Implant survival rates after maxillary
Massimo Del Fabbro, Gabriele
Rosano, Silvio Taschieri
Department of Technologies for Health, Dental
Clinic, IRCCS Galeazzi Institute, University of
Milan, Milan, Italy
Placement of dental implants in the atrophic posterior
maxilla is a challenging procedure in the presence of
reduced maxillary bone height. Various clinical proce-
dures and materials have been developed to overcome
the problem of reduced bone volume. One of the most
frequently used surgical interventions for obtaining
adequate bone height prior to the placement of endos-
seous implants in the posterior maxilla is grafting to the
floor of the maxillary sinus.
The sinus augmentation technique was first presented
in the late 1970s in a series of lectures by Tatum (1), who
then published a paper on the subject several years later.
The first clinical study, in which autogenous cancellous
bone from the lateral iliac crest was used as graft mate-
rial, adopting a modified Caldwell-Luc procedure to
approach the maxillary sinus, was published in 1980 (2).
Since then, the sinus grafting technique has evolved over
time and has been used by a growing number of clini-
cians, as shown by an increasing body of scientific liter-
ature. Several modifications to the original protocol have
been carried out in order to improve the predictability of
clinical outcomes and, at the same time, to reduce donor
site morbidity caused by bone harvesting. In particular,
various types of allografts, xenografts and alloplastic
materials have been used as bone substitutes, alone or in
combination with autogenous bone, to simplify the
grafting phase and to minimize the patient?s discomfort.
While autogenous bone has long been considered the
gold standard grafting material because of its osteoin-
ductive and osteoconductive properties, alternative
materials have, in general, no osteoinductive potential
but are considered to provide a scaffold for optimal bone
growth. The efficacy of the graft material in promoting
graft maturation and providing optimal long-term sup-
port to endosseous implants is one of the most critical
factors for the success of the sinus augmentation proce-
dure. It seems therefore of interest to determine whether
survival rates of implants differ when inserted in different
Another variable that may affect the process of bone
formation around implants is the implant surface con-
figuration. There is histologic and clinical evidence sug-
gesting that a more favourable implant–bone interface is
established on rough-surfaced implants compared with
machined implants, especially in poor quality bone (3–8).
It is therefore expected that, when inserted in grafted
bone, the outcome of implants with a textured surface is
better than those with a machined surface. It can also be
Del Fabbro M, Rosano G, Taschieri S. Implant survival rates after maxillary sinus
augmentation. Eur J Oral Sci 2008; 116: 497–506. ? 2008 The Authors. Journal
compilation ? 2008 Eur J Oral Sci
Implant therapy in the atrophic posterior maxilla becomes challenging in the
presence of reduced maxillary bone height. Sinus augmentation can be performed
for resolving this condition prior to implant placement. The aim of this article was
therefore to evaluate implant survival rates in the grafted sinus taking into account
the influence of the implant surface, graft material, and implant placement timing.
A systematic review of the literature was performed. Articles retrieved from elec-
tronic databases were screened using specific inclusion criteria, and data extracted
were divided according to: graft material (autogenous, non-autogenous, composite
graft), implant surface (machined or textured), and implant placement (simultaneous
with grafting or delayed). Fifty-nine articles were included. Survival rates for
implants placed in grafts made of bone substitutes alone and grafts of composite
material were slightly better than the survival rates for implants placed in 100%
autogenous grafts. Over 90% of implants associated with non-autogenous grafts
had a textured surface. Textured surfaces achieved better outcomes compared with
machined surfaces, and this was independent of the graft material. Simultaneous
and delayed procedures had similar outcomes. It may be concluded that bone
substitutes can be successfully used for sinus augmentation, reducing donor-site
morbidity. Long-term studies are needed to confirm the performance of non-
autogenous grafts. The use of implants with a textured surface may improve the
outcome in any graft type.
Dr Massimo Del Fabbro, Universit? di Milano,
Istituto Ortopedico Galeazzi, Via R. Galeazzi 4,
20161 Milano, Italy
Key words: bone substitutes; dental implants;
maxillary sinus; sinus augmentation; system-
Accepted for publication August 2008
Eur J Oral Sci 2008; 116: 497–506
Printed in Singapore. All rights reserved
? 2008 The Authors.
