Influence of Maxillary Sinus Width on Transcrestal Sinus Augmentation Outcomes: Radiographic Evaluation Based on Cone Beam CT Xiaofei Zheng, MDS;*,† Minhua Teng, MDS;*,† Fengjuan Zhou, MDS;*,† Jun Ye, MDS;*,† Guanda Li, MDS;* Anchun Mo, DDS‡

ABSTRACT Background: Maxillary sinus elevation is a predictable procedure to vertically enhance bone volume in the posterior maxilla for successful implant placement. It is speculated that graft bone resorption and remodeling which require angiogenesis may be affected by the dimensions of maxillary sinus cavity. Purpose: The aim of this study is to investigate the effect of sinus width (SW) on the outcomes of transcrestal sinus lift with simultaneous implant placement based on cone beam CT (CBCT). Materials and Methods: A total of 57 elevated sites in 33 patients were included in this study. All the patients were treated with transcrestal sinus lift procedure associated with simultaneous implant placement using a composite graft material of autogenous bone and Bio-Oss. For each patient, CBCT scans were performed preoperatively, immediately after surgery and 6 months after surgery. Measurements of the linear parameters were conducted on the preoperative and postoperative CBCT images. The correlation of SW with graft resorption (GR) was analyzed using Pearson’s correlation test with or without the classification of residual bone height. Results: The average width of maxillary sinus was 13.68 1 2.66 mm. The mean height of apical graft bone decreased from 2.85 mm immediately after surgery to 1.38 mm after 6 months. A positive association between SW and GR (r = 0.323, p = .014) was found in general. Conclusion: The findings show that graft bone resorption in elevated sinus has a positive correlation with the SW. KEY WORDS: bone grafting, cone beam CT, dental implant, maxillary sinus width, sinus floor elevation

loss often lead to inadequate bone height.1 Consequently, oral rehabilitation with proper dental implants in the posterior maxillary quadrants presents a clinical challenge. Nevertheless, this tough problem in the posterior maxilla can be overcome by the operation of sinus floor elevation, which was initially described by Tatum at an implant conference in 1976 and subsequently published by Boyne and James in 1980.2,3 This sinus lift procedure creates surgical access through a lateral opening in the external wall of the maxillary sinus to dissect the Schneiderian membrane for its apical displacement. The space underneath the lifted sinus mucosa is filled with bone graft, and implants can be inserted either simultaneously or delayed. Apart from lateral window technique, sinus floor can be elevated by a less invasive technique, namely transcrestal sinus floor elevation (tSFE) introduced by

INTRODUCTION In the posterior maxilla, alveolar bone resorption and an increase of sinus pneumatization following tooth

*Resident, State Key Laboratory of Oral Diseases, Sichuan University, Chengdu, Sichuan, China; Dental Implant Center, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China; † National Clinical Key Specialty on Oral Implantology, Chengdu, Sichuan, China; ‡professor, Dental Implant Center, West China Hospital of Stomatology, Sichuan University, Chengdu, Sichuan, China; National Clinical Key Specialty on Oral Implantology, Chengdu, Sichuan, China Corresponding Author: Prof. Anchun Mo, DDS, Dental Implant Center, West China Hospital of Stomatology, Sichuan University, No. 14, Section 3 of RenMinNanLu, Chengdu, Sichuan 610041, China; e-mail: [email protected] Conflict of Interest: No conflict of interest. © 2015 Wiley Periodicals, Inc. DOI 10.1111/cid.12298

