Simultaneous Sinus Lift and Implant Installation:

Prospective Study of Consecutive Two Hundred

Seventeen Sinus Lift and Four Hundred

Sixty-Two Implants

Hyun-Suk Cha, DDS, MSD, PhD;* Andrew Kim, DDS, MS;† Hessam Nowzari, DDS, PhD;†

Hoo-Sun Chang, MD, PhD;‡ Kang-Min Ahn, DDS, MSD, PhD§

ABSTRACT

Purpose: If less than 4 mm of residual bone is remained in posterior maxilla, two-stage operation is recommended for

implant installation. However, if primary stability could be obtained using tapered designed implants, one-stage surgery

could be performed with reliable success rate in severely resorbed maxilla. The purpose of this prospective study was to

evaluate survival and success rates of the implants simultaneously placed into grafted sinus using rough-surfaced implant.

Materials and Methods: A total of two hundred seventeen consecutive sinus lifting through lateral approach and four

hundred sixty-two simultaneous implants were installed from November 2003 for 5.5 years. Xenogenic bone was used

solely for bone graft materials. Second surgery was performed around 6 months after operation and porcelain fused metal

or gold crown was used for definitive restorations. Cumulative survival and success rates were evaluated according to

residual alveolar bone height (RABH), smoking status, and Schneiderian membrane perforation.

Results: The mean follow-up was 57.1 1 15.6 (36–98) months. Of the four hundred sixty-two implants, two hundred

sixty-two implants (56.7%: group 1) were installed in posterior maxilla less than 4-mm RABH and two hundred implants

(43.3%: group 2) were placed in over 5-mm RABH. The cumulative survival and success rates were 98.91% and 96.54%.

There was no statistically significant difference in success rate between group 1 and group 2 (p = .3135). Perforation of the

membrane was not related to success (p = .7162), but smoking status is significantly related with implant failure (p = .0003).

Conclusions: Sinus lifting with simultaneous implant placement could be used to treat atrophic maxilla in patients with

minimal RABH when initial stability could be obtained by using taper designed implants with surgical techniques. Smoking

is a possible factor for implant failure. Membrane perforation did not have an adverse effect on implant success if the

membrane was repaired with absorbable membrane and fibrin glue.

KEY WORDS: dental implant, perforation, residual alveolar bone, Schneiderian membrane, sinus lifting, smoking,

xenogenic bone

INTRODUCTION

Sinus lifting and implant placement are predictable

treatment options for pneumatized sinus and severely

resorbed maxillary posterior reconstruction. A

minimum of 4 to 5 mm of residual bone height is

traditionally recommended for the one-stage surgical

procedure of sinus lifting and implant placement to

ensure initial stability from preexisting residual bone.1–4

However, these criteria have been determined arbitrarily

without controlled studies.3–6 In efforts to improve

primary stability and osseointegration, implant designs

and surface treatments have evolved in recent years.

*Associate professor, Department of Prosthodontics, Asan Medical

Center, College of Medicine, University of Ulsan, Seoul, Korea;

†Department of Advanced Periodontics, University of Southern California,

Los Angeles, CA, USA; ‡Department of PreventiveMedicine &

Public Health, College of Medicine, Yonsei University, Seoul, Korea;

§associate professor, Department of Oral and Maxillofacial Surgery,

AsanMedical Center, College of Medicine,University of Ulsan, Seoul,

Korea

Reprint requests: Professor Kang-Min Ahn, Department of Oral

and Maxillofacial Surgery, College of Medicine, University of

Ulsan, Seoul Asan Medical Center, Seoul 138-736, Korea; e-mail:

ahnkangmin@hanmail.net

© 2012 Wiley Periodicals, Inc.

DOI 10.1111/cid.12012

1

Reports in the literatures indicate that frictional resistance

created by rough-surfaced implant combined

with modified surgical techniques can improve initial

implant stability.7,8 In severely resorbed or pneumatized

posterior maxilla, optimal initial stability could be

obtained by underpreparing implant osteotomies and

using tapered designed implants. Various studies have

evaluated sinus lifting and simultaneous implant installation

and showed no relationship between implant

failure and residual alveolar bone height.9,10 Others have

reported that the amount of residual bone height significantly

influences the implant survival rate in sinus

lifting.11 Recently, systemic reviews reported that simultaneous

and delayed implant installation displayed

similar survival rates.12,13 Peleg and colleagues adopted a

one-stage surgical technique that allows implant placement

in as little as 1 to 2 mm of residual bone using

microtextured or coated implants at least 13 mm in

length with predictable success rate.9,10,14 However, these

studies had varying methodologies including implant

design, bone graft materials, and healing periods. The

effect of preoperative residual bone height on success

rate is inconclusive due to the diversity of the study

designs.