Journal compilation ? 2008 Eur J Oral Sci
European Journal of
appealing to investigate if it is the graft type or the
implant surface (or a particular combination of these)
that is mainly responsible for the treatment outcome in
terms of the implant survival rate.
While the graft type and the implant characteristics
can be chosen by the clinician, other variables of the
sinus-augmentation procedure can be dictated by the
specific clinical situation. For example, the choice of
placing implants simultaneously to the grafting proce-
dure or at a later stage can be influenced by the amount
of residual crestal bone height. It has long been assumed
that when the latter is less than 5 mm no adequate
mechanical stability can be provided for the placement of
endosseous implants. Primary implant stability is, in fact,
considered mandatory for the success of the simulta-
neous procedure. However, more recent evidence chal-
lenges this concept, showing
requirements are met success can be achieved when
placing implants simultaneously to grafting, even if the
residual crest bone height is limited to as little as 1 mm
The primary objective of this systematic review was to
assess the survival rate of implants placed in grafted
maxillary sinus, based on clinical reports from 1986 to
February 2007, and to determine if it is affected by the
graft material, the implant surface texture, and the
implant placement timing with respect to the grafting
Material and methods
The search protocol used the following electronic databases:
MEDLINE, with a time limit from 1986 to February 2007;
EMBASE, with a time limit from 1988 to February 2007;
and the Cochrane Oral Health Group Specialized Trials
Register up to February 2007. Keywords such as ?maxillary
sinus lift?, ?sinus augmentation?, ?sinus floor elevation?, ?sinus
graft?, ?bone graft?, ?endosseous implants?, ?oral implants?,
and ?dental implants? were used, alone and in combination,
for searching the databases. The search was limited to
studies involving human subjects. Restrictions were not
placed regarding type of study design and language usage.
A further hand search was performed on the major
international journals in the field of implant dentistry
and of oral and maxillofacial surgery from 1986 to
2007 (Clinical Oral Implants Research, Implant Den-
tistry, International Journal of Oral & Maxillofacial
Implants, International Journal of Oral & Maxillofacial
Surgery, International Journal of Periodontics & Restorative
Dentistry, Journal of Oral & Maxillofacial Surgery, Journal
of Periodontology). Finally, the bibliographies of the most
relevant papers and review articles were examined to
identify additional potentially relevant articles.
The titles and abstracts of the articles were screened by two
authors (MDF, GR). Articles were selected according to the
following inclusion criteria:(i) a lateral approach to the
maxillary sinus was used, either the Caldwell-Luc technique,
where the bone lid is entirely removed, or the lateral swing
door technique, according to Tatum (1);(ii) at least 20 sinus
augmentations were carried out;(iii) ?root-form? implants
were used;(iv) fewer than 5% of the patients were lost
during follow-up; (v) mean follow-up was no less than
12 months of implant loading, or the follow-up range
exceeded 24 months; and (iv) the implant survival rate was
clearly indicated or calculable from data reported in the
Publications that did not meet the above inclusion criteria
and those that were not dealing with original clinical cases
(e.g. reviews, technical reports) were excluded. Multiple
group of authors were identified, with very similar databases
of patients, materials, methods and outcomes, the authors
were contacted to clarify whether the pool of patients was
indeed the same. In case of multiple publications relative to
consecutive phases of the same study only the most recent
data (those with the longer follow-up) were considered.
The characteristics of included studies were independently
assessed by two reviewers and the publications were
grouped by study design [randomized controlled trials
(RCT), controlled trials (CT), case series (CS) or retro-
spective studies (RS). The extracted data were grouped
according to the following three parameters.
Type of graft material. This group was divided into three
subgroups: (i) autogenous bone alone; (ii) autogenous bone
in combination with bone substitutes; and (iii) bone sub-
Type of implant surface. This group was made up of two
subgroups: (i) machined surface; and (ii) textured surface.
Implant placement timing. This group comprised two
subgroups: (i) simultaneous technique; and (ii) delayed
Each subgroup was further divided according to the mean
follow-up duration: shorter than 36 months or equal to or
longer than 36 months. The main outcome considered for
the analysis was the implant survival rate.