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Summers.4 In this procedure, a small osteotomy is performed through the alveolar crest of the edentulous site at the inferior border of the maxillary sinus. The intrusion osteotomy procedure fractures the sinus floor and elevates the sinus membrane, thus creating a “tent” for bone graft placement or blood clot formation.5 Despite through different approaches, these two classical procedures are performed with the same aim that a space is created by elevating the sinus membrane and filled with graft bone materials or blood clot in order to enhance the vertical bone volume and provide the platform for implant placement in the edentulous posterior maxilla.6 Compared with the lateral window technique, the transcrestal procedure is considered to be less invasive and can reduce patient morbidity, as well as treatment time and cost. Nowadays, tSFE is applied with increasing frequency for implant placement in the posterior maxilla. The anatomic characteristics of the maxillary sinus have a critical impact on the outcomes of sinus floor elevation. The success of sinus floor augmentation, to some extent, depends on the evaluation of the inner aspect of the maxillary sinus. The presence of anatomic variations within the maxillary sinus such as sinus septa, sinus floor convolution, and thin Schneiderian membrane can complicate membrane elevation and decrease the success of sinus floor augmentation.7–9 Moreover, the morphology of the sinus cavity correlates with the outcome of sinus lift procedure. The lateral (buccal) wall and the medial (palatal) wall are two important walls of the maxillary sinus for the sinus floor elevation. The angle between the medial and lateral sinus wall was associated with the incidence of membrane perforation.10 The sites with sharper angles are at a higher risk of membrane perforation.11 The mediolateral distance of the maxillary sinus was negatively associated with the total percentage of vital bone after sinus lift through lateral window technique.12 To the best of our knowledge, the influence of mediolateral dimension (sinus width [SW]) on the changes of sinus graft quantity after tSFE procedure has not been evaluated. According to a previous study, the vertical resorption of graft material was higher with longer mesial–distal width of the graft in elevated maxillary sinus by means of lateral window technique.13 Similarly, we assume that a higher resorption of the graft may occur with a wider lateral–medial dimension of the sinus. Hence, the aim of the present study is to investi-

gate the influence of SW on the outcomes of tSFE with simultaneous implant placement based on cone beam CT (CBCT). MATERIALS AND METHODS Patient Selection From the patients who visited the Dental Implant Department of West China Hospital of Stomatology for sinus floor elevation and implant placement, the qualified subjects were selected. Inclusion criteria for enrollment in this study were as follows. •

• •



Patients performed with sinus floor lift by transcrestal technique associated with simultaneous implant placement; The use of composite graft materials consisting of autogenous bone and Bio-Oss particles; Complete CBCT scans obtained preoperatively, immediately after surgery, and 6 months after surgery; The opposing jaw presented either natural dentition or restored with fixed implant-supported prosthesis so that the same location of the recipient site could be identified on the preoperative and postoperative CBCT images.

All the selected patients provided informed consent to participate in this study. The study was conducted according to the World Medical Association Declaration and approved by the Ethical Committee of Sichuan University for studies involving human subjects (Ethics Reference No.WCHSIRB-D-2012052). Surgical Procedure All patients were treated by one experienced operator using the tSFE procedure with simultaneous implant placement. The surgical processes are briefly described here. Prior to the surgery, patients rinsed with 0.12% chlorhexidine mouthwash for 1 minute. After local anesthesia, full-thickness flaps were reflected following a crestal incision and vertical releasing incisions if necessary. The implant site preparation was started with a pilot drill to the depth of 1 mm away from the sinus floor. Then cautious, gentle tap on a series of osteotomes was performed to fracture the bony sinus floor and provide the best tactile feedback in this pivotal step, thus minimizing the risk of membrane perforation. As grafting material, Bio-Oss particles (Geistlich Pharma AG, Wolhusen, Switzerland) were mixed with autologous

Influence of Sinus Width on Sinus Augmentation

bone in a 2:1 ratio. Most of autogenous bone was harvested during drilling process at low speed. Under the condition that the available bone was insufficient, autogenous bone was obtained from other implant site of the same individual or the adjacent sites. The graft mixture was inserted into the created space underneath the augmented sinus membrane, and implants were placed simultaneously. The incidence of membrane perforation was evaluated by the Valsalva maneuver immediately after the sinus floor fracture, which was reevaluated by the posteoperative CBCT scan. The mucoperiosteal flap was repositioned and sutured.

One Volume Viewer (J. Morita Mfg. Corp.). According to the implant site on the postoperative CBCT scan, the planned site on the preoperative CBCT scan was adjusted to the same coronal section as postoperative CBCT image. All the measurements of the linear variables were performed on the coronal images with the measuring tool that possessed by the analysis software (Figure 1). The precision of the measuring system is 0.01 mm. The linear items to be analyzed are as follows. •

Postoperative Care and Healing Time All subjects received appropriate postoperative instruction and were prescribed with a pharmacologic regime that included amoxicillin/clavulanate potassium tablets (500/125 mg TID for 7 days) or, if allergic to penicillin, azithromycin (300 mg TID for 7 days), as well as analgesics (Ibuprofen 400 mg every 6 hours). Sutures were removed after 10 days. A healing period of 6 months was maintained before second-stage surgery. Then the final prostheses were delivered.