To the authors’ best knowledge, a large-scale prospective

study evaluating sinus lifting and simultaneous

implant installation using only xenogenic bone in

severely resorbed maxilla has not been reported. This

prospective study evaluated implants (rough surface

310 mm length) immediately placed into grafted maxillary

sinuses using lateral window approach (xenogenic

bone only) irrespective of residual bone height. The

purpose of this prospective study was to evaluate the

survival and success rates of the implants simultaneously

placed into grafted sinus and evaluate whether

there are any differences in survival and success rates

regarding residual alveolar bone height, smoking status,

and membrane perforation.

MATERIALS AND METHODS

Preoperative Evaluation and Inclusion and

Exclusion Criteria

A total of two hundred seventeen consecutive lateral

window sinus lifts and four hundred sixty-two implant

installations were performed by one experienced oral

and maxillofacial surgeon at the Department of Oral

andMaxillofacial Surgery at Seoul AsanMedical Center.

The Asan Medical Center Institutional Review Board

approved the clinical trial. The inclusion and exclusion

criteria are reported in Table 1. Every patient underwent

a medical and dental history evaluation including the

presence of illness, medications, and smoking habits.

Patients were examined intraorally and extraorally

using panoramic radiograph and cone beam computed

tomography (CT) scan.

Implant Selection

Implants (Implantium®, Dentium Co., Seoul, Korea)

with microthreads in the coronal part with sand blasting,

large grit, and acid etching surface were used in this

study. This tapered implant design has a table that is

0.2 mm wider than lower body area to increase initial

stability in bone. The coronal aspect (2 mm) of the

implant consists of microthreads. The lengths and diameters

of the implants that were used in this study were 10

TABLE 1 Criteria for Patient Selection

Inclusion Criteria Exclusion Criteria

• Posterior maxillary bone

deficiency (residual

alveolar bone 1–8 mm)

without the need for

multiple interventions

(e.g., simultaneous ridge

augmentations)

• Good periodontal health

• More than 2 months of

healing period after

extraction

• Good general health: those

with controlled medical

conditions with physician’s

approval

• Stable mental health

condition

• Ability to complete at least

36 months of clinical

follow-up

• Willingness to provide

signed informed consent

form

• Uncontrolled diabetes

mellitus and hypertension

• History of myocardial

infarction within 6 months

• Use of immunosuppressive

medication

• Use of intravenous

bisphosphonate

• Presence of

immunodeficiency disease

• History of irradiation

associated with head and

neck cancer

• Evidence of acute and

chronic sinusitis

• Presence of cyst or tumor

in maxillary sinus

• History of Caldwell-Luc

operation

• Pregnancy at the time of

operation

• Alcohol or drug abuse

• Unlikely to comply with

study procedures according

to investigators’ judgment

2 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2012

and 12 mm and 3.3, 3.8, 4.3, and 4.8 mm (determined

by the width of the residual ridge), respectively.

Surgical Technique

The modified Caldwell-Luc approach was used to gain

access to the sinus cavity. The lateral wall of the maxilla

was exposed with a full-thickness mucoperiosteal flap

made with crestal incision and two vertical incisions on

the buccal side of the residual alveolar ridge mesially and

distally. The size of the lateral window was determined

by the number of implants to be installed with consideration

to minimize the size of the lateral window as

possible. A #2 carbide round bur was used to create a

window on the lateral maxillary wall using low speed

straight angle handpiece.When the Schneiderian membrane

was visualized under the groove, a #2 diamond

round bur was used to prevent membrane tearing. The

window bone was temporarily removed rather than

infracturing into the sinus (Figure 1). Implant osteotomy

was prepared according to the manufacturer’s

instructions. Countersink drills were not used to optimize

primary stability.

Residual alveolar bone was initially evaluated using

panoramic radiograph and CT scans. After sinus membrane

elevation, the position of the osteotomy was

marked with a sterilized pencil according to surgical

stent. The exact measurement of the clinical residual

alveolar bone was obtained using a depth gauge

(Figure 2).