The search provided a total of 496 articles reporting
maxillary sinus augmentation in combination with
dental implant placement (Fig. 1). Of these, only 59 met
all inclusion criteria for quantitative data analysis
(Fig. 2). These articles (9, 11–67 and Testori T,
unpublished data) were published in a 14-yr period
from 1993 to February 2007 (Fig. 1) and reported data
concerning more than 13,000 implants placed in the
grafted sinuses of over 4,000 patients (Table 1). The
overall implant survival rate from these studies was
93.62%. Of the 59 articles examined, four were RCT
(6.8%), 11 were CT (18.6%), 23 were CS (39.0%), and
21 were RS (35.6%).
The selected articles showed considerable differences in
patients? residual crestal bone height, type of implants
placed, graft materials used, success and survival criteria,
and duration of follow-up. Moreover, there were differ-
ences in the study design and objectives, patient?s inclu-
sion and exclusion criteria, data reporting and methods
of statistical analysis. All articles included in our analysis
provided outcomes considering the implant as the unit of
Del Fabbro et al.
Influence of graft material
Data from all included studies, except eight papers (11,
37, 41, 54, 59, 60, 64, 66), could be allocated to at least
one of the three subgroups considered in our analysis.
Those eight studies, together accounting for 1,133
patients and 3,588 implants, used various types of graft
materials but did not provide sufficient details to allow
the data to be split according to the various subgroups in
the present analysis.
In the subgroup using combination grafts, nine dif-
ferent graft materials were used in combination with
autogenous bone: deproteinized bovine bone (Bio-Oss;
Geistlich Pharma, Wolhusen, Switzerland), deminera-
lized freeze-dried bone allograft (DFDBA; Musculoske-
letal Foundation, Holmhoel, NJ, USA and Dentsply/
Friadent/Ceramed, Mannheim, Germany), hydroxyapa-
tite (HA; Berkeley Advanced Biomaterials, Berkeley,
CA, USA), OsteoGraf/N (Dentsply Friadent/Ceramed,
Mannheim, Germany), Int-200 (Interpore International;
Irving, CA, USA), b-TCP (Cerasorb?; Curasan AG,
OsteoGraf/N + FDBA, BioPlant HTR (Replacement
Therapy Materials, Mechelen, Belgium). (FDBA, freeze-
OsteoGraf/N + DFDBA,
Holmhoel, NJ, USA and Dentsply/Friadent/Ceramed,
In the subgroup using only bone substitutes, many
different graft materials were used: Bio-Oss, DFDBA,
HA, OsteoGraf/N + DFDBA, FDBA, OsteoGraf/N,
b-TCP, calcium sulfate, HA + DFDBA, DFDBA +
Bio-Oss, HA + Bio-Oss,
(Platelet-Rich Plasma; SmartPrep, Harvest Technologies,
Norwell, MA, USA) + Bio-Oss, bovine HA + fibrin
glue, phycogenic material + fluorohydroxyapatite, and
marine algae. In an RCT (60), the osteoinductive sub-
stance bone morphogenetic protein 2 (rhBMP-2; Wyeth/
Genetics Institute, Cambridge, MA, USA), embedded in
a resorbable collagen sponge, was also used.
It was not the purpose of the present study to analyze
separately the performance of each bone substitute or of
any reported combination among them. Table 2 shows
the overall implant survival rates according to the type of
graft material used; the overall survival rate using 100%
autogenous bone grafts was lower (88.9%) with respect
to combined grafts (94.7%) and 100% bone substitutes
(96.1%). In the last two columns of Table 2, the data
were further split according to type of implant surface.
Unfortunately, to date, long-term reports on sinus floor
elevation using bone substitute materials are, as a result
of their relatively recent introduction, rather scarce
compared with the numerous reports on the use of
bone allograft; MusculoskeletalFoundation,
DFDBA + Int-200,PRP
Influence of implant surface
Independently of the graft material, all implants with a
machined surface displayed a mean survival rate of
86.3% (for 950 patients and 3,346 implants placed),
while implants with a rough surface displayed a mean
survival rate of 96.7% (for 2,544 patients and 8,303
implants placed). This comparison between smooth and
rough implant surfaces did not take into consideration
198619871988 198919901991 199219931994 19951996 1997 199819992000 200120022003 2004 20052006
Year of publication
No. of articles
Fig. 1. Number of articles per year between 1986 and 2006 with respect to patients rehabilitated by means of implants placed in
grafted maxillary sinus. The number of articles per year included in the present review is shown between parentheses above each bar.