Radiographic Evaluation For each patient, CBCT imaging was performed preoperatively, immediately after surgery, and 6 months after surgery using a CBCT machine (3D Accuitomo 170®, J. Morita Mfg. Corp., Kyoto. Japan). The imaging parameters were set at 80 kV, 4.5 mA, with scan time 23.0 seconds, slice thickness 0.125 mm, and a field of view that varied based on the scanned region. The CBCT scans of each patient were transferred to a desktop computer. The coronal, sagittal, and axial images were reformatted and analyzed using i-Dixel

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Residual alveolar bone height (RBH): the presurgical distance from the alveolar crest to the maxillary sinus floor; SW: the distance between lateral sinus wall and medial wall at the height of 5 mm above the sinus floor in the planned sites; Implant protrusion (IP): the mean distance from the initial sinus floor to the apex of the implant assessed at buccal and palatal sides; Height of the graft apically (aGH): the mean distance occupied by a radiopaque sign between the implant apex and the new sinus floor (the border of the grafting material) as assessed at the buccal and palatal aspects of implants; Extent of the sinus lift (SL): the distance between the initial sinus floor and the elevated sinus floor calculated as the sum of IP and aGH; Graft bone resorption (GR): the difference between aGH measured immediately after surgery and that measured 6 months after surgery.

Radiographic measurements are illustrated in Figure 2. RBH and SW at the planned implant sites were measured on the preoperative CBCT scan, while measurements of other items (IP, aGH, SL) were obtained on

Figure 1 Coronal images on CBCT scans. A, Preoperative radiograph. B, CBCT scan immediately implant placement. C, Radiograph 6 months after surgery.

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Figure 2 Schematic representation of the investigated parameters. A, residual bone height (RBH); B, the width of maxillary sinus (SW); C, the length of implant protrusion (IP); D, the graft height apically (aGH); E, the height of sinus lift (SL). Among these parameters, A and B were analyzed on preoperative CBCT; C–E were repeatedly measured on postsurgical CBCT scans.

postoperative CBCT images. Radiographic measurement and analysis were performed by a single trained investigator.

TSIII (Korea), and Ankylos (German). Implant characteristics are shown in details in Table 1. Surgical and Postsurgical Complications

Statistical Analysis All data analyses were performed using a statistical software package (SPSS 16.0 KO, SPSS Inc., Chicago, IL, USA). Descriptive statistics (means 1 SD) were calculated. The associations of parameters (SW, RBH, SL, IP, and aGH) with GR were quantified by means of the Pearson’s correlation test. A categorical analysis of correlation between SW and GR was performed based on the classification of RBH, which was divided into three categories: 2 mm 2 RBH < 4 mm, 4 mm 2 RBH < 6 mm, and 6 mm 2 RBH < 8 mm. Statistical significance was set at p < .05.

In this study, no perforation was detected by the Valsalva test, which was also verified by the immediately postoperative CBCT. The overall procedure was well tolerated by the patients who complain of only slight postoperative swelling and minor discomfort. At 6 months after surgery, the wound healing was uneventful, and no implant failure was recorded. Radiographic Analysis A total of 57 elevated sites were analyzed. The SW ranged from 7.88 to 21.63 mm, with a mean value of 13.68 1 2.66 mm. The mean of preoperative RBH was

RESULTS Study Population Of 85 sites screened, 57 sites in 33 patients (11 women and 22 men) were qualified for the analysis. The main reasons for exclusion were the lack of complete CBCT scans and the use of other graft materials, such as HA and TCP. The average age of the patients was 50 years, ranging from 30 to 70 years. Of these patients, 31 received unilateral sinus lift and two bilateral. Among the 57 implants, 50 implants were placed in the molar area, and the rest were in the premolar region. The distribution of the implants according to their location in the jaw is displayed in Figure 3. Three different types of implant fixtures were used: Bicon (America), Osstem

Figure 3 Distribution of 57 implants placed in posterior maxilla through the procedure of transcrestal sinus floor elevation.