Xenogenic bone (Bio-Oss®, Geistlich Pharma,Wolhusen,

Switzerland) was soaked with gentamycin (gentamicin

sulfate, Choongwae Pharm, Seoul, Korea) for 5

minutes before application into the maxillary sinus and

grafted until it filled the elevated sinus cavity. The dental

implants were initially placed into the grafted sites using

an automated handpiece and finalized using a hand

wrench with a torque gauge. If the initial stability of

15 Ncm was not obtained by torque gauge, it was

replaced with larger diameter implant.

In case of membrane perforation, porcine membrane

(Bio-Gide, Geistlich Pharma, Wolhusen, Switzerland)

and fibrin glue (Greenplast®, Green Cross Co.

Ltd., Seoul, Korea) were used to repair the perforated

area. The buccal window bone was repositioned to the

original site using fibrin glue. All implants were submerged

and the mucoperiosteal flap was closed using

4-0 Vicryl (Johnson & Johnson, Ethicon, England).

Implants were divided into two groups. Group 1

included implants installed in the posterior maxilla

with residual alveolar bone height of <5 mm. Group 2

included implants installed with alveolar bone height of

35 mm. The survival rate of each group was evaluated.

The smoking status and membrane perforation were

recorded and the same evaluation was performed.

Postoperative Management

Patients were prescribed augmentin (potassium clavulanate

125 mg + amoxicillin sodium 250 mg, two times

daily), airtal (aceclofenac 100 mg, two times daily) for 5

days, prednisolone (10 mg, two times daily) for 2 days,

and hexamedin (0.2% chlorhexidine mouthwash, three

times daily for 5 days). Clindamycin (300 mg, three

times daily) was prescribed to patients with penicillin

allergy. Patients were instructed to avoid blowing their

noses and cough/sneeze with their mouths open when

Figure 1 Diagram of the surgical procedure. Lateral window

was temporarily removed during the sinus membrane elevation.

Xenogenic bone was grafted into the sinus and implant was

placed. Implant has the microthreads and tapered design to

maximize initial stability.

Figure 2 Measurement of the residual alveolar bone using

depth gauge.

Simultaneous Sinus Lift and Implant Installation 3

necessary for at least 2 weeks after surgery to prevent

increased pressure in the operated sinus. Sutures were

removed 10 days after surgery. Patients with removable

prosthesis were instructed not to wear their prosthesis

for 2 weeks after surgery. All patients were instructed to

follow a soft diet for 1 week. Dentures were relined after

sutures removed and monthly thereafter with a soft

tissue conditioner.

Time Schedule for Second Surgery and

Prosthodontic Treatment

Uncovery surgery was performed about 6 months after

implant placement.Marginal bone level, implant mobility,

and presence of fistula were examined. Final impression

was taken 2 weeks after second surgery. All patients

were treated with a fixed implant-supported prosthesis

for final restoration. The final tightening torque of abutment

was 32 Ncm. The screw-retained porcelain fused

metal or gold crown was fabricated for definitive restorations

and temporary cement was used for luting. At

the day of final restoration, baseline periapical radiographs

were taken to evaluate marginal bone resorption.

Patients were recalled every 6 months for 3 years after

prosthesis delivery and annually after 3 years. Every

recall visit, the final restorations were removed and

cleaned to examine implant mobility, excessive cement,

and screw loosening in splinted bridges.

Radiographic Analysis

Periapical radiographs (long-cone paralleling technique)

and panoramic radiographs were taken immediately

after surgery, 1 month, 6 months, 1 year postoperation,

and annually thereafter.An independent examiner interpreted

all radiographs. The changes frombaseline (day of

final prosthodontic treatment) were calculated for all

follow-up periods. The implant used in this study has

microthreads in the coronal portion which is 2 mm.

Marginal bone loss was measured on radiographs using

the implant microthreads as internal standard (Figure 3).

Measurement of the marginal bone change was performed

with image analysis software (ImageJ, 1.44p,

National Institutes of Health, Bethesda,MD, USA).

Criteria for Implant Success Rates and

Implant Survival

Those meeting the following parameters were considered

as successful implants, which were suggested by

Albrektsson and colleagues: (1) absence of persistent

pain; (2) absence of peri-implant infection with suppuration;

(3) absence of implant mobility; (4) absence

of continuous peri-implant radiolucency; and (5) periimplant

bone resorption <1.5 mm in the first year

of function and <0.2 mm in the subsequent years.15

Implant survival was defined as functional implants

that followed parameters (1) to (4).