Fig. 2. Flow diagram showing the steps of the systematic
Implant survival after sinus lift procedure
Articles selected according to inclusion criteria, in chronological order
Lozada et al. (12)
Up to 60
Keller et al. (13)
Blomqvist et al. (14)
Hurzeler et al. (15)
B/C/B + C/A + B
Triplett & Schow (16)
Wheeler et al. (17)
A + B/B
Zinner & Small (18)
A + B/E
7 to > 60
Block & Kent (19)
Daelemans et al. (20)
Up to 80 (40.2)
Block et al. (21)
Blomqvist et al. (22)
Froum et al. (23)
F/F + A/F +D/F + A + D
Fugazzotto & Vlassis (24)
Kaptein et al. (25)
A + B
Up to 70 (55)
Peleg et al. (9)
Van Den Bergh et al. (26)
Watzek et al. (27)
A/A + B/B
Buchmann et al. (28)
> 36 to > 60
De Leonardis & Pecora (29)
Johansson et al. (30)
Keller et al. (31)
Up to 144 (57.1)
Lekholm et al. (33)
Peleg et al. (34)
A + D
Lorenzoni et al. (35)
Up to 60 (40.4)
Olson et al. (36)
A/B/D/B + D/A + D
Up to 71 (38.2)
Tarnow et al. (37)
Van Den Bergh et al. (38)
Wannfors et al. (39)
Bahat & Fontanessi (40)
A + B/A + C
Geurs et al. (41)
Kahnberg et al. (42)
12 to > 60 (39.8)
Raghoebar et al. (43)
Tawil & Mawla (44)
Becktor et al. (45)
Hallman et al. (46)
A/A + C/C
Engelke et al. (47)
A + G
0–60 (> 12)
McCarthy et al. (48)
Philippart et al. (49)
12 to > 48 (31.5)
Rodriguez et al. (50)
C + I
6–36 (> 12)
Stricker et al. (51)
Valentini & Abensur (52)
C + D/C
Hallman & Zetterqvist (53)
B + K
Del Fabbro et al.
John & Wenz (54)
A/A + C/C
Itiurriaga et al. (55)
Hallman & Nordin (56)
Hatano et al. (57)
A + C
Schwarz-Arad et al. (58)
A/A + C/A + D/C
Shlomi et al. (59)
A/A + C
Boyne et al. (60)
Butz & Huys (61)
A + N
Up to 156
Simunek et al. (63)
Wallace et al. (64)
A + C/C
Karabuda et al. (65)
Peleg et al. (11)
A/A + C/A + D
Scarano et al. (66)
Mardinger et al. (67)
T. Testori et al. (unpublished data)
A/A + C/A + O
A, autogenous bone; B, hydroxyapatite (HA); C, Bio-Oss; D, demineralized freeze-dried bone allograft (DFDBA); E, freeze-dried bone allograft (FDBA); F, OsteoGraf/N; G, tricalcium
phosphate (TCP); H, calcium sulphate; I, platelet-rich plasma (PRP); J, bone morphogenetic protein-2 (BMP-2); K, fibrin glue; L, phycogenic material + fluorohydroxyapatite; M,
marine algae; N, BioPlant HTR; O, BioGran; P, Cerasorb; 1, simultaneous procedure; 2, delayed procedure; RCT, randomized controlled trial; CT, controlled trial; CS, case series; retro,
Implant survival after sinus lift procedure
the degree of roughness, the type of coating or the
procedure adopted to roughen the implant surface.
Seven papers (accounting for 525 patients and 1,513
implants) were not classifiable because more than one
implant type was utilized for surgery, and separate sur-
vival rates for each implant type were not reported (12,
23, 32, 37, 41, 50, 60).
Graft material and implant surface
Because the introduction of textured surfaces as well as
the use of bone substitutes is of a more recent date than
the use of machined surfaces and autogenous bone, an
analysis was conducted to determine if the proportion of
implants would correlate with a given surface and the
type of graft material. Figure 3 shows that machined
implants have been used much more often in combina-
tion with autogenous bone than with bone substitute
materials, where the proportion of implants with an
osteoconductive surface is overwhelming. The latter
combination was observed, especially in the most
recently published articles. These studies also showed the
Influence of implant placement timing
according to implant placement timing. Data from the
two subgroups (simultaneous vs. delayed protocol) were
very similar. Twelve papers (accounting for 671 patients
and 2,303 implants) were not classifiable because both
implant placement timing protocols were used, but sep-
arate survival rates were not reported (23, 31, 33, 45, 48,
59–61, 63–65, 67).
showstheoverall implant survivalrates
Published data on sinus graft procedures have rapidly
increased since the Sinus Consensus Conference of 1996
(68). The overall implant survival rate found in the
present review (93.8%) is higher than that reported by
the Sinus Consensus Conference (90.0% for implants
with at least 3 yr of function) (68) and by more recent
systematic reviews that adopted selection criteria similar
to those of the present study (69, 70). Indeed, most
clinical reports published in recent years on this subject
reported excellent results, mainly regarding the use of
combined grafts or bone substitutes alone, in association
with textured surface implants.
Graft material and implant surface
In this review, it was found that implants inserted in
grafts composed of bone substitutes alone, or in grafts
composed of a mixture of autogenous bone and
Overall implant survival rates according to the graft material and implant surface
(no. of implants)
% (no. of implants)
< 36 months
> 36 months
< 36 months
> 36 months
< 36 months
> 36 months
NC, not classifiable.
*A total of 12 patients in two studies (46, T. Testori, unpublished data) received two different graft materials in their maxillary sinuses
in bilateral augmentation procedures.
Fig. 3. Proportion of implants with a machined or textured
surface, associated with the various types of graft material. The
implant survival rate for each subgroup is indicated between
parentheses above the bars. The actual number of implants in
each subgroup is shown in the last two columns of Table 2
Del Fabbro et al.
substitutes, may achieve higher survival rates than im-
plants associated with the use of autogenous bone (Ta-
ble 2). However, it can be misleading to state that
combined grafts or bone substitutes per se produce better
results than 100% autogenous bone.
The superiority of a given material over another must
be assessed by means of RCTs, whose number in the
pertinent scientific literature is still too scarce to draw
Furthermore, the effect of the implant surface must be
taken into consideration. In the present review, it was
found that over 90% of implants used in association with
bone substitutes had a textured surface, while implants
used with autogenous bone were mostly machined
(about 60%, as shown in Fig. 3). The survival rate for
implants with a textured surface was strikingly constant
(between 94.9% and 96.7%) regardless of the graft
material with which they were associated. On the other
hand, the outcome of implants with a machined surface
was inferior compared to implants with a textured
surface, in any type of graft material analyzed (especially
for autogenous bone, Table 2). Similar differences in
performance between the two types of surface were also
reported previously (69, 70). This finding is in line with
other recent studies that showed the superiority of
rough-surfaced implants over smooth-surfaced implants,
especially when placed in poor-quality bone or in high-
risk patients, such as smokers (7, 71) and those with
uncontrolled diabetes (72).
Although in good quality bone the success of the
implant does not strictly depend on the implant surface,
in aged patients (where the posterior maxilla often
shows severe osseous atrophy) the use of textured sur-
faces may positively affect the outcome of implant
treatment. In addition, the discomfort of being hospi-
talized for an extra-oral harvesting procedure under
general anaesthesia, increasing the morbidity of the
intervention, may promote the use of combined grafts
or bone substitutes alone in association with implants
having an osteoconductive surface, in order to overcome
Influence of implant placement timing
This review also found that the implant survival rate is
not dependent on the use of either a ?simultaneous? or a
?delayed? protocol for implant placement in a sinus floor
augmentation procedure. Similar implant survival rates
were reported with both techniques, which is in agree-
ment with previous studies (68–70). The amount of
residual crestal bone in the posterior maxilla, as it relates
to achieving primary implant stability, is a primary fac-
tor used by the clinician in choosing a simultaneous over
a delayed implant placement. If the residual bone is
sufficient to provide implants with adequate ?primary?
stability, the simultaneous protocol can be recommended
and implants may be placed at the same time of grafting.
On the contrary, for cases where residual crestal bone
height is extremely reduced (so as not to provide stability
to implants) a delayed protocol is recommended. In the
latter case, some authors propose the use of a combined
graft with an autogenous component, to improve the
osteoinductive and osteogenic features of the graft
Influence of the surgical technique
Another variable that may influence treatment outcome
is the surgical approach to grafting the maxillary