Influence of Sinus Width on Sinus Augmentation

TABLE 1 Implant Characteristics Implant Type

Bicon OsstemGSIII

Ankylos

Number

Diameter (mm)

Length (mm)

22 8 2 2 3 3 10 5 2

5 6 4 4.5 4.5 5 5 4.5 4.5

6 5.7 11.5 10 11.5 8.5 10 9.5 11

4.38 1 1.56 mm, ranging from 2 to 7.96 mm. Results of SW and RBH measured on presurgical CBCT images are given in Table 2. Mean IP was 3.03 1 1.32 mm. The aGH amounted to 2.85 1 1.15 mm immediately after surgery, while it reduced to 1.38 1 1.29 mm 6 months later. The GR was 1.47 1 0.65 mm. Mean SL achieved at implant placement was 5.88 1 1.63 mm, decreasing to 4.35 1 1.75 mm after 6 months. Table 3 displays the average and standard deviation of the variables on postoperative CBCT scans. Analysis of the relation between SW and GR using the Pearson’s correlation coefficient revealed a positive association (r = 0.323, p = .014; Table 4). Categorical analysis of correlation after stratification of RBH revealed that a positive correlation between SW and GR exited in groups of 2 mm 2 RBH < 4 mm and 4 mm 2 RBH < 6 mm, while no correlation was found in the group of 6 mm 2 RBH < 8 mm (Table 5). The scatter plot is displayed in Figure 4. No statistically significant correlation between other variables (RBH, SL, IP, and aGH) and GR was found (data not shown).

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TABLE 3 Postsurgical Radiographic Measurements (Mean 1 SD) Variable

Immediately after surgery

6 months after surgery

3.03 1 1.32 2.85 1 1.15 5.88 1 1.63

no data 1.38 1 1.29 4.35 1 1.75

IP aGH SL Data in millimeter.

of maxillary sinus directly determines the dissection distance of sinus membrane from buccal wall to palatal wall and relates to the complexity of the operation, which might be associated with the incidence of intraoperative complications.14 The hinge osteotomy technique in which a hinge bone window is created in the lateral wall of maxilla and then pushed inward may not be indicated in a sinus with either too small or too large SW. In an extraordinarily large sinus, it is difficult for the inserted implant to contact with the intruded trapdoor. The rotation of the trapdoor into the narrow maxillary sinus is not possible, owing to the lack of SW.15 So, in a maxillary sinus with extreme SW, complete osteotomy technique or transcrestal technique would be recommended. In addition, a modality of choice among grafting materials in relation to SW was brought forward.16 Jang and colleagues reported the rate of graft material

TABLE 4 Pearson’s Correlation Test of Sinus Width and Graft Bone Resorption Correlation Analysis

GR

SW (n = 57)

r p Value

0.323 .014

GR = resorption of graft bone; SW = sinus width.

DISCUSSION The distance between the lateral and the medial sinus wall, namely SW, is a critical anatomic factor in sinus augmentation. For lateral window procedure, the width

TABLE 5 Pearson’s Correlation Test of Sinus Width and Graft Bone Resorption Based on the Classification of RBH GR

TABLE 2 Radiographic Measurements on Preoperative CBCT Scan Variable

RBH SW

SW

Mean (mm)

SD (mm)

Min (mm)

Max (mm)

4.38 13.68

1.56 2.66

2.00 7.88

7.96 21.63

2 mm 2 RBH < 4 mm 4 mm 2 RBH < 6 mm 6 mm 2 RBH < 8 mm

r

p Value

n

0.492 0.458 −0.178

.011 .024 .702

26 24 7

GR = resorption of graft bone; SW = sinus width.