Statistical Methods

Data were collected with regard to success rate and survival

rate according to the residual alveolar bone height

and smoking status. Descriptive statistics and survival

analyses were computed with SPSS statistical software

(version 12.0, SPSS, Inc., Chicago, IL, USA). The

primary analysis of interest was the assessment of the

relationship between residual alveolar bone height and

implant survival rate. The comparison between group

1 and group 2 was performed with the chi-square test.

The success rates of implants in smoking versus nonsmoking

group and membrane perforated versus

nonperforated groups were evaluated with the same

methods. Any patient who smoked more than one

cigarette a day was considered a smoker following the

definition by Wallace.16 Implant survival was defined as

the length of time of implant survival from the date

of implant installation to the date of implant failure.

Implant survival rate was analyzed using the Kaplan-

Meier analysis, and a group comparison was made

using the log-rank test. The statistical significance

(p < .05) of the results was determined.

Figure 3 Periapical radiograph of the implants placed in the

grafted sinus bone. The known length of the microthreads in

implant was used as an internal standard (arrow = 2.0 mm).

4 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2012

RESULTS

Summary of Patient Data

A total of two hundred seventeen sinus lifts and

four hundred sixty-two implants were placed simultaneously

in one hundred sixty-one patients. Among one

hundred sixty-one patients, 56 patients (male : female

[M : F] = 39:17) received bilateral sinus lifts and one

hundred five patients had unilateral sinus lifts and

implant installation (M : F = 57:48). The mean duration

of follow-up of patients after implant placement was

57.1 1 15.6 (36–98) months. Implants were installed

from the first premolar to second molar area (78.2%

molars). A total of two hundred sixty-two of four

hundred sixty-two implants (56.7%) were placed in

ridges that had residual bone height of <5 mm(group 1)

and two hundred implants (43.3%) were installed in

35 mm (group 2). Distribution of the implants placed

in each group and diameters of implants were listed

in Table 2.

Survival and Success Rates

A total of five implants from four patients (M : F = 3:1)

were removed during the follow-up periods. The cumulative

survival rate was 98.91% (four hundred fifty-seven

of four hundred sixty-two). The survival rate was

slightly higher in group 2 than in group 1 according to

Kaplan-Meier survival analysis but was not statistically

significant (p = .2866, Figure 4).

After second-stage surgery, no patient presented

with persistent pain, peri-implant infection with

suppuration, and mobility of implant. A total of 11

implants (group 1 = three implants; group 2 = eight

implants) in seven patients (M : F = 3:4) showed more

bone loss than the acceptable parameters according to

Albrektsson and colleagues’ success criteria (>1.5 mmof

marginal bone loss in the first year of function or

>0.2 mm in the subsequent years). Including the five

implants that were removed, a total of 16 implants did

not follow the implant success criteria. The cumulative

success rate was 96.54% (group 1 = 97.33%, group

2 = 95.50%) (Table 3). According to chi-square test

(Table 4), there was no statistically significant difference

in success rate between the two groups (p = .3135).

Clinical photographs and radiographs of one-stage

surgery and implant installation are shown in Figure 5,

A–E.

Sinus Membrane Perforation and

Implant Success

A total of 35 of two hundred seventeen (16.13%) sinus

membranes were perforated during surgery. Membrane

perforations were repaired with collagen membrane,

fibrin glue. Bone grafts and implants were installed as

planned without delay in any case. A total of 68 of four

hundred sixty-two (14.72%) implants were placed in

perforated sinuses and three (4.41%) implants of these

failed. According to chi-square test with Fisher’s exact

test (Table 5), there was no statistically significant difference

in success rate between the implants placed in perforated

and nonperforated sinuses (p = .7162).

Smoking Habits in Implant Success

Among one hundred sixty-one patients, 18 patients

(M : F = 17:1) were smokers. They were heavy smokers

and all of them smoked at least 10 cigarettes a day before

TABLE 2 Distribution of Implant Diameter by

Residual Alveolar Bone Height

RAB

Implants

Diameter (mm) No. Placed

1–4 mm 3.4 3

3.8 46

4.3 96

4.8 117

Total 262

5–8 mm 3.4 6

3.8 31

4.3 86

4.8 77

Total 200

RAB = residual alveolar bone.

Figure 4 Kaplan-Meier survival analysis between group 1 and

group 2.

