154
171
215
171
66
4528
1
2
0
15
0
2
0
6
2
6
9
1
11
4
0
8
18
7
1
0
8
11
24
0
0
4
7
2
11
4
164
253
147
45
304
112
132
58
78
191
82
44
93
159
25
36
202
465
137
12
59
36
154
94
117
14
62
69
150
69
48
3447
0.40
1.36
0
4.93
0
1.52
0
7.69
1.05
7.32
20.45
1.08
6.92
16.0
0
3.96
3.87
5.11
8.33
0
22.22
7.14
25.53
0
0
6.45
10.14
1.33
15.9
8.33
98.8
96.0
100
86.2
100
95.6
100
79.4
96.8
80.3
54.1
96.8
81.3
61.9
100
88.8
89.0
85.8
77.9
100
51.3
80.7
46.5
100
100
82.4
73.8
96.1
62.0
77.9
6.04 (3.87–9.43)
83.4 (75.4–89.1)
Bornstein et al.
Galindo-Moreno et al.
Krennmair et al.
Lindenmüller & Lambrecht
Weingart et al.
Baccar et al.
Iturriaga & Ruiz
Hallman & Zetterqvist
Mazor et al.
Hallman & Nordin
McCarthy et al.
Stricker et al.
Engelke et al.
Rodriguez et al.
Mangano et al.
Kan et al.
Raghoebar et al.
Hising et al.
Cordioli et al.
Van den Bergh et al.
Wannfors et al.
Keller et al.
Johansson et al.
Van den Bergh et al.
Zitzmann & Schärer
Watzek et al.
Raghoebar et al.
Zinner & Small
Blomqvist et al.
Wheeler et al.
Total
Summary estimate (95% CI)n
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
Table 5. Annual failure rates and survival of machined surface implants inserted in combination with sinus floor elevation
Study
Marchetti et al.
Hatano et al.
Hallman & Zetterqvist
Valentini & Abensur
McCarthy et al.
Hallman et al.
Tawil & Mawla
Raghoebar et al.
Kahnberg et al.
Wannfors et al.
Keller et al.
Johansson et al.
Zitzmann & Schärer
Daelemans et al.
Raghoebar et al.
Schliephake et al.
Lundgren et al.
Blomqvist et al.
Total
Summary
estimate (95% CI)n
Year of
publication
Total
no. of
implants
Mean
follow-up
time (years)
No. of
failure
Before
loading
After
loading
Total
implant
exposure
time
Estimated
failure rate
(per 100
implant years)
Estimated
survival
after
3 years (%)
2007
2004
2004
2003
2003
2002
2001
2001
2001
2000
1999
1999
1998
1997
1997
1997
1997
1996
78
361
79
54
81
76
61
392
91
150
139
131
20
121
171
85
46
171
2307
2.3
3
5
5.8
2.4
1
1.7
4.7
5
1
4.2
3
1.4
3.2
1.6
3.2
1.2
1.4
2.8
5
21
9
7
16
8
9
32
35
24
20
32
0
8
9
20
9
30
294
NR
4
NR
NR
16
NR
NR
18
20
18
14
21
0
5
7
NR
5
23
151
8.1%
NR
17
NR
NR
9
NR
NR
14
15
6
6
11
0
3
2
NR
4
7
94
179
1047
309
292
197
75
101
1840
293
136
578
316
28
384
275
210
57
241
6558
2.79
2.01
2.91
2.40
8.12
10.67
8.91
1.74
11.95
17.65
3.46
10.13
0
2.08
3.27
9.52
15.79
12.45
92.0
94.2
91.6
93.1
78.4
72.6
76.5
94.9
69.9
58.9
90.1
73.8
100
93.9
90.6
75.1
62.3
68.8
6.86 (4.80–9.80)
81.4 (74.5–86.6)
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
227
Table 6. Annual failure rate and survival of rough surface implants inserted in combination with sinus floor elevation
Study
Bornstein et al.
Marchetti et al.
Galindo-Moreno et al.
Krennmair et al.
Peleg et al.
Karabuda et al.
Lindenmüller & Lambrecht
Weingart et al.
Baccar et al.
Iturriaga & Ruiz
Peleg et al.
Mazor et al.
Hallman & Nordin
Engelke et al.
Stricker et al.
Mangano et al.
Valentini & Abensur
Kan et al.
Cordioli et al.
Van den Bergh et al.
Watzek et al.
Van den Bergh et al.
Kaptein et al.
Zinner & Small
Wheeler et al.
Year of Total no.
Mean
No. of Before
After
Total
publi- of implants follow-up failure loading loading implant
cation
time (years)
exposure
time
2008
2007
2007
2007
2006a
2006
2006
2005
2005
2004
2004
2004
2004
2003
2003
2003
2003
2002
2001
2000
1998
1998
1998
1996
1996
111
62
263
12
2132
259
201
284
112
223
436
276
196
211
183
28
133
228
27
69
154
161
357
215
66
6399
5
2.3
2
3.7
3.5
3
3.8
2
3
1
1
1.8
1.6
2
2.3
3
6.8
3.4
1
2.5
3.1
2.7
4.4
3
2
3.0
2
2
2
0
44
11
20
0
2
0
3
2
12
11
1
0
3
23
1
0
7
0
44
3
5
198
Summary estimate (95% CI)n
0
NR
2
0
15
3
10
0
NR
0
3
2
6
9
1
0
NR
NR
1
0
4
0
NR
0
4
60
1.1%
2
NR
0
0
29
8
10
0
NR
0
0
0
6
2
0
0
NR
NR
0
0
3
0
NR
3
1
64
502
143
552
45
7620
752
764
556
335
223
433
502
322
404
416
84
842
768
26
171
481
447
1586
645
132
18,751
Estimated
failure rate
(per 100
implant years)
Estimated
survival
after
3 years (%)
0.40
1.40
0.36
0
0.58
1.46
2.62
0
0.60
0
0.69
0.40
3.73
2.72
0.24
0
0.36
2.99
3.85
0
1.46
0
2.77
0.47
3.79
98.8
95.9
98.9
100
98.3
95.7
92.4
100
98.2
100
97.9
98.8
89.4
92.2
99.3
100
98.9
91.4
89.1
100
95.7
100
92.0
98.6
89.3
1.19 (0.76–1.86) 96.5 (94.6–97.7)
n
Based on random-effects Poisson regression, test for heterogeneity po0.000.
0.6% and the annual failure rate was
0.6% as well, translating into a survival
of 98.3% after 3 years.
Five studies investigated the influence of smoking, although not clearly
defined, on implant survival after sinus
floor elevation. The patients were
divided according to their smoking status. A group of non-smokers with 2159
implants and a group of smokers who
received 863 implants were analysed.
The group of smokers had a higher
annual failure rate (3.54%) compared
with an annual failure rate of 1.86%
for the non-smokers (Table 13). However, this difference did not reach statistical difference (p 5 0.158) in Poisson
regression analysis (Table 15).
Six studies compared, within the
same patient cohort, the survival of
implants inserted in combination with
sinus floor elevation, with implants
inserted in residual neighbouring bone
without bone augmentation. Nine hundred and eighty-nine implants were
placed in sinus floor elevated sites, and
552 implants were inserted in a conventional way. The group of sinus implants
had a higher annual failure rate (8.72%)
compared with an annual failure rate of
5.99% for the implants inserted in pristine bone (Table 14). However, in a
Poisson regression analysis, this difference did not reach statistical difference
(p 5 0.277) (Table 15).
The 26 prospective studies and the 22
retrospective studies were also analyzed
separately. For the prospective studies,
based on 4202 implants, the annual failure rate was 3.86% (95% CI: 2.28%–
6.54%), and for the retrospective studies,
based on 7647 implants, the annual failure rate was 3.10% (95% CI: 2.06%–
4.66%) (Table 15). The difference in
event rates in a Poisson regression analysis confirmed the absence of a study
design effect (p 5 0.553) (Table 15).
Discussion
This systematic review is the first part of
a series addressing the survival and
complication rates of grafts and
implants placed in sinus augmentation
sites via the lateral and transalveolar
techniques.
The main indication for maxillary
sinus floor elevation utilizing a lateral
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
approach is the reduced residual bone
height, neither allowing standard implant
placement nor placement of implants in
combination with minor sinus floor elevation using the transalveolar approach.
Previous reviews did not consider the
amount of residual bone height in the
selection of studies. In one study (Geurs
et al. 2001), 20 out of 349 implants were
lost. 13 were lost at sites with residual
bone height of o4 mm, while 7 were
lost where residual bone height was
between 4 mm to 8 mm. No implants
were lost when the residual bone height
was 48 mm. This study showed that the
amount of residual bone height significantly influenced the implant survival
after sinus floor elevation.
In a recent publication (Lundgren et
al. 2004), 19 implants were inserted in
12 sinuses without any grafting material. The authors did not report any
implant loss and hence, advocated that
no grafting material was needed for
sinus floor elevation. The authors, however, stated that the mean residual bone
height was 7 mm. It must, therefore be
questioned whether implant survival
was due to the sinus floor elevation or
228
Pjetursson et al.
Table 7. Summary of annual failure rates, relative failure rates and survival estimates for implants inserted in combination with sinus floor
elevation.
Type of grafting
materials
Bone substitutes alone
Autogenous bone & bone
substitutes
Autogenous bone
particulated
Autogenous bone block
p-valuen
Total
number
of implants
Total
implant
exposure
time
Mean
follow-up
time
Estimated
annual
failure rate
3 year survival
summary
estimate
(95% CI)
Relative
failure
raten
1151
5236
3455
17,642
3.0
3.4
2.59w (1.38–4.85)
1.47w (0.98–2.19)
92.5%w (86.5%–95.9%)
95.7%w (93.6%–97.1%)
1.00 (Ref.)