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Figure 4 Scatter plot diagrams illustrating the distribution of GR relative to SW with the corresponding correlation coefficient values. A, The general distribution of GR relative to SW without RBH classification. B, The distribution of GR relative to SW in the group of 2 mm 2 RBH < 4 mm. C, The distribution of GR relative to SW in the group of 4 mm 2 RBH < 6 mm. D, The distribution of GR relative to SW in the group of 6 mm 2 RBH < 8 mm.

contacting with bony sinus wall was higher in a narrow sinus than in a wide sinus, thus contributing to more new bone formation by receiving vascular supply from the sinus wall. In authors’ opinion, the value of 12.1 mm was used as the threshold to divide narrow and wide sinus. In a narrow sinus, grafting materials with exclusively osteoconductive potential can be used for sinus floor elevation, while autogenous bone with osteogenic ability would be the optimal choice in a large sinus. Moreover, reflection of the sinus membrane on the medial wall through lateral window approach was suggested in a large sinus under the circumstance where autogenous bone was not available. Besides the choice of surgical options and grafting materials, SW may play a vital part in the change of bone quality and quantity during graft remodeling process following sinus augmentation. Successful graft consolidation depends on the progressive resorption of graft

materials and apposition of new bone, followed by functional remodeling.17 Avila and colleagues conducted a study to assess the influence of SW on bone maturation of an allograft following sinus elevation by lateral technique and observed that the total percentage of vital bone was lower in the maxillary sinus with greater buccal–palatal distance. The result demonstrated that the maturation of graft material was hindered in the situation where the dimension of the maxillary sinus was excessive.12 The stability of augmented bone height represents an important factor for implant success.18 It is required and advantageous that the graft materials employed for sinus lift to be resorbed and replaced over time with patients’ own bone. The stability of implant may be influenced when the graft material is resorbed at a rate faster than that of new bone formation. To our best knowledge, there is few article reporting the influence of

Influence of Sinus Width on Sinus Augmentation

SW on the change of graft volume in the process of consolidation after sinus lift surgery. The present study was conducted to investigate the influence of SW on the outcomes of tSFE procedure with simultaneous implant placement, especially on the change of graft quantity, using a composite graft material of autogenous bone and Bio-Oss. According to CBCT obtained immediately after surgery, the grafted sinus floor was consistently located above the implant apex. During 6 months of healing time, the bone graft underwent resorption and remolding with a mean value of 1.47 mm for GR, leading to the decrease of SL. Statistical analysis showed that a significantly positive correlation exited between SW and graft bone resorption. Considering that RBH is an important anatomical factor that may have influence on GR, the relation of RBH and GR was analyzed, and no statistical correlation was found, which was similar to the report that RBH does not appear to influence the maturation and consolidation of an allograft in the maxillary sinus.19 Furthermore, a categorical analysis of correlation between SW and GR was performed based on the classification of RBH. The results revealed that a positive correlation between SW and GR exited in groups of 2 mm 2 RBH < 4 mm and 4 mm 2 RBH < 6 mm. However, no correlation was found in the group of 6 mm 2 RBH < 8 mm, which may be caused by the small number of sample (n = 7). The correlation between SW and GR means that the absorption of composite graft material is larger in a maxillary sinus with greater width. The events of graft remodeling require the presence of a stable scaffold, ample blood supply, and the migration of osteogenic cells, which could be affected by the volume of sinus bony cavity.12 As to the observation in this study, several possible explanations are as follows. Firstly, sufficient vascular supply is important for the remodeling of graft materials. The posterior lateral nasal artery on the medial wall of the maxillary sinus together with posterior superior alveolar artery and infraorbital artery located on the lateral wall provides blood supply for the graft bone materials.20,21 If the buccal–palatal distance is extremely wide, the graft cannot achieve adequate angiogenesis for normal remolding, resulting in much bone resorption. While in a sinus with narrower width, less resorption occurred due to enough vascular supply. Secondly, the membrane tension that developed following sinus floor elevation and graft materials