Simultaneous Sinus Lift and Implant Installation 5

and after operation.A total of 48 implants were placed in

smokers and seven (14.58%) implants failed, whereas a

total of four hundred fourteen implants were placed in

nonsmokers and nine (2.17%) implants failed. According

to chi-square test with Fisher’s exact test (Table 6),

there was a statistically significant difference in success

rate between the smokers and nonsmokers (p = .0003)

and implants placed in smokers and nonsmokers

(p = .0005).

Management of Failed Implant

The causes of the five implant removals were the following:

one implant with acute infection and suppuration 1

month after surgery, three implants with loss of integration

during uncovery surgery, and one implant removal

due to significant peri-implant bone loss after 2 years of

loading. The implant that was removed due to acute

postoperative infection had a membrane perforation.

After 3 months of healing, a short implant (8 mm

length, 4.8 mm–diameter) was placed in the failed

implant site. The implant was considered successful

during a 3-year follow-up (Figure 6, A–C).

The three implants (two patients) that were

removed during uncovery surgery were replaced with

wider diameter implants at the failed sites. All replaced

implants integrated after 6 months of healing and

definitive restorations were delivered successfully. The

implant that was removed after 2 years was the middle

implant of three consecutive implants that were restored

with a fixed partial denture. The patient was a heavy

smoker who smoked more than 40 cigarettes/day. The

implant was removed and the void in the definitive restoration

that was associated with the failed implant was

filled with resin.

DISCUSSION

Sinus lifting is a predictable treatment option for hard

tissue augmentation in the maxillary sinus for facilitation

of implant placement. In a systematic review of

dental implants placed in the posterior maxilla using

sinus lifting and bone graft,Wallace and Froum17 demonstrated

an average survival rate of 92.6% and Del

Fabbro and colleagues12 reported an average survival

rate of 91.5%. A systematic review about simultaneous

sinus lifting and implant placement reported a survival

rate of 90.1% after 3 years of follow-up.18 In the present

study, the cumulative survival and success rates were

TABLE 3 Residual Alveolar Bone Height and Survival, Success Rate

RABH (mm) NOI Removed Failed TF FR

Group 1 1 37 0 1 1 0.22

2 60 2 0 2 0.43

3 92 1 1 2 0.43

4 73 1 1 2 0.43

Group 2 5 69 0 4 4 0.87

6 87 1 1 2 0.43

7 44 0 3 3 0.65

Total 462 5 11 16 3.46

Group 1: residual alveolar bone height of <5 mm; group 2: alveolar bone height of 35 mm.

FR = failure rate; NOI = number of implants placed; RABH = residual alveolar bone height; TF = total failed implants.

TABLE 4 Implant Success according to the Residual Alveolar Bone

Number of Implants

Success Failure Success Rate p Value

Group 1 255 7 97.33% (255/262) .3135

Group 2 191 9 95.50% (191/200)

Total 446 16 96.54% (446/462)

Group 1: residual alveolar bone height of <5 mm; group 2: alveolar bone height of 35 mm.

6 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2012

98.5% and 95.6%, respectively, with an average

follow-up of 57.1 1 15.6 (36–98) months. The results

were favorable compared with other reports despite the

fact that the implants were placed immediately during

sinus lift surgery irrespective of residual bone height

using only Bio-Oss as the bone substitute.19–21 These

differences may be attributed due to implant design,

surface treatment, and surgical skill.

Sinus lifting and implant placement are typically

separated into two stages of surgery when residual

alveolar bone height is less than 4 to 5 mm. However,

these criteria were arbitrarily established when parallel

A B

C

E

D

Figure 5 A, Panoramic radiograph showing loss of right maxillary second premolar and pneumatization of the maxillary sinus. The

residual alveolar bone was 3 mm. B, After elevation of the full-thickness flap, window design was drawn using sterilized pencil. C,

Removal of the lateral sinus wall (wall-off technique). D, After bone graft and implant installation, lateral wall was repositioned to

the original site. E, Panoramic radiograph 4 years after operation.

TABLE 5 Sinus Membrane Perforation and Implant

Success

MP No. of Sinus Success Failure p Value

Yes 35 65 3 .7162

No 182 381 13

Total 217 446 16

Failure = failed implant; MP = membrane perforation; Success =

successful implant.

Simultaneous Sinus Lift and Implant Installation 7

implant designs were the only available options.

Studies demonstrated that marginal bone loss was not

related to the amount of preoperative residual bone

and that success rate was similar when primary stability

was achieved.9,19 In the present study, residual alveolar

bone was divided into two groups according to

Jensen’s criteria of 4 mm and showed that residual

alveolar bone had no effect on the survival and success

rates of implants. The benefits for sinus lifting and

simultaneous implant placement are the following:

reduced number of surgeries, reduced treatment time,

and lateral window access to the maxillary sinus during

implant placement. Fixture designs (e.g., implant

taper) can affect the initial stability of the implant.22

Tapered implant designs increase the compression of

bone and primary stability when placed into a conventional

parallel osteotomy.23 O’Sullivan and colleagues

demonstrated that a 1° taper had more initial stability

than parallel implants and a 2° taper could not be

inserted completely in the same osteotomies. Because

primary stability is important in achieving osseointegration,

2,19 selecting implants that maximize primary

stability is essential when bone is limited in the maxillary

sinus. In this study, tapered implants were used

and had comparable success rates between residual

bone heights of 1 to 4 and 5 to 8 mm.

TABLE 6 Smoking and Implant Success

Smoking No of Pt. Success Failure p Value NOI Success Failure p Value

Yes 18 12 6 .0003 48 41 7 .0005

No 143 138 5 414 405 9

NOI = number of implants; Pt = patients.

A

B C

Figure 6 A, Sinus lifting and implant installation. Membrane was perforated during sinus lifting. Implant was removed after 1

month. B, Short implant was placed 3 months after healing. C, Definitive restoration after 3-year follow-up.

8 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2012

A variety of bone graft materials may be used for

sinus augmentation including autogenous bone from

intraoral and extraoral sites, no graft, mineralized or

demineralized freeze-dried allogeneic bone, xenogenic

bone, alloplastic (e.g., hydroxyapatite and tricalcium

phosphate), growth factors, or combination of

materials.24–29 Hurzeler and colleagues30 reported that

there were no differences in implant survival rate with

five different grafting materials. Maiorana and colleagues

demonstrated that alloplasts and xenografts

were reliable for bone regeneration in subantral cavities.

25 In the present study, xenograft alone was used to

augment the maxillary sinus floor. The advantages of

xenografts are the following: no additional surgical site

for bone harvesting, reducing surgical time, and lower

resorption rate.31

The most common intra-operative complication in

sinus lifting is the perforation of the Schneiderian membrane

that has an average occurrence of 19.5% (range

5–56%).32–35 This investigation had a membrane perforation

rate of 16.13%, which was comparable with other

studies. Several authors have reported that membrane

perforation was associated with an increased

failure rate,32 whereas other studies demonstrated that

adequately repaired perforations have no effect on the

survival of implants.9 In the present study, membrane

perforations were repaired with Bio-Gide and fibrin

glue, and its occurrence did not have a significant

adverse effect on implant survival and success. A modified

Caldwell-Luc approach was used in this study. To

prevent membrane exposure, a diamond bur was used

when the window preparation was in close proximity to

the Schneiderian membrane. After isolating the lateral

bony window, it was temporarily removed (rather than

infracturing into the sinus), which increased access and

visibility for membrane dissection and insertion of sinus

elevation instruments. After placement of graft materials,

the sinus opening was covered with the lateral bony

window36 to function as a barrier membrane. Studies

reported that placement of a membrane over the lateral

window had higher implant survival rates than without

a membrane.13,37 Cho and colleagues suggested that the

repositioned bony window is an adequate membrane

after demonstrating healing of the window and regeneration

in the gap with the lateral wall borders.38

Smoking has been associated with increased risk of

implant failure.39,40 In a prospective clinical investigation,

Bain andMoy demonstrated an implant failure rate

of 11.3% for smokers and 4.8% for nonsmokers. Dental

implants placed in grafted maxillary sinuses are also

associated with higher implant failures. Kan and colleagues

demonstrated higher failure rates in smokers

than in nonsmokers in a retrospective study, evaluating

dental implants in grafted sinuses. The present study is

in agreement with these findings and revealed an association

of smoking with a higher failure rate (14.58% for

smokers and 2.17% for nonsmokers) of implants placed

immediately into grafted sinuses.

CONCLUSION

Sinus lifting with simultaneous implant placement can

be used to treat the atrophic maxilla in patients irrespective

of residual bone when careful surgical methods and

taper designed implants are used. Immediate sinus lift

with implant placement can reduce the number of surgeries

and overall treatment time. Smoking is a possible

factor for implant failure. Membrane perforation did

not have an adverse effect on implant success if the

membrane was properly repaired.

ACKNOWLEDGMENTS

This study was self-funded and all authors declare no

interests with any company enlisted in this study.

REFERENCES

1. Zitzmann NU, Scharer P. Sinus elevation procedures in the

resorbed posterior maxilla. Comparison of the crestal and

lateral approaches. Oral Surg Oral Med Oral Pathol Oral

Radiol Endod 1998; 85:8–17.

2. Misch CE, Dietsh F. Endosteal implants and iliac crest grafts

to restore severely resorbed totally edentulous maxillae – a

retrospective study. J Oral Implantol 1994; 20:100–110.

3. Jensen OT, Sennerby L. Histologic analysis of clinically

retrieved titanium microimplants placed in conjunction

with maxillary sinus floor augmentation. Int J Oral Maxillofac

Implants 1998; 13:513–521.

4. Jensen J, Sindet-Pedersen S, Oliver AJ. Varying treatment

strategies for reconstruction of maxillary atrophy with

implants: results in 98 patients. J Oral Maxillofac Surg 1994;

52:210–216; discussion 216–218.

5. Fugazzotto PA. Augmentation of the posterior maxilla: a

proposed hierarchy of treatment selection. J Periodontol

2003; 74:1682–1691.

6. Misch CE, Hoar J, Beck G, Hazen R, Misch CM. A bone

quality-based implant system: a preliminary report of stage I

& stage II. Implant Dent 1998; 7:35–42.

7. Skalak R, Zhao Y. Interaction of force-fitting and surface

roughness of implants. Clin Implant Dent Relat Res 2000;

2:219–224.

Simultaneous Sinus Lift and Implant Installation 9

8. Yamamichi N, Itose T, Neiva R,Wang HL. Long-term evaluation

of implant survival in augmented sinuses: a case series.

Int J Periodontics Restorative Dent 2008; 28:163–169.

9. Ardekian L, Oved-Peleg E, Mactei EE, Peled M. The clinical

significance of sinus membrane perforation during augmentation

of the maxillary sinus. J Oral Maxillofac Surg 2006;

64:277–282.

10. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation

with simultaneous implant placement in the

severely atrophic maxilla. J Periodontol 1998; 69:1397–1403.

11. Geurs NC, Wang IC, Shulman LB, Jeffcoat MK. Retrospective

radiographic analysis of sinus graft and implant placement

procedures from the Academy of Osseointegration

Consensus Conference on Sinus Grafts. Int J Periodontics

Restorative Dent 2001; 21:517–523.

12. Del FabbroM, Testori T, Francetti L,Weinstein R. Systematic

review of survival rates for implants placed in the grafted

maxillary sinus. Int J Periodontics Restorative Dent 2004;

24:565–577.

13. Wallace SS. Maxillary sinus augmentation: evidence-based

decision making with a biological surgical approach.

Compend Contin Educ Dent 2006; 27:662–668; quiz 669,

680.

14. Mazor Z, Peleg M, Gross M. Sinus augmentation for

single-tooth replacement in the posterior maxilla: a 3-year

follow-up clinical report. Int J Oral Maxillofac Implants

1999; 14:55–60.

15. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The

long-term efficacy of currently used dental implants: a

review and proposed criteria of success. Int J OralMaxillofac

Implants 1986; 1:11–25.

16. Wallace RH. The relationship between cigarette smoking and

dental implant failure. Eur J Prosthodont Restor Dent 2000;

8:103–106.

17. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation

on the survival of endosseous dental implants. A systematic

review. Ann Periodontol 2003; 8:328–343.

18. Pjetursson B, Tan WC, Zwahlen M, Lang NP. A systemic

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; 35:216–240.

19. Herzberg R, Dolev E, Schwartz-Arad D. Implant marginal

bone loss in maxillary sinus grafts. Int J Oral Maxillofac

Implants 2006; 21:103–110.

20. Pejrone G, Lorenzetti M, Mozzati M, Valente G,

Schierano GM. Sinus floor augmentation with autogenous

iliac bone block grafts: a histological and histomorphometrical

report on the two-step surgical technique. Int J Oral

Maxillofac Surg 2002; 31:383–388.

21. Tong DC, Rioux K, Drangsholt M, Beirne OR. A review of

survival rates for implants placed in grafted maxillary

sinuses using meta-analysis. Int J Oral Maxillofac Implants

1998; 13:175–182.

22. O’Sullivan D, Sennerby L,Meredith N.Measurements comparing

the initial stability of five designs of dental implants:

a human cadaver study. Clin Implant Dent Relat Res 2000;

2:85–92.

23. O’Sullivan D, Sennerby L,Meredith N. Influence of implant

taper on the primary and secondary stability of osseointegrated

titanium implants. Clin Oral Implants Res 2004;

15:474–480.

24. Valentini P, Abensur DJ.Maxillary sinus grafting with anorganic

bovine bone: a clinical report of long-term results. Int

J Oral Maxillofac Implants 2003; 18:556–560.

25. Maiorana C, Sigurta D, Mirandola A, Garlini G, Santoro F.

Sinus elevation with alloplasts or xenogenic materials

and implants: an up-to-4-year clinical and radiologic

follow-up. Int J Oral Maxillofac Implants 2006; 21:426–

432.

26. Mazor Z, Peleg M, Garg AK, Luboshitz J. Platelet-rich plasma

for bone graft enhancement in sinus floor augmentation

with simultaneous implant placement: patient series study.

Implant Dent 2004; 13:65–72.

27. Velich N,Nemeth Z, Toth C, Szabo G. Long-termresults with

different bone substitutes used for sinus floor elevation. J

Craniofac Surg 2004; 15:38–41.

28. Lundgren S, Andersson S, Gualini F, Sennerby L. Bone reformation

with sinus membrane elevation: a new surgical

technique for maxillary sinus floor augmentation. Clin

Implant Dent Relat Res 2004; 6:165–173.

29. Kim YK, Yun PY, Lim SC, Kim SG, Lee HJ, Ong JL. Clinical

evaluations of OSTEON as a new alloplastic material in sinus

bone grafting and its effect on bone healing. J BiomedMater

Res B Appl Biomater 2008; 86:270–277.

30. Hurzeler MB, Quinones CR, Kirsch A, Schupbach P,

Krausse A, Strub JR, et al. Maxillary sinus augmentation

using different grafting materials and dental implants in

monkeys. Part III. Evaluation of autogenous bone combined

with porous hydroxyapatite. Clin Oral Implants Res 1997;

8:401–411.

31. Klongnoi B, Rupprecht S, Kessler P, et al. Lack of beneficial

effects of platelet-rich plasma on sinus augmentation using a

fluorohydroxyapatite or autogenous bone: an explorative

study. J Clin Periodontol 2006; 33:500–509.

32. Testori T, Wallace SS, Del Fabbro M, et al. Repair of large

sinus membrane perforations using stabilized collagen

barrier membranes: surgical techniques with histologic and

radiographic evidence of success. Int J Periodontics Restorative

Dent 2008; 28:9–17.

33. Asensio E, Mont L, Rubin JM, et al. [Prospective and comparative

study of pacemaker implants carried out at the electrophysiology

laboratory and the operating room]. Rev Esp

Cardiol 2000; 53:805–809.

34. Pikos MA. Maxillary sinus membrane repair: report of a

technique for large perforations. Implant Dent 1999; 8:29–

34.

10 Clinical Implant Dentistry and Related Research, Volume *, Number *, 2012

35. Timmenga NM, Raghoebar GM, Boering G, van

Weissenbruch R. Maxillary sinus function after sinus lifts

for the insertion of dental implants. J Oral Maxillofac Surg

1997; 55:936–939; discussion 940.

36. Simion M, Fontana F, Rasperini G, Maiorana C. 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. Int J Periodontics

Restorative Dent 2004; 24:208–221.

37. Tawil G,Mawla M. Sinus floor elevation using a bovine bone

mineral (Bio-Oss) with or without the concomitant use of a

bilayered collagen barrier (Bio-Gide): a clinical report of

immediate and delayed implant placement. Int J Oral Maxillofac

Implants 2001; 16:713–721.

38. Cho YS, Park HK, Park CJ. Bony window repositioning

without using a barrier membrane in the lateral approach

for maxillary sinus bone grafts: clinical and radiologic results

at 6 months. Int J Oral Maxillofac Implants 2012; 27:211–

217.

39. Kan JY, Rungcharassaeng K, Lozada JL, Goodacre CJ. Effects

of smoking on implant success in grafted maxillary sinuses.

J Prosthet Dent 1999; 82:307–311.

40. Bain CA, Moy PK. The association between the failure of

dental implants and cigarette smoking. Int J Oral Maxillofac

Implants 1993; 8:609–615.

Simultaneous Sinus Lift and Implant Installation 11