0.36 (0.26–0.49)
po0.001
1269
2129
1.7
5.69w (1.50–21.50)
84.3%w (52.5%–95.6%)
0.68 (0.44–1.04)
p 5 0.077
1926
6312
3.2
7.41w (4.44–12.34)
80.1%w (69.1%–87.5%)
0.79 (0.60–1.04)
p 5 0.090
n
w
Based on multivariable random-effect Poisson regression.
Based on random-effects Poisson regression.
Table 8. Summary of annual failure rates, relative failure rates and survival estimates for rough surface implants inserted in combination with sinus
floor elevation
Type of grafting
materials
Bone substitutes
alone
Autogenous bone &
bone substitutes
Autogenous bone
particulated
Autogenous bone
block
Total
number
of implants
701
Total
implant
exposure
time
2198
Mean
follow-up
time
Estimated
annual
failure rate
3 year survival
summary
estimate
(95% CI)
3.1
1.13w (0.40–3.22)
96.7%w (90.8%–98.8%)
w
w
Relative
failure
raten
p-valuen
1.00 (Ref.)
3995
12,550
3.1
1.10 (0.66–1.81)
96.8% (94.7%–98.0%)
0.83 (0.49–1.41)
p 5 0.492
851
1642
1.9
0.06w (0.01–0.43)
99.8%w (98.7%–100%)
0.07 (0.009–0.49)
p 5 0.008
53
236
4.5
1.27w (0.26–3.71)
96.3%w (89.5%–99.2%)
1.00 (0.59–1.70)
p 5 0.995
n
w
Based on multivariable random-effect Poisson regression.
Based on random-effects Poisson regression.
the presence of 7 mm of residual bone
before the intervention.
In the present systematic review, studies that did not report the residual bone
height or studies with mean residual
bone height at the site of implant placement of more than 6 mm bone height
were excluded.
Based on 48 studies included and
reporting on 12,020 implants after a
mean follow-up time of 2.8 years, the
annual failure rate was 3.48%, translating into a 3-year implant survival of
90.1%. This is in agreement with previous reviews (Jensen et al. 1998, Wallace & Froum 2003) that reported a
survival rate of 90.0% and 91.8%,
respectively. With the use of rough surface implants, however, the 3-year survival rate increased to 96.5% and the
additional use of a membrane over the
lateral window further improved the
survival rate to 98.3%.
With regards to grafting materials
used, when all machined and rough
surface implants were included in the
analysis, studies utilizing bone substitutes alone or in combination with autogenous bone, showed higher survival
rates when compared with studies using
solely autogenous bone. On the other
hand, if only studies reporting on rough
surface implants were included in the
analysis, the 3-year survival rates were
similar for all types of grafting materials
ranging from 96.3% to 99.8%.
One randomized controlled clinical
trial (RCT) (Wannfors et al. 2000)
attempted to compare one- and twostage sinus floor elevations. This RCT
based on 40 patients divided into two
groups. The one-stage protocol with
75 implants placed reported a survival rate of 85.5% as compared with
the two-stage protocol with 90.5%
survival rate for 74 implants placed.
The present systematic review, however, did not reveal any statistically
significant difference between the two
protocols.
When performing sinus floor elevation, the risk of complications must be
considered and the appropriate treatment provided. The most frequently
encountered complication was the perforation of the sinus membrane
which occurred in 19.5% of the interventions, but it did not seem to influence
implant survival. The prevalence of
membrane perforation is in agreement
with previous studies (Block &
Kent 1997, Timmenga et al. 1997, Pikos
1999) reporting a perforation risk ranging between 10%–40%. In 1.9%
of the procedures, there was excessive
graft resorption resulting in impossible
implant placement.
Instead of performing a formal quality assessment of the included studies
and sensitivity analysis, this review used
stringent inclusion criteria. In order to
obtain more homogeneity, only studies
reporting on a mean residual bone
height of 6 mm or less were included
in this review. Nevertheless, 48 studies
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
229
Systematic review of sinus floor elevation
Table 9. Annual failure rates and survival of implants inserted simultaneously with sinus floor elevation (one-stage), grouped by grafting materials
Study
Year of
publication
Total
no. of
implants
Mean
follow-up
time (years)
Autogenous bone block
Raghoebar et al.
2001
86
Kahnberg et al.
2001
91
Wannfors et al.
2000
76
Khoury
1999
467
Keller et al.
1999
139
Johansson et al.
1999
131
Daelemans et al.
1997
121
Blomqvist et al.
1996
171
Autogenous particulated bone
Peleg et al.
2004
218
Combination of autogenous bone and bone substitutes
Marchetti et al.
2007
32
Galindo-Moreno et al.
2007
215
Peleg et al.
2006a
2132
Hatano et al.
2004
361
Peleg et al.
2004
218
Mazor et al.
2004
276
Engelke et al.
2003
175
Cordioli et al.
2001
27
Solely bone substitutes
Rodriguez et al.
2003
70
Mangano et al.
2003
28
Valentini & Abensur
2003
55
Tawil & Mawla
2001
41
Zitzmann & Schärer
1998
7
Zinner & Small
1996
215
Mixture of various combinations
Lindenmüller & Lambrecht
2006
168
Kan et al.
2002
152
5672
Summary estimate (95% CI)n
Estimated
failure rate
(per 100
implant years)
Estimated
survival
after
3 years (%)
404
293
68
1611
578
316
384
241
1.73
11.95
23.53
1.18
3.46
10.13
2.08
12.45
94.9
69.9
49.4
96.5
90.1
73.8
93.9
68.8
0
216
0.93
97.3
NR
1
15
4
1
0
NR
1
NR
0
29
17
0
2
NR
0
74
427
7620
1047
217
502
335
26
5.41
0.23
0.58
2.01
0.46
0.40
1.19
3.85
85.0
99.3
98.3
94.2
98.6
98.8
96.5
89.1
0
0
4
NR
0
0
5
0
3
NR
0
3
115
84
333
68
10
645
4.35
0
2.10
11.75
0
0.47
87.8
100
93.9
70.3
100
98.6
NR
NR
122
2.4%
NR
NR
125
639
512
16,765
2.19
2.15
93.6
93.8
4.07 (2.56–6.46)
88.5 (82.4–92.6)
No. of
failure
Before
loading
After
loading
7
35
16
19
20
32
8
30
NR
20
11
0
14
21
5
23
NR
15
5
19
6
11
3
7
2
2
2.3
2
3.5
3
1
1.8
2
1
4
1
44
21
1
2
4
1
1.6
3
6
1.7
1.4
3
5
0
7
8
0
3
3.8
3.4
3.0
14
11
295
4.7
3
1
2.8
4.2
3
3.2
1.4
1
Total
implant
exposure
time
n
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
with over 12,000 implants were available for analysis.
No language restriction was applied
in the present systematic review resulting in the initial inclusion of articles in
English, Mandarin, German, Dutch, Italian and French languages.
In the absence of appropriate RCTs, a
lower level of evidence, i.e., prospective and retrospective cohort studies
were included in the present systematic review. As prospective and retrospective studies were on different
levels of evidence, the results were
also analyzed separately for the two
groups of studies. The annual failure
rate, however, did not reveal significant difference between the two
groups indicating an absence of design
effect.
One limitation of the present review
is the assumption of a constant annual
event rate throughout the follow-up time
after placement of the reconstruction.
Hence, it must be kept in mind that the
mean observation period was an average
of 2.8 years when interpreting the
results.
The percentage of implant failure was
usually higher in the first year. This, in
turn, means that annual failure rates
based on a mean follow-up time of 3
years should not be extrapolated to
follow-up times measured in decades.
In the present study, the incidence of
implant loss before functional loading
was significantly higher for machined
surface implants compared with roughsurfaced implants with 8.1% versus
1.1%, respectively. Moreover, the present review demonstrated that longitudinal studies with observation periods of 10 years or more are completely
lacking.
The studies included were mainly
conducted in an institutional environ-
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
ment, such as universities or specialists’
clinics. Therefore, the long-term outcomes observed may not be generalized
to dental services provided in routine
private practice.
Literature based systematic reviews
of prognosis and survival outcomes are
hampered by a variety of problems (Altman 2001). The present systematic
review revealed several shortcomings
in the clinical studies reporting on sinus
floor elevation. Many of the studies on
the survival of implants placed in sinus
grafted sites failed to report the original
residual bone height at the site of presumptive implant placement and on
graft failures.
There is also a lack of RCTs with
sufficient statistical power comparing
various grafting materials.
Hence, it appears appropriate to make
the following recommendations: Only
studies with rough-surface implants
Year of
publication
Total no. of
implants
25
3
0
0
6
8
0
9
2
0
3
1
27
9
7
18
44
4
12
3
2
1
0
0
0
6
17
12
219
2
1
1
1
2.7
1.2
5
3.7
2.3
2
5
5
2
4.6
4.4
2.6
1.6
6.4
1
1.7
2.5
1.7
1.4
3.8
5
3.4
3.6
No. of
failure
4.7
4.5
Mean follow-up
time (years)
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
n
Autogenous bone block
Raghoebar et al.
2001
306
Watzek et al.
1998
53
Autogenous particulated bone
Weingart et al.
2005
284
Iturriaga & Ruiz
2004
223
Hallman et al.
2002
33
Wannfors et al.
2000
74
Van den Bergh et al.
1998
161
Lundgren et al.
1997
46
Combination of autogenous bone and bone substitutes
Bornstein et al.
2008
111
Krennmair et al.
2007
12
Marchetti et al.
2007
108
Galindo-Moreno et al.
2007
48
Ewers
2005
614
Hallman & Zetterqvist
2004
79
Engelke et al.
2003
36
Hising et al.
2001
104
Kaptein et al.
1998
357
Watzek et al.
1998
85
Solely bone substitutes
Hallman & Nordin
2004
196
Valentini & Abensur
2003
132
Hallman et al.
2002
43
Tawil & Mawla
2001
20
Van den Bergh et al.
2000
69
Watzek et al.
1998
16
Zitzmann & Schärer
1998
13
Mixture of various combinations
Lindenmüller & Lambrecht
2006
33
Papa et al.
2005
228
Kan et al.
2002
76
3560
Summary estimate (95% CI)n
Study
NR
17
NR
44
1.8%
6
3
NR
0
0
0
0
0
0
NR
2
0
NR
NR
NR
NR
1
0
0
NR
7
0
5
NR
3
Before
loading
NR
0
NR
44
6
0
NR
1
0
0
0
2
0
NR
0
27
NR
NR
NR
NR
3
0
0
NR
1
0
4
NR
0
After
loading
125
1055
256
12,562
322
840
43
33
171
27
18
502
45
248
95
3070
309
69
475
1586
218
556
223
32
68
447
57
1436
236
Total implant
exposure time
Table 10. Annual failure rates and survival of implants inserted ‘‘delayed’’ (two-stage) after sinus floor elevation, grouped by grafting materials
86.6
95.3
86.9
90.9 (85.2–94.5)
3.19 (1.90–5.35)
89.4
98.9
87.0
91.3
100
100
100
98.8
100
96.4
96.9
97.4
91.6
73.8
89.3
92.0
94.6
100
100
57.0
70.3
100
62.3
94.9
96.3
Estimated survival
after 3 years (%)
4.80
1.61
4.69
3.73
0.36
4.65
3.03
0
0
0
0.40
0
1.21
1.05
0.88
2.91
10.14
3.79
2.77
1.83
0
0
18.75
11.76
0
15.79
1.74
1.27
Estimated failure rate
(per 100 implant years)
230
Pjetursson et al.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
2008
2007
2007
2006a
2006
2005
2005
2004
2002
2001
2001
1998
1996
Year of
publication
111
263
12
2132
259
284
614
276
43
29
27
20
215
4285
Total no. of
implants
5
2
3.7
3.5
3
2
5
1.8
1
1.7
1
1.4
3
3.4
Mean follow-up
time (years)
2
2
0
44
11
0
27
2
2
2
1
0
3
96
No. of
failure
0
2
0
15
3
0
0
2
NR
NR
1
0
0
23
0.5%
Before
loading
2
0
0
29
8
0
27
0
NR
NR
0
0
3
69
After
loading
502
552
45
7620
752
556
3070
502
43
48
26
28
645
14,389
Total implant
exposure time
0.72 (0.52–1.01)
0.40
0.36
0
0.58
1.46
0
0.88
0.40
4.65
4.17
3.85
0
0.47
Estimated failure rate
(per 100 implant years)
2007
2004
2004
2003
2003
2003
2003
2003
2002
2002
2001
2001
2001
2001
2000
1999
1999
1998
1998
1998
1997
Year of
publication
140
361
79
70
28
187
183
81
33
26
32
104
392
91
69
139
131
155
161
357
171
2990
Total no. of
implants
2.3
3
5
1.6
3
6.1
2.3
2.4
1
3.5
1.7
4.6
4.7
5
2.5
4.2
3
3.1
2.7
4.4
1.6
3.4
Mean follow-up
time (years)
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
n
Summary estimate (95% CI)n
Marchetti et al.
Hatano et al.
Hallman & Zetterqvist
Rodriguez et al.
Mangano et al.
Valentini & Abensur
Stricker et al.
McCarthy et al.
Hallman et al.
Kan et al.
Tawil & Mawla
Hising et al.
Raghoebar et al.
Kahnberg et al.
Van den Bergh et al.
Keller et al.
Johansson et al.
Watzek et al.
Van den Bergh et al.
Kaptein et al.
Raghoebar et al.
Study
7
21
9
5
0
10
1
16
6
0
7
18
32
35
0
20
32
7
0
44
9
279
No. of
failure
6
4
NR
0
0
7
1
16
NR
0
NR
NR
18
20
0
14
21
4
0
NR
7
118
4.9%
Before
loading
1
17
NR
5
0
3
0
9
NR
0
NR
NR
14
15
0
6
11
3
0
NR
2
86
After
loading
322
1047
309
115
84
1134
416
197
32
90
52
475
1840
293
171
578
316
481
447
1586
275
10,260
Total implant
exposure time
4.04 (2.40–6.80)
2.17
2.01
2.91
4.35
0
0.88
0.24
8.12
18.75
0
1.35
3.79
1.74
11.95
0
3.46
10.13
1.46
0
2.77
3.27
Estimated failure rate
(per 100 implant years)
Table 12. Annual failure rate and survival of implants inserted in combination with sinus floor elevation where the lateral window was not covered with a membrane
Based on random-effects Poisson regression, test for heterogeneity p 5 0.0003.
n
Summary estimate (95% CI)n
Bornstein et al.
Galindo-Moreno et al.
Krennmair et al.
Peleg et al.
Karabuda et al.
Weingart et al.
Ewers
Mazor et al.
Hallman et al.
Tawil & Mawla
Cordioli et al.
Zitzmann & Schärer
Zinner & Small
Study
Table 11. Annual failure rate and survival of implants inserted in combination with sinus floor elevation where the lateral window was covered with a membrane
88.6 (81.5–93.1)
93.7
94.2
91.6
87.8
100
97.4
99.3
78.4
57.0
100
66.8
89.3
94.9
69.9
100
90.1
73.8
95.7
100
92.0
90.6
Estimated survival
after 3 years (%)
97.9 (96.7–98.6)
98.8
98.9
100
98.3
95.7
100
97.4
98.8
87.0
88.2
89.1
100
98.6
Estimated survival
after 3 years (%)
Systematic review of sinus floor elevation
231
232
80.5
71.0
94.8
87.5
82.3
93.1
72.4
83.5 (75.7–89.0)
7.23
11.43
1.80
4.44
6.50
1.37
10.75
5.99 (3.87–9.27)
should be included in future analyses, as
the use of machined surface implants
tended to skew the survival rates due to
low survival rates in sinus grafted sites.
Long-term cohort studies on implants
should be prospective, have complete
follow-up information preferentially
with similar lengths of follow-up for
all patients. This, in turn, means that
data on well-defined time periods should
be reported for the entire cohort,
especially for the different years after
installation.
The following conclusions can be
drawn from this systematic review:
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
77.0 (65.7–84.9)
8.72 (5.44–13.98)
Summary estimate (95% CI)n
n
91.6
89.4
69.9
58.9
73.8
90.6
68.8
5
1.6
3
1
3
1.6
1.4
1.9
Hallman & Zetterqvist
Hallman & Nordin
Kahnberg et al.
Wannfors et al.
Johansson et al.
Raghoebar et al.
Blomqvist et al.
2004
2004
2001
2000
1999
1997
1996
79
196
91
150
131
171
171
989
2.91
3.73
11.95
17.65
10.13
3.27
12.45
29
22
33
138
131
76
132
552
estimated survival
after 3 years (%)
estimated failure rate
(per 100 implant years)
total no. of
implants
estimated failure rate
(per 100 implant years)
estimated survival
after 3 years (%)
total no. of
implants
Implants in native bone
94.6 (90.7–96.9)
1.86 (1.05–3.27)
89.9 (81.2–94.7)
3.54 (1.80–6.95)
Implants with sinus floor elevation
Mean follow-up
time (years)
Year of
publication
Study
Based on random-effects Poisson regression, test for heterogeneity po0.0001.
n
Summary estimate (95% CI)n
Table 14. Comparison of annual failure rates and survival of implant inserted in combination with sinus floor elevation and implants inserted in non-augmented residual bone
94.3
98.5
94.8
93.2
91.2
1.96
0.52
1.77
2.34
3.05
91.4
97.9
89.1
84.1
85.7
Marchetti et al.
Peleg et al.
Lindenmüller & Lambrecht
Kan et al.
Geurs et al.
2007
2006b
2006
2002
2001
2.3
3.5
3.8
3.4
2.5
3.3
29
627
82
70
55
863
2.99
0.71
3.85
5.77
5.15
111
1505
119
158
266
2159
estimated survival
after 3 years (%)
estimated failure rate
(per 100 implant years)
total no. of
implants
estimated survival
after 3 years (%)
estimated failure rate
(per 100 implant years)
total no. of
implants
Smokers
Mean follow-up
time (years)
Year of
publication
Study
Table 13. Comparison of annual failure rates and survival of implants inserted in combination with sinus floor elevation, in smokers and non-smokers
Non- smokers
Pjetursson et al.
(1) Based on implant-based analysis,
the estimated annual implant failure
rate was 3.5% (95% CI: 2.5%–
4.9%). This translated into a 3-year
implant survival of 90.1% (95% CI:
86.4%–92.8%) based on implant
level.
(2) However, when failure rates was
analyzed based on subject level, the
estimated annual failure was 6.04%
(95% CI: 3.87%–9.43%) translating
into 16.6% (95% CI: 10.9%–24.6%)
of the subjects experiencing implant
loss over 3 years.
(3) The annual failure rate of machined
surface implants (6.9%) was significantly (po0.0001) higher than that
for rough surface implants (1.2%).
(4) The annual failure rate was significantly higher (4.0% versus 0.7%)
(p 5 0.001) when no membrane was
used to cover the lateral window
after the grafting procedure.
(5) In rough surface implants the 3-year
survival rates ranged between
96.3% and 99.8% depending on
the grafting material used.
(a.) The lowest annual failure rate
(0.1%) of rough surface implants
was observed using autogenous
particulated bone graft.
(b.) The annual failure rates of rough
surface implants were similar using
bone substitutes (1.1%) and combinations of autogenous bone and
bone substitutes (1.1%).
(6) Perforation of the sinus membrane
occurring in 19.5% of the procedures
was the most frequently reported
complication. The mean incidence
of post-operative graft infection was
2.9%. Graft loss resulting in inability
of implant placement was reported in
1.9% of cases.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
p 5 0.553
p 5 0.277
w
4202
Based on random-effects Poisson regression.
Based on multivariable random-effect Poisson regression.
7647
n
Study design
233
References
Implants inserted with sinus floor elevation
8.72 (5.44–13.98)
77.0% (65.7%–84.9%)
Retrospective studies
3.10 (2.06–4.66)
91.1% (87.0%–94.0%)
989
552
Bone availability
Implants inserted in residual bone
5.99 (3.87–9.27)
83.5% (75.7%–89.0%)
Prospective cohort studies
3.86 (2.28–6.54)
89.1% (82.2%–93.4%)
p 5 0.158
89.9% (81.2%–94.7%)
Smokers
3.54 (1.80–6.95)
863
94.6% (90.7%–96.9%)
2159
Smoking status
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1.86 (1.05–3.27)
p 5 0.001
2989
4285
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for lateral window
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0.73 (0.52–1.01)
97.8% (97.0%–98.4%)
Without membrane coverage
4.04 (2.40–6.80)
88.6% (81.5%–93.1%)
po0.0001
96.4% (94.6%–97.7%)
6399
81.4% (74.5%–86.6%)
2307
Implant surface
Machined surface
6.86 (4.80–9.80)
Rough surface
1.20 (0.78–1.84)
p 5 0.461
Delayed implant placement
3.18 (1.92–5.28)
90.9% (85.4%–94.4%)
3560
5672
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4.07 (2.56–6.46)
88.5% (82.4%–92.6%)
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of implants
3 year survival
summary estimate (95% CI)n
Estimated annual
failure raten
Total number
of implants
Type of comparison
Table 15. Annual failure rates and survival estimates of implants inserted in combination with sinus floor elevation.
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failure raten
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bone grafts to enable placement of SLAsurfaced implants: preliminary results after
15–40 months. Clinical Oral Implants
Research 14, 207–212.
Summers, R. B. (1994) A new concept in
maxillary implant surgery: the osteotome
technique. Compendium 15, 152–154–156,
158 passim; quiz 162.
Tan, W. C., Lang, N. P., Zwahlen, M. &
Pjetursson, B. E. (2008) A systematic review
of the success of sinus floor elevation and
survival of implants inserted in combination
with sinus floor elevation. Part II: Transalveolar technique. Journal of Clinical Periodontology 35 (Suppl. 8), 241–253.
Tatum, H. Jr. (1986) Maxillary and sinus
implant reconstructions. Dental Clinics of
North America 30, 207–229.
Tawil, G. & Mawla, M. (2001) Sinus floor
elevation using a bovine bone mineral (BioOss) with or without the concomitant use of a
bilayered collagen barrier (Bio-Gide): a clinical report of immediate and delayed implant
placement. International Journal of Oral
Maxillofacial Implants 16, 713–721.
Timmenga, N. M., Raghoebar, G. M., Boering,
G. & Van Weissenbruch, R. (1997) Maxillary
sinus function after sinus lifts for insertion of
dentalimplants. Journal of Oral and Maxillofacial Implants 55, 936–939.
Valentini, P. & Abensur, D. J. (2003) Maxillary
sinus grafting with anorganic bovine bone: a
clinical report of long-term results. International Journal of Oral Maxillofacial Implants
18, 556–560.
van den Bergh, J. P., ten Bruggenkate, C. M.,
Krekeler, G. & Tuinzing, D. B. (1998) Sinusfloor elevation and grafting with autogenous
iliac crest bone. Clinical Oral Implants
Research 9, 429–435.
van den Bergh, J. P., ten Bruggenkate, C. M.,
Krekeler, G. & Tuinzing, D. B. (2000)
Maxillary sinusfloor elevation and grafting
with human demineralized freeze dried
bone. Clinical Oral Implants Research 11,
487–493.
Velich, N., Nemeth, Z., Toth, C. & Szabo, G.
(2004) Long-term results with different bone
substitutes used for sinus floor elevation.
Journal of Craniofacial Surgery 15, 38–41.
Wallace, S. S. & Froum, S. J. (2003) Effect of
maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Annuals of Periodontology 8,
328–343.
Wannfors, K., Johansson, B., Hallman, M. &
Strandkvist, T. (2000) A prospective randomized study of 1- and 2-stage sinus inlay
bone grafts: 1-year follow-up. International
Journal of Oral Maxillofacial Implants 15,
625–632.
Watzek, G., Weber, R., Bernhart, T., Ulm, C. &
Haas, R. (1998) Treatment of patients with
extreme maxillary atrophy using sinus floor
augmentation and implants: preliminary
results. International Journal of Oral Maxillofacial Surgery 27, 428–434.
Weingart, D., Bublitz, R., Petrin, G., Kalber, J.
& Ingimarsson, S. (2005) [Combined sinus
lift procedure and lateral augmentation. A
treatment concept for the surgical and
prosthodontic rehabilitation of the extremely
atrophic maxilla]. Mund Kiefer und
Gesichtschirurgie 9, 317–323. (Article in
German).
Wheeler, S. L., Holmes, R. E. & Calhoun, C. J.
(1996) Six-year clinical and histologic study
of sinus-lift grafts. International Journal of
Oral Maxillofacial Implants 11, 26–34.
Zinner, I. D. & Small, S. A. (1996) Sinus-lift
graft: using the maxillary sinuses to support
implants. Journal American Dental Association 127, 51–57.
Zitzmann, N. U. & Schärer, P. (1998) Sinus
elevation procedures in the resorbed posterior
maxilla. Comparison of the crestal and lateral
approaches. Oral Surgery Oral Medicine
Oral Pathology Oral Radiology Endodontology 85, 8–17.
List of excluded full text articles and
the reason for exclusion
Ardekian, L., Oved-Peleg, E., Mactei, E. E. &
Peled, M. (2006) The clinical significance of
sinus membrane perforation during augmentation of the maxillary sinus. Journal of Oral
Maxillofacial Surgery 64, 277–282. Exclusion criteria: no information on residual bone
height.
Artzi, Z., Parson, A. & Nemcovsky, C. E.
(2003) Wide-diameter implant placement
and internal sinus membrane elevation in
the immediate postextraction phase: clinical
and radiographic observations in 12 consecutive molar sites. International Journal of Oral
Maxillofacial Implants 18, 242–249. Exclusion criteria: sinus augmentation via transalveolar technique.
Avera, S. P., Stampley, W. A. & McAllister, B.
S. (1997) Histologic and clinical observations
of resorbable and nonresorbable barrier membranes used in maxillary sinus graft containment. International Journal of Oral
Maxillofacial Implants 12, 88–94. Exclusion
criteria: sample size of less than 10 patients.
Barone, A., Santini, S., Sbordone, L., Crespi, R.
& Covani, U. (2006) A clinical study of the
outcomes and complications associated with
maxillary sinus augmentation. International
Journal of Oral Maxillofacial Implants 21,
81–85. Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
235
Becktor, J. P., Isaksson, S. & Sennerby, L.
(2004) Survival analysis of endosseous
implants in grafted and nongrafted edentulous maxillae. International Journal of Oral
Maxillofacial Implants 19, 107–115. Exclusion criteria: no information on residual bone
height.
Block, M. S., Kent, J. N., Kallukaran, F. U.,
Thunthy, K. & Weinberg, R. (1998) Bone
maintenance 5 to 10 years after sinus grafting. Journal of Oral Maxillofacial Surgery
56, 706–714; discussion 714–705. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Blomqvist, J. E., Alberius, P. & Isaksson, S.
(1998) Two-stage maxillary sinus reconstruction with endosseous implants: a prospective
study. International Journal of Oral Maxillofacial Implants 13, 758–766. Exclusion criteria: no information on residual bone height.
Brägger, U., Gerber, C., Joss, A., Haenni, S.,
Meier, A., Hashorva, E. & Lang, N. P. (2004)
Patterns of tissue remodeling after placement
of ITI dental implants using an osteotome
technique: a longitudinal radiographic case
cohort study. Clinical Oral Implants Research
15, 158–166. Exclusion criteria: sinus augmentation via transalveolar technique.
Bruschi, G. B., Scipioni, A., Calesini, G. &
Bruschi, E. (1998) Localized management of
sinus floor with simultaneous implant placement: a clinical report. International Journal
of Oral Maxillofacial Implants 13, 219–226.
Exclusion criteria: sinus augmentation via
transalveolar technique.
Buchmann, R., Khoury, F., Faust, C. & Lange,
D. E. (1999) Peri-implant conditions in periodontally compromised patients following
maxillary sinus augmentation. A long-term
post-therapy trial. Clinical Oral Implants
Research 10, 103–110. Exclusion criteria:
no survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Butz, S. J. & Huys, L. W. (2005) Long-term
success of sinus augmentation using a synthetic alloplast: a 20 patients, 7 years clinical
report. Implant Dentistry 14, 36–42. Exclusion criteria: no information on residual bone
height.
Cavicchia, F., Bravi, F. & Petrelli, G. (2001)
Localized augmentation of the maxillary
sinus floor through a coronal approach for
the placement of implants. International
Journal of Periodontics and Restorative Dentistry 21, 475–485. Exclusion criteria: sinus
augmentation via transalveolar technique.
Chanavaz, M. (1996) Sinus grafting related to
implantology. Statistical analysis of 15 years
of surgical experience (1979–1994). Journal
of Oral Implantology 22, 119–130. Exclusion
criteria: no information on residual bone
height.
Chanavaz, M. (2000) Sinus graft procedures and
implant dentistry: a review of 21 years of
surgical experience (1979–2000). Implant
Dentistry 9, 197–206. Exclusion criteria: no
information on residual bone height.
236
Pjetursson et al.
Chen, L. & Cha, J. (2005) An 8-year retrospective study: 1,100 patients receiving 1,557
implants using the minimally invasive
hydraulic sinus condensing technique. Journal of Periodontology 76, 482–491. Exclusion criteria: sinus augmentation via
transalveolar technique.
Chen, T. W., Chang, H. S., Leung, K. W., Lai,
Y. L. & Kao, S. Y. (2007) Implant placement
immediately after the lateral approach of the
trap door window procedure to create a
maxillary sinus lift without bone grafting: a
2-year retrospective evaluation of 47
implants in 33 patients. Journal of Oral
Maxillofacial Surgery 65, 2324–2328. Exclusion criteria: mean residual bone height
46 mm or majority of implants placed in
sites with residual bone height 46 mm.
Chiapasco, M. & Ronchi, P. (1994) Sinus lift
and endosseous implants–preliminary surgical and prosthetic results. European Journal
of Prosthodontics and Restorative Dentistry
3, 15–21. Exclusion criteria: mean follow-up
o1 year in function.
Coatoam, G. W. & Krieger, J. T. (1997) A fouryear study examining the results of indirect
sinus augmentation procedures. Journal of
Oral Implantology 23, 117–127. Exclusion criteria: Sinus augmentation via transalveolar technique.
Cordaro, L. (2003) Bilateral simultaneous augmentation of the maxillary sinus floor with
particulated mandible. Report of a technique
and preliminary results. Clinical Oral
Implants Research 14, 201–206. Exclusion
criteria: sample size of less than 10 patients.
Cosci, F. & Luccioli, M. (2000) A new sinus lift
technique in conjunction with placement of
265 implants: a 6-year retrospective study.
Implant Dentistry 9, 363–368. Exclusion
criteria: Sinus augmentation via transalveolar technique.
Cranin, A. N., Russell, D., Andrews, J. P. &
Mehrali, M. (1993) Immediate implantation
into the posterior maxilla after antroplasty:
the Cranin-Russell Operation. Journal of
Oral Implantology 19, 143–150. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
de Lange, G. L., Kuiper, L., Blijdorp, P. A.,
Hutter, W. & Mulder, W. F. (1997) [Fiveyear evaluation of implants in the resorbed
maxilla]. Nederlands Tijdschrift Voor Tandheelkunde 104, 274–276. (Article in Dutch).
Exclusion criteria: no information on residual bone height.
De Leonardis, D. & Pecora, G. E. (1999)
Augmentation of the maxillary sinus with
calcium sulfate: one-year clinical report
from a prospective longitudinal study. International Journal of Oral Maxillofacial
Implants 14, 869–878. Exclusion criteria:
mean follow-up o1 year in function.
Deporter, D., Todescan, R. & Caudry, S. (2000)
Simplifying management of the posterior
maxilla using short, porous-surfaced dental
implants and simultaneous indirect sinus elevation. International Journal of Periodontics
and Restorative Dentistry 20, 476–485.
Exclusion criteria: sinus augmentation via
transalveolar technique.
Deporter, D. A., Caudry, S., Kermalli, J. &
Adegbembo, A. (2005) Further data on the
predictability of the indirect sinus elevation
procedure used with short, sintered, poroussurfaced dental implants. International Journal of Periodontics and Restorative Dentistry
25, 585–593. Exclusion criteria: sinus augmentation via transalveolar technique.
Deporter, D. A., Todescan, R., Watson, P. A.,
Pharoah, M., Pilliar, R. M. & Tomlinson, G.
(2001) A prospective human clinical trial of
Endopore dental implants in restoring the
partially edentulous maxilla using fixed
prostheses. International Journal of Oral
Maxillofacial Implants 16, 527–536. Exclusion criteria: sinus augmentation via transalveolar technique.
Dimonte, M., Inchingolo, F., Di Palma, G. &
Stefanelli, M. (2002) [Maxillary sinus lift in
conjunction with endosseous implants. A
long-term follow-up scintigraphic study].
Minerva Stomatology 51, 161–165 (Article
in Italian). Exclusion criteria: no survival
data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Diserens, V., Mericske, E. & Mericske-Stern, R.
(2005) Radiographic analysis of the transcrestal sinus floor elevation: short-term
observations. Clinical Implant Dentistry and
Related Research 7, 70–78. Exclusion criteria: mean follow-up o1 year in function.
Eckert, S. E., Meraw, S. J., Weaver, A. L. &
Lohse, C. M. (2001) Early experience with
Wide-Platform Mk II implants. Part I:
implant survival. Part II: evaluation of risk
factors involving implant survival. International Journal of Oral Maxillofacial Implants
16, 208–216. Exclusion criteria: not reporting on sinus floor elevation.
Ellegaard, B., Baelum, V. & Kolsen-Petersen, J.
(2006) Non-grafted sinus implants in periodontally compromised patients: a time-toevent analysis. Clinical Oral Implants
Research 17, 156–164. Exclusion criteria:
no information on residual bone height.
Ellegaard, B., Kolsen-Petersen, J. & Baelum, V.
(1997) Implant therapy involving maxillary
sinus lift in periodontally compromised
patients. Clinical Oral Implants Research 8,
305–315. Exclusion criteria: no information
on residual bone height.
Ferrigno, N., Laureti, M. & Fanali, S. (2006)
Dental implants placement in conjunction
with osteotome sinus floor elevation: a 12year life-table analysis from a prospective study on 588 ITI implants. Clinical
Oral Implants Research 17, 194–205. Exclusion criteria: sinus augmentation via transalveolar technique.
Froum, S. J., Tarnow, D. P., Wallace, S. S.,
Rohrer, M. D. & Cho, S. C. (1998) Sinus
floor elevation using anorganic bovine
bone matrix (OsteoGraf/N) with and without
autogenous bone: a clinical, histologic, radiographic, and histomorphometric analysis–
Part 2 of an ongoing prospective study.
International Journal of Periodontics and
Restorative Dentistry 18, 528–543. Exclusion
criteria: no information on residual bone
height.
Froum, S. J., Wallace, S. S., Elian, N., Cho, S.
C. & Tarnow, D. P. (2006) Comparison of
mineralized cancellous bone allograft (Puros)
and anorganic bovine bone matrix (Bio-Oss)
for sinus augmentation: histomorphometry at
26 to 32 weeks after grafting. International
Journal of Periodontics and Restorative Dentistry 26, 543–551. Exclusion criteria: no
survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Fugazzotto, P. A. (1999) Sinus floor augmentation
at the time of maxillary molar extraction: technique and report of preliminary results. International Journal of Oral Maxillofacial Implants 14, 536–542. Exclusion criteria: sinus
augmentation via transalveolar approach.
Fugazzotto, P. A. (2003) GBR using bovine
bone matrix and resorbable and nonresorbable membranes. Part 2: clinical results.
International Journal of Periodontics and
Restorative Dentistry 23, 599–605. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Fugazzotto, P. A. & De, P. S. (2002) Sinus floor
augmentation at the time of maxillary molar
extraction: success and failure rates of 137
implants in function for up to 3 years. Journal
of Periodontology 73, 39–44. Exclusion criteria: sinus augmentation via transalveolar
approach.
Fugazzotto, P. A. & Vlassis, J. (1998) Longterm success of sinus augmentation using
various surgical approaches and grafting
materials. International Journal of Oral Maxillofacial Implants 13, 52–58. Exclusion criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Goga, D., Romieux, G., Bonin, B., Picard, A. &
Saffarzadeh, A. (2000) [Pre-implantation
iliac graft in the sinus. Retrospective study
of the complications encountered in 100
cases]. Revue de Stomatologie et de Chirurgie Maxillofaciale 101, 303–308. (Article in
French) Exclusion criteria: mean follow-up
o1 year in function.
Guarnieri, R., Grassi, R., Ripari, M. & Pecora,
G. (2006) Maxillary sinus augmentation
using granular calcium sulfate (surgiplaster
sinus): radiographic and histologic study at 2
years. International Journal of Periodontics
and Restorative Dentistry 26, 79–85. Exclusion criteria: no survival data or no distinction of survival data between implants placed
in sites with various grafting techniques.
Guttenberg, S. A. (1993) Longitudinal report
on hydroxyapatite-coated implants and advanced surgical techniques in a private practice. Compendium (Suppl. 15), S549–S553;
quiz S565–566. Exclusion criteria: no survival data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Hallman, M., Hedin, M., Sennerby, L. &
Lundgren, S. (2002) A prospective 1-year
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
clinical and radiographic study of implants
placed after maxillary sinus floor augmentation with bovine hydroxyapatite and autogenous bone. Journal of Oral Maxillofacial
Surgery 60, 277–284; discussion 285–276.
Exclusion criteria: multiple publications on
the same patient cohorts.
Hallman, M., Sennerby, L., Zetterqvist, L. &
Lundgren, S. (2005) A 3-year prospective
follow-up study of implant-supported fixed
prostheses in patients subjected to maxillary
sinus floor augmentation with a 80:20 mixture of deproteinized bovine bone and autogenous bone clinical, radiographic and
resonance frequency analysis. International
Journal of Oral Maxillofacial Surgery 34,
273–280. Exclusion criteria: multiple publications on the same patient cohorts.
Halpern, K. L., Halpern, E. B. & Ruggiero, S.
(2006) Minimally invasive implant and sinus
lift surgery with immediate loading. Journal
of Oral Maxillofacial Surgery 64, 1635–
1638. Exclusion criteria: no survival data
or no distinction of survival data between
implants placed in sites with various grafting
techniques.
Haris, A. G., Szabo, G., Ashman, A., Divinyi,
T., Suba, Z. & Martonffy, K. (1998) Fiveyear 224-patient prospective histological
study of clinical applications using a synthetic bone alloplast. Implant Dentistry 7,
287–299. Exclusion criteria: no survival
data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Hürzeler, M. B., Kirsch, A., Ackermann, K. L.
& Quinones, C. R. (1996) Reconstruction of
the severely resorbed maxilla with dental
implants in the augmented maxillary sinus:
a 5-year clinical investigation. International
Journal of Oral Maxillofacial Implants 11,
466–475. Exclusion criteria: mean residual
bone height 46 mm or majority of implants
placed in sites with residual bone height
46 mm.
Jensen, J. & Sindet-Pedersen, S. (1991) Autogenous mandibular bone grafts and osseointegrated implants for reconstruction of the
severely atrophied maxilla: a preliminary
report. Journal of Oral Maxillofacial Surgery
49, 1277–1287. Exclusion criteria: combination of grafting techniques.
Jensen, J., Sindet-Pedersen, S. & Oliver, A. J.
(1994) Varying treatment strategies for
reconstruction of maxillary atrophy with
implants: results in 98 patients. Journal of
Oral Maxillofacial Surgery 52, 210–216;
discussion 216–218. Exclusion criteria: no
information on residual bone height.
Jian, S., Cheynet, F., Amrouche, M., Chossegros, C., Ferrara, J. J. & Blanc, J. L. (1999)
[Maxillary pre-implant rehabilitation: a study
of 55 cases using autologous bone graft
augmentation]. Revue de Stomatologie et de
Chirurgie Maxillofaciale 100, 214–220.
(Article in French). Exclusion criteria: no
information on residual bone height.
Kan, J. Y., Rungcharassaeng, K., Lozada, J. L.
& Goodacre, C. J. (1999) Effects of smoking
on implant success in grafted maxillary
sinuses. Journal of Prosthetic Dentistry 82,
307–311. Exclusion criteria: no information
on residual bone height.
Kaptein, M. L., De Lange, G. L. & Blijdorp, P.
A. (1999) Peri-implant tissue health in reconstructed atrophic maxillae–report of 88
patients and 470 implants. Journal of Oral
Rehabilitation 26, 464–474. Exclusion criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Karabuda, C., Ozdemir, O., Tosun, T., Anil, A.
& Olgac, V. (2001) Histological and clinical
evaluation of 3 different grafting materials
for sinus lifting procedure based on 8 cases.
Journal of Periodontology 72, 1436–1442.
Exclusion criteria: sample size of less than
10 patients.
Kassolis, J. D., Rosen, P. S. & Reynolds, M. A.
(2000) Alveolar ridge and sinus augmentation utilizing platelet-rich plasma in combination with freeze-dried bone allograft: case
series. Journal of Periodontology 71, 1654–
1661. Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Keller, E. E., Eckert, S. E. & Tolman, D. E.
(1994) Maxillary antral and nasal one-stage
inlay composite bone graft: preliminary
report on 30 recipient sites. Journal of Oral
Maxillofacial Surgery 52, 438–447; discussion 447–438. Exclusion criteria: multiple
publications on the same patient cohorts.
Kent, J. N. & Block, M. S. (1989) Simultaneous
maxillary sinus floor bone grafting and placement of hydroxylapatite-coated implants.
Journal of Oral Maxillofacial Surgery 47,
238–242. Exclusion criteria: sample size of
less than 10 patients.
Khatiblou, F. A. (2005) Sinus floor augmentation and simultaneous implant placement.
Part I: the 1-stage approach. Journal of
Oral Implantology 31, 205–208. Exclusion
criteria: sinus augmentation via transalveolar approach.
Khatiblou, F. A. (2005) Sinus floor augmentation and simultaneous implant placement.
Part II: the 2-stage approach. Journal of
Oral Implantology 31, 209–212. Exclusion
criteria: sinus augmentation via transalveolar approach.
Komarnyckyj, O. G. & London, R. M. (1998)
Osteotome single-stage dental implant placement with and without sinus elevation: a
clinical report. International Journal of Oral
Maxillofacial Implants 13, 799–804. Exclusion criteria: sinus augmentation via transalveolar technique.
Kübler, N. R., Will, C., Depprich, R., Betz, T.,
Reinhart, E., Bill, J. S. & Reuther, J. F.
(1999) [Comparative studies of sinus floor
elevation with autologous or allogeneic bone
tissue]. Mund Kiefer und Gesichtschirurgie 3
(Suppl 1), S53–S60. Exclusion criteria: no
information on residual bone height.
Lambrecht, J. T., Filippi, A., Kunzel, A. R. &
Schiel, H. J. (2003) Long-term evaluation of
submerged and nonsubmerged ITI solidscrew titanium implants: a 10-year life table
analysis of 468 implants. International Jour-
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
237
nal of Oral Maxillofacial Implants 18, 826–
834. Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
Leblebicioglu, B., Ersanli, S., Karabuda, C.,
Tosun, T. & Gokdeniz, H. (2005) Radiographic evaluation of dental implants placed
using an osteotome technique. Journal of
Periodontology 76, 385–390. Exclusion
criteria: sinus augmentation via transalveolar technique.
Lekholm, U., Wannfors, K., Isaksson, S. &
Adielsson, B. (1999) Oral implants in combination with bone grafts. A 3-year retrospective multicenter study using the
Branemark implant system. International
Journal of Oral Maxillofacial Surgery 28,
181–187. Exclusion criteria: no information
on residual bone height.
Levin, L. & Schwartz-Arad, D. (2005) The
effect of cigarette smoking on dental implants
and related surgery. Implant Dentistry 14,
357–361. Exclusion criteria: no survival
data or no distinction of survival data
between implants placed in sites with various
grafting techniques.
Levine, R. A., Ganeles, J., Jaffin, R. A., Donald,
S. C., Beagle, J. R. & Keller, G. W. (2007)
Multicenter retrospective analysis of wideneck dental implants for single molar replacement. International Journal of Oral
Maxillofacial Implants 22, 736–742. Exclusion criteria: sinus augmentation via transalveolar technique.
Lin, Y., Wang, X. & Qiu, L. (1998) [Maxillary
sinus lifting, bone graft, and simultaneously
placement of implants]. Zhonghua Kou
Qiang Yi Xue Za Zhi 33, 326–328. Exclusion
criteria: sample size of less than 10 patients.
Lorenzetti, M., Mozzati, M., Campanino, P. P.
& Valente, G. (1998) Bone augmentation of
the inferior floor of the maxillary sinus with
autogenous bone or composite bone grafts: a
histologic-histomorphometric
preliminary
report. International Journal of Oral Maxillofacial Implants 13, 69–76. Exclusion criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Lorenzoni, M., Pertl, C., Wegscheider, W.,
Keil, C., Penkner, K., Polansky, R. &
Bratschko, R. O. (2000) Retrospective analysis of Frialit-2 implants in the augmented
sinus. International Journal of Periodontics
and Restorative Dentistry 20, 255–267.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Lundgren, S., Andersson, S., Gualini, F. &
Sennerby, L. (2004) Bone reformation with
sinus membrane elevation: a new surgical
technique for maxillary sinus floor augmentation. Clinical Implant Dentistry and Related
Research 6, 165–173. Exclusion criteria:
mean residual bone height 46 mm or majority of implants placed in sites with residual
bone height 46 mm.
Maiorana, C., Redemagni, M., Rabagliati, M. &
Salina, S. (2000) Treatment of maxillary
238
Pjetursson et al.
ridge resorption by sinus augmentation with
iliac cancellous bone, anorganic bovine bone,
and endosseous implants: a clinical and histologic report. International Journal of Oral
Maxillofacial Implants 15, 873–878. Exclusion criteria: mean follow-up o1 year in
function.
Maiorana, C., Sigurta, D., Mirandola, A., Garlini, G. & Santoro, F. (2005) Bone resorption
around dental implants placed in grafted
sinuses: clinical and radiologic follow-up
after up to 4 years. International Journal of
Oral Maxillofacial Implants 20, 261–266.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Maiorana, C., Sigurta, D., Mirandola, A., Garlini, G. & Santoro, F. (2006) Sinus elevation
with alloplasts or xenogenic materials and
implants: an up-to-4-year clinical and radiologic follow-up. International Journal of
Oral Maxillofacial Implants 21, 426–432.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Maiorana, C., Sommariva, L., Brivio, P., Sigurta, D. & Santoro, F. (2003) Maxillary sinus
augmentation with anorganic bovine bone
(Bio-Oss) and autologous platelet-rich
plasma: preliminary clinical and histologic
evaluations. International Journal of Periodontics and Restorative Dentistry 23, 227–
235. Exclusion criteria: no information on
residual bone height.
Mayfield, L. J., Skoglund, A., Hising, P., Lang,
N. P. & Attstrom, R. (2001) Evaluation
following functional loading of titanium fixtures placed in ridges augmented by deproteinized bone mineral. A human case study.
Clinical Oral Implants Research 12, 508–
514. Exclusion criteria: sample size of less
than 10 patients.
Mazor, Z., Peleg, M., Garg, A. K. & Chaushu,
G. (2000) The use of hydroxyapatite bone
cement for sinus floor augmentation with
simultaneous implant placement in the
atrophic maxilla. A report of 10 cases. Journal of Periodontology 71, 1187–1194. Exclusion criteria: no information on residual bone
height.
Mazor, Z., Peleg, M. & Gross, M. (1999) Sinus
augmentation for single-tooth replacement in
the posterior maxilla: a 3-year follow-up
clinical report. International Journal of Oral
Maxillofacial Implants 14, 55–60. Exclusion
criteria: multiple publications on the same
patient cohorts.
McDermott, N. E., Chuang, S. K., Woo, V. V. &
Dodson, T. B. (2006) Maxillary sinus augmentation as a risk factor for implant failure.
International Journal of Oral Maxillofacial
Implants 21, 366–374. Exclusion criteria: no
survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Misch, C. E. & Dietsh, F. (1994) Endosteal
implants and iliac crest grafts to restore
severely resorbed totally edentulous maxillae–a retrospective study. Journal of Oral
Implantology 20, 100–110. Exclusion criteria: no information on residual bone height.
Nedir, R., Bischof, M., Vazquez, L., SzmuklerMoncler, S. & Bernard, J. P. (2006) Osteotome sinus floor elevation without grafting
material: a 1-year prospective pilot study with
ITI implants. Clinical Oral Implants Research
17, 679–686. Exclusion criteria: sinus augmentation via transalveolar technique.
Nemcovsky, C. E., Winocur, E., Pupkin, J. &
Artzi, Z. (2004) Sinus floor augmentation
through a rotated palatal flap at the time of
tooth extraction. International Journal of
Periodontics and Restorative Dentistry 24,
177–183. Exclusion criteria: Sinus augmentation via transalveolar technique.
Neyt, L. F., De Clercq, C. A., Abeloos, J. V. &
Mommaerts, M. Y. (1997) Reconstruction of
the severely resorbed maxilla with a combination of sinus augmentation, onlay bone
grafting, and implants. Journal of Oral Maxillofacial Surgery 55, 1397–1401. Exclusion
criteria: combination of grafting techniques.
Nkenke, E., Schlegel, A., Schultze-Mosgau, S.,
Neukam, F. W. & Wiltfang, J. (2002) The
endoscopically controlled osteotome sinus
floor elevation: a preliminary prospective
study. International Journal of Oral Maxillofacial Implants 17, 557–566. Exclusion criteria: Sinus augmentation via transalveolar
technique.
Noumbissi, S. S., Lozada, J. L., Boyne, P. J.,
Rohrer, M. D., Clem, D., Kim, J. S. & Prasad,
H. (2005) Clinical, histologic, and histomorphometric evaluation of mineralized solventdehydrated bone allograf (Puros) in human
maxillary sinus grafts. Journal of Oral
Implantology 31, 171–179. Exclusion criteria: sample size of less than 10 patients.
Oliva, J., Oliva, X. & Oliva, J. D. (2007) Oneyear follow-up of first consecutive 100 zirconia dental implants in humans: a comparison
of 2 different rough surfaces. International
Journal of Oral Maxillofacial Implants 22,
430–435. Exclusion criteria: no information
on residual bone height.
Olson, J. W., Dent, C. D., Dominici, J. T.,
Lambert, P. M., Bellome, J., Bichara, J. &
Morris, H. F. (1997) The influence of maxillary sinus augmentation on the success of
dental implants through second-stage surgery. lmplant Dentistry 6, 225–228. Exclusion criteria: mean follow-up o1 year in
function.
Olson, J. W., Dent, C. D., Morris, H. F. & Ochi,
S. (2000) Long-term assessment (5 to 71
months) of endosseous dental implants
placed in the augmented maxillary sinus.
Annuals of Periodontology 5, 152–156.
Exclusion criteria: no information on residual bone height.
Ormianer, Z., Palti, A. & Shifman, A. (2006)
Survival of immediately loaded dental
implants in deficient alveolar bone sites augmented with beta-tricalcium phosphate.
Implant Dentistry 15, 395–403. Exclusion
criteria: no survival data or no distinction
of survival data between implants placed in
sites with various grafting techniques.
Peleg, M., Garg, A. K. & Mazor, Z. (2006)
Healing in smokers versus nonsmokers: survival rates for sinus floor augmentation with
simultaneous implant placement. International Journal of Oral Maxillofacial Implants
21, 551–559. Exclusion criteria: multiple
publications on the same patient cohorts.
Peleg, M., Mazor, Z., Chaushu, G. & Garg, A.
K. (1998) Sinus floor augmentation with
simultaneous implant placement in the
severely atrophic maxilla. Journal of Periodontology 69, 1397–1403. Exclusion criteria:
multiple publications on the same patient
cohorts.
Peleg, M., Mazor, Z. & Garg, A. K. (1999)
Augmentation grafting of the maxillary sinus
and simultaneous implant placement in
patients with 3 to 5 mm of residual alveolar
bone height. International Journal of Oral
Maxillofacial Implants 14, 549–556. Exclusion criteria: multiple publications on the
same patient cohorts.
Petrungaro, P. S. (2005) Implant placement and
provisionalization in extraction, edentulous,
and sinus grafted sites: a clinical report on
1,500 sites. Compendium of Continuing Education in Dentistry 26, 879–890. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Pinholt, E. M. (2003) Branemark and ITI dental
implants in the human bone-grafted maxilla:
a comparative evaluation. Clinical Oral
Implants Research 14, 584–592. Exclusion
criteria: no information on residual bone
height.
Pjetursson, B. E., Rast, C., Brägger, U., Zwatilen, M. & Lang, N.P. (2008) Maxillary sinus
floor elevation using the osteotome technique
with or without grafting material. Part 1 –
implant survival and patient’s perception.
Clinical Oral Implants Research (in press).
Raghoebar, G. M., Brouwer, T. J., Reintsema,
H. & Van Oort, R. P. (1993) Augmentation of
the maxillary sinus floor with autogenous
bone for the placement of endosseous
implants: a preliminary report. Journal of
Oral Maxillofacial Surgery 51, 1198–1203;
discussion 1203–1195. Exclusion criteria:
multiple publications on the same patient
cohorts.
Reinert, S., Konig, S., Bremerich, A., Eufinger,
H. & Krimmel, M. (2003) Stability of bone
grafting and placement of implants in the
severely atrophic maxilla. British Journal of
Oral Maxillofacial Surgery 41, 249–255.
Exclusion criteria: combination of grafting
techniques.
Regev, E., Smith, R. A., Perrott, D. H. & Pogrel,
M. A. (1995) Maxillary sinus complications
related to endosseous implants. International
Journal of Oral Maxillofacial Implants 10,
451–461. Exclusion criteria: no survival data
or no distinction of survival data between
implants placed in sites with various grafting
techniques.
Rodoni, L. R., Glauser, R., Feloutzis, A. &
Hammerle, C. H. (2005) Implants in the
posterior maxilla: a comparative clinical and
radiologic study. International Journal of
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard
Systematic review of sinus floor elevation
Oral Maxillofacial Implants 20, 231–237.
Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
Rosen, P. S., Summers, R., Mellado, J. R.,
Salkin, L. M., Shanaman, R. H., Marks, M.
H. & Fugazzotto, P. A. (1999) The boneadded osteotome sinus floor elevation technique: multicenter retrospective report of
consecutively treated patients. International
Journal of Oral Maxillofacial Implants 14,
853–858. Exclusion criteria: sinus augmentation via transalveolar technique.
Schwartz-Arad, D., Herzberg, R. & Dolev, E.
(2004) The prevalence of surgical complications of the sinus graft procedure and their
impact on implant survival. Journal of Periodontology 75, 511–516. Exclusion criteria:
no information on residual bone height.
Simion, M., Fontana, F., Rasperini, G. & Maiorana, C. (2004) Long-term evaluation of
osseointegrated implants placed in sites augmented with sinus floor elevation associated
with vertical ridge augmentation: a retrospective study of 38 consecutive implants
with 1- to 7-year follow-up. International
Journal of Periodontics and Restorative Dentistry 24, 208–221. Exclusion criteria: combination of grafting techniques.
Small, S. A., Zinner, I. D., Panno, F. V.,
Shapiro, H. J. & Stein, J. I. (1993) Augmenting the maxillary sinus for implants: report of
27 patients. International Journal of Oral
Maxillofacial Implants 8, 523–528. Exclusion
criteria: multiple publications on the same
patient cohorts.
Smedberg, J. I., Johansson, P., Ekenback, D. &
Wannfors, D. (2001) Implants and sinus-inlay
graft in a 1-stage procedure in severely
atrophied maxillae: prosthodontic aspects in
a 3-year follow-up study. International Journal of Oral Maxillofacial Implants 16, 668–
674. Exclusion criteria: no survival data or
no distinction of survival data between
implants placed in sites with various grafting
techniques.
Sotirakis, E. G. & Gonshor, A. (2005) Elevation
of the maxillary sinus floor with hydraulic
pressure. Journal of Oral Implantology 31,
197–204. Exclusion criteria: Sinus augmentation via transalveolar technique.
Stavropoulos, A., Karring, T. & Kostopoulos, L.
(2007) Fully vs. partially rough implants in
maxillary sinus floor augmentation: a randomized-controlled clinical trial. Clinical Oral
Implants Research 18, 95–102. Exclusion
criteria: sinus augmentation via transalveolar technique.
Steigmann, M. & Garg, A. K. (2005) A comparative study of bilateral sinus lifts performed with platelet-rich plasma alone
versus alloplastic graft material reconstituted
with blood. Implant Dentistry 14, 261–266.
Exclusion criteria: mean residual bone
height 46 mm or majority of implants placed
in sites with residual bone height 46 mm.
Stricker, A., Voss, P. J., Gutwald, R., Schramm,
A. & Schmelzeisen, R. (2003) Maxillary
sinus floor augmention with autogenous
bone grafts to enable placement of SLAsurfaced implants: preliminary results after
15-40 months. Clinical Oral Implants
Research 14, 207–212. Exclusion criteria:
no information on residual bone height.
Strietzel, F. P. & Nowak, M. (1999) Höhenverlauf des Limbus alveolaris bei Implantationen
mit der Osteotomtechnik. Retrospective
Untersuchung. Mund Kiefer und GesichtsChirurgie 3, 309–313. Exclusion criteria:
Not reporting on sinus floor elevation.
Szabo, G., Huys, L., Coulthard, P., Maiorana,
C., Garagiola, U., Barabas, J., Nemeth, Z.,
Hrabak, K. & Suba, Z. (2005) A prospective
multicenter randomized clinical trial of autogenous bone versus beta-tricalcium phosphate
graft alone for bilateral sinus elevation: histologic and histomorphometric evaluation.
International Journal of Oral Maxillofacial
Implants 20, 371–381. Exclusion criteria:
combination of grafting techniques.
Szabo, G., Suba, Z., Hrabak, K., Barabas, J. &
Nemeth, Z. (2001) Autogenous bone versus
beta-tricalcium phosphate graft alone for
bilateral sinus elevations (2- and 3-dimensional computed tomographic, histologic, and
histomorphometric evaluations): preliminary
results. International Journal of Oral Maxillofacial Implants 16, 681–692. Exclusion
criteria: sample size of less than 10 patients.
Tadjoedin, E. S., de Lange, G. L., Lyaruu, D.
M., Kuiper, L. & Burger, E. H. (2002) High
concentrations of bioactive glass material
(BioGran) vs. autogenous bone for sinus floor
elevation. Clinical Oral Implants Research
13, 428–436. Exclusion criteria: sample size
of less than 10 patients.
Tarnow, D. P., Wallace, S. S., Froum, S. J.,
Rohrer, M. D. & Cho, S. C. (2000) Histologic
and clinical comparison of bilateral sinus
floor elevations with and without barrier
membrane placement in 12 patients: part 3
of an ongoing prospective study. International Journal of Periodontics and Restorative
Dentistry 20, 117–125. Exclusion criteria: no
information on residual bone height.
Tatum, O. H. Jr., Lebowitz, M. S., Tatum, C. A.
& Borgner, R. A. (1993) Sinus augmentation.
Rationale, development, long-term results.
New York State Dental Journal 59, 43–48.
Exclusion criteria: no survival data or no
distinction of survival data between implants placed in sites with various grafting
techniques.
Thor, A., Wannfors, K., Sennerby, L. & Rasmusson, L. (2005) Reconstruction of the
severely resorbed maxilla with autogenous
bone, platelet-rich plasma, and implants: 1year results of a controlled prospective 5-year
study. Clinical Implant Dentistry and Related
Research 7, 209–220. Exclusion criteria:
combination of grafting techniques.
Tidwell, J. K., Blijdorp, P. A., Stoelinga, P. J.,
Brouns, J. B. & Hinderks, F. (1992) Composite grafting of the maxillary sinus for placement of endosteal implants. A preliminary
report of 48 patients. International Journal of
Oral Maxillofacial Surgery 21, 204–209.
Exclusion criteria: combination of grafting
techniques.
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Journal compilation r 2008 Blackwell Munksgaard
239
Timmenga, N. M., Raghoebar, G. M., van
Weissenbruch, R. & Vissink, A. (2003) Maxillary sinus floor elevation surgery. A clinical,
radiographic and endoscopic evaluation.
Clinical Oral Implants Research 14, 322–
328. Exclusion criteria: mean follow-up o1
year in function.
Toffler, M. (2004) Osteotome-mediated sinus
floor elevation: a clinical report. International Journal of Oral Maxillofacial Implants
19, 266–273. Exclusion criteria: sinus augmentation via transalveolar technique.
Turunen, T., Peltola, J., Yli-Urpo, A. & Happonen, R. P. (2004) Bioactive glass granules
as a bone adjunctive material in maxillary
sinus floor augmentation. Clinical Oral
Implants Research 15, 135–141. Exclusion
criteria: no survival data or no distinction of
survival data between implants placed in
sites with various grafting techniques.
Valentini, P. & Abensur, D. (1997) Maxillary
sinus floor elevation for implant placement
with demineralized freeze-dried bone and
bovine bone (Bio-Oss): a clinical study of
20 patients. International Journal of Periodontics and Restorative Dentistry 17, 232–
241. Exclusion criteria: multiple publications
on the same patient cohorts.
Valentini, P., Abensur, D., Wenz, B., Peetz, M.
& Schenk, R. (2000) Sinus grafting with
porous bone mineral (Bio-Oss) for implant
placement: a 5-year study on 15 patients.
International Journal of Periodontics and
Restorative Dentistry 20, 245–253. Exclusion
criteria: multiple publications on the same
patient cohorts.
van Steenberghe, D., Naert, I., Bossuyt, M., De
Mars, G., Calberson, L., Ghyselen, J. &
Branemark, P. I. (1997) The rehabilitation
of the severely resorbed maxilla by simultaneous placement of autogenous bone grafts
and implants: a 10-year evaluation. Clinical
Oral Investigations 1, 102–108. Exclusion
criteria: sample size of less than 10 patients.
Vitkov, L., Gellrich, N. C. & Hannig, M. (2005)
Sinus floor augmentation via hydraulic
detachment and elevation of the Schneiderian
membrane. Clinical Oral Implants Research
16, 615–621. Exclusion criteria: sinus augmentation via transalveolar technique.
Wallace, S. S., Froum, S. J., Cho, S. C., Elian,
N., Monteiro, D., Kim, B. S. & Tarnow, D. P.
(2005) Sinus augmentation utilizing anorganic bovine bone (Bio-Oss) with absorbable and
nonabsorbable membranes placed over the
lateral window: histomorphometric and clinical analyses. International Journal of Periodontics and Restorative Dentistry 25, 551–
559. Exclusion criteria: no information on
residual bone height.
Williamson, R. A. (1996) Rehabilitation of the
resorbed maxilla and mandible using autogenous bone grafts and osseointegrated
implants. International Journal of Oral Maxillofacial Implants 11, 476–488. Exclusion
criteria: no survival data or no distinction
of survival data between implants placed in
sites with various grafting techniques.
Winter, A. A., Pollack, A. S. & Odrich, R. B.
(2002) Placement of implants in the severely
240
Pjetursson et al.
atrophic posterior maxilla using localized
management of the sinus floor: a preliminary
study. International Journal of Oral Maxillofacial Implants 17, 687–695. Exclusion criteria: sinus augmentation via transalveolar
technique.
Wood, R. M. & Moore, D. L. (1988) Grafting of
the maxillary sinus with intraorally harvested
autogenous bone prior to implant placement.
International Journal of Oral Maxillofacial
Implants 3, 209–214. Exclusion criteria: no
survival data or no distinction of survival
data between implants placed in sites with
various grafting techniques.
Yildirim, M., Spiekermann, H., Biesterfeld, S.
& Edelhoff, D. (2000) Maxillary sinus augmentation using xenogenic bone substitute
material Bio-Oss in combination with venous
blood. A histologic and histomorphometric
study in humans. Clinical Oral Implants
Clinical Relevance
Scientific rationale for the study: In
maxillary sites with residual bone
height of 6 mm or less, implant placement with lateral approach sinus
floor elevation is a possible option.
Implant survival rate and complications related to the procedure, with
Research 11, 217–229. Exclusion criteria:
mean follow-up o1 year in function or no
loading time.
Yildirim, M., Spiekermann, H., Handt, S. &
Edelhoff, D. (2001) Maxillary sinus augmentation with the xenograft Bio-Oss and autogenous intraoral bone for qualitative
improvement of the implant site: a histologic
and histomorphometric clinical study in
humans. International Journal of Oral Maxillofacial Implants 16, 23–33. Exclusion criteria: mean follow-up o1 year in function.
Zhao, B. D., Wang, Y. H., Xu, J. S., Zheng, J.,
Gong, D. L. & Yu, Y. (2007) [Clinical study
of maxillary sinus floor elevation with simultaneous placement of implants from the top
of alveoli.]. Shanghai Kou Qiang Yi Xue 16,
480–483. (Article in Chinese) Exclusion
criteria: sinus augmentation via transalveolar technique.
Zijderveld, S. A., Zerbo, I. R., van den Bergh, J.
P., Schulten, E. A. & ten Bruggenkate, C. M.
(2005) Maxillary sinus floor augmentation
using a beta-tricalcium phosphate (Cerasorb)
alone compared to autogenous bone grafts.
International Journal of Oral Maxillofacial
Implants 20, 432–440. Exclusion criteria:
mean follow-up o1 year in function.
factors affecting implant survival
were examined.
Principal findings: Despite the limited amount of residual bone height,
the estimated 3-year implant survival
in lateral approach sinus augmented
sites is predictable. Incidences of
surgical complications are low.
Practical implications: In maxillary
edentulous sites with a mean height
of 6 mm or less, implant installation
is predictable with lateral approach
sinus floor elevation, especially when
rough textured implants are used.
Address:
Bjarni E. Pjetursson
Department of Reconstructive Dentistry
University of Iceland
Vatnsmyrarvegur 16
IS 101 Reykjavik
Iceland
E-mail: [email protected]
r 2008 The Authors
Journal compilation r 2008 Blackwell Munksgaard