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insertion may play a role in graft resorption (GR). When the sinus membrane is elevated by the same extent, the membrane tension in a wide maxillary sinus is somewhat larger than that in a narrow sinus. Increased membrane tension may transfer compressive force to the graft material, thus leading to faster or more bone resorption. Furthermore, the support from the lateral and medial bony sinus wall may influence the morphology of the graft materials inserted in the augmented sinus. A better support of the elevated membrane and the graft bone is possible in a sinus with short lateral–medial distance. Graft materials would be more likely to collapse in a wider sinus because of the absence of enough support from the bony sinus walls. Noteworthy of attention is that in the present study, the measurement level for SW was determined on 5 mm above the sinus floor in the planned implant site on preoperative CBCT scan. In a previous study, the SW was measured at the apical end level of the implants that would be placed in the preoperative CT.16 Owing to the use of both short and long implants in this study, the measurement level at the implant apex would not be appropriate. In a study assessing the outcomes of sinus floor elevation by lateral window procedure, SW was measured at 8, 10, and 12 mm from the alveolar crest.12 According to previous studies, the extent of sinus lift by transcrestal technique ranged from 6.4 mm to 7.7 mm,18,22–24 so the measurement level of 5 mm chosen in this study approximates to the height of sinus lift with the transcrestal approach. Although satisfied outcomes and high success rate of sinus lift without any graft material have been reported in both animal and human studies,25–30 the apical displacement of the sinus floor obtained by sinus lift can be enhanced and better maintained by condensing graft material under the elevated sinus membrane.21 Pjetursson and colleagues reviewed that optimal outcomes of tSFE surgery can be expected with the additional use of bone graft material.31 In this study, a mixture of autogenous bone and Bio-Oss was used, which contained the osteogenic cells and served to maintain the created space. During the osseointegration period, the graft material undergoes consolidation, which means that graft material is resorbed by osteoclast and replaced by new vital bone. Anorganic bovine bone appears to be replaced at the rate of regular bone during remodeling, and the time for resorption in humans is 6

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months,32 which is consistent with another study.18 Kim and colleagues reported that largest amount of grafted height loss occurred during the first 6 months in both transcrestal and lateral sinus floor elevation groups, and subsequent changes were minimal. Based on the abovementioned results, GR during the 6 months of healing period can represent the total change of graft volume to some extent. Therefore, in this study, an observation period of 6 months is still feasible and significant for the analysis of the correlation between SW and GR. Another remarkable aspect of the present study is the use of CBCT. Before the surgery of sinus floor lift, the preoperative bone quantity and quality, as well as configuration of maxillary sinus, should be radiographically evaluated.33 However, panoramic radiograph or periapical radiograph can only provide two-dimensional information. So, the application of three-dimensional images is necessary, such as conventional CT or CBCT. Compared with conventional CT, CBCT allows a lower radiation dose, a shorter acquisition time, and a reduced cost. Moreover, CBCT can provide submillimeter accuracy for linear measurements.34 The American academy of Oral and Maxillofacial Radiology proposes that CBCT is an imaging method of gaining the detailed information for the assessment of all dental implant sites.35 It is also recommended that the occurrence of continued bone GR after dental implant placement should be investigated further using CBCT.36 Monitoring the effects of sinus augmentation by volumetric measurements using CBCT has been described as an accurate method.37 In this study, the application of CBCT can ensure accurate measurement and assessment of linear variables. The information on the correlation between SW and GR provided by this study can be referred to under the circumstance that graft material is considered in clinical practice of maxillary sinus augmentation. Less or no additional graft material is practicable for a narrow maxillary sinus, while more graft bone materials should be used in the elevated sinus with greater SW in order to achieve and maintain implant stability. CONCLUSION Based on the results of this study, conclusion can be drawn that GR in the elevated sinus has a positive correlation with the SW. This information can be used for

reference when the graft material is considered in clinical practice of sinus floor elevation. According to the SW, bone grafting with appropriate amount is chosen in the sinus lift procedure. REFERENCES 1. 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. 2. Tatum H Jr. Maxillary and sinus implant reconstruction. Dent Clin North Am 1986; 30:207–229. 3. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Maxillofac Surg 1980; 38:613–616. 4. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium 1994; 15:154– 156. 5. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. 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. J Clin Periodontol 2008; 35:241–254. 6. Woo I, Le BT. Maxillary sinus floor elevation: review of anatomy and two techniques. Implant Dent 2004; 13:28–32. 7. Cakur B, Sumbullu MA, Durna D. Relationship among Schneiderian membrane, Underwood’s septa, and the maxillary sinus inferior border. Clin Implant Dent Relat Res 2013; 15:83–87. 8. Chanavaz M. Maxillary sinus: anatomy, physiology, surgery, and bone grafting related to implantology – eleven years of surgical experience (1979–1990). J Oral Implantol 1990; 16:199–209. 9. Kang SJ, Shin SI, Herr Y, Kwon YH, Kim GT, Chung JH. Anatomical structures in the maxillary sinus related to lateral sinus elevation: a cone beam computed tomographic analysis. Clin Oral Implants Res 2013; 24(Suppl A100):75– 81. 10. Cho SC, Wallace SS, Froum SJ, Tarnow DP. Influence of anatomy on Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis. Pract Proced Aesthet Dent 2001; 13:160–163. 11. Velloso GR, Vidigal GM Jr, de Freitas MM, Garcia de Brito OF, Manso MC, Groisman M. Tridimensional analysis of maxillary sinus anatomy related to sinus lift procedure. Implant Dent 2006; 15:192–196. 12. Avila G, Wang HL, Galindo-Moreno P, et al. The influence of the bucco-palatal distance on sinus augmentation outcomes. J Periodontol 2010; 81:1041–1050. 13. Galindo-Moreno P, Fernández-Jiménez A, O’Valle F, et al. Marginal bone loss in implants placed in grafted maxillary sinus. Clin Implant Dent Relat Res 2014; 25:378–384. 14. Chan HL, Suarez F, Monje A, Benavides E, Wang HL. Evaluation of maxillary sinus width on cone-beam computed

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27. Kim HR, Choi BH, Xuan F, Jeong SM. The use of autologous venous blood for maxillary sinus floor augmentation in conjunction with sinus membrane elevation: an experimental study. Clin Oral Implants Res 2010; 21:346–349. 28. Hatano N, Sennerby L, Lundgren S. Maxillary sinus augmentation using sinus membrane elevation and peripheral venous blood for implant-supported rehabilitation of the atrophic posterior maxilla: case series. Clin Implant Dent Relat Res 2007; 9:150–155. 29. Sohn DS, Lee JS, Ahn MR, Shin HI. New bone formation in the maxillary sinus without bone grafts. Implant Dent 2008; 17:321–331. 30. Balleri P, Veltri M, Nuti N, Ferrari M. Implant placement in combination with sinus membrane elevation without biomaterials: a 1-year study on 15 patients. Clin Implant Dent Relat Res 2012; 14:682–689. 31. Pjetursson BE, Ignjatovic D, Matuliene G, Brägger U, Schmidlin K, Lang NP. Transalveolar maxillary sinus floor elevation using osteotomes with or without grafting material. Part II radiographic tissue remodeling. Clin Oral Implants Res 2009; 20:677–683. 32. McAllister BS, Margolin MD, Cogan AG, Buck D, Hollinger JO, Lynch SE. Eighteen-month radiographic and histologic evaluation of sinus grafting with anorganic bovine bone in the chimpanzee. Int J Oral Maxillofac Implants 1999; 14:361–368. 33. Petrikowski CG, Pharoah MJ, Schmitt A. Presurgical radiographic assessment for implants. J Prosthet Dent 1989; 61:59–64. 34. Loubele M, Van Assche N, Carpentier K, et al. Comparative localized linear accuracy of small-field cone-beam CT and multislice CT for alveolar bone measurements. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:512–518. 35. Yoshimine S, Nishihara K, Nozoe E, Yoshimine M, Nakamura N. Topographic analysis of maxillary premolars and molars and maxillary sinus using cone beam computed tomography. Implant Dent 2012; 21:528–535. 36. Klijn RJ, van den Beucken JJ, Bronkhorst EM, Berge SJ, Meijer GJ, Jansen JA. Predictive value of ridge dimensions on autologous bone graft resorption in staged maxillary sinus augmentation surgery using Cone-Beam CT. Clin Oral Implants Res 2012; 23:409–415. 37. Stratemann SA, Huang JC, Maki K, Miller AJ, Hatcher DC. Comparison of cone beam computed tomography imaging with physical measures. Dentomaxillofac Radiol 2008; 37:80–93.

Influence of Maxillary Sinus Width on Transcrestal Sinus Augmentation Outcomes: Radiographic Evaluation Based on Cone Beam CT.

Maxillary sinus elevation is a predictable procedure to vertically enhance bone volume in the posterior maxilla for successful implant placement. It i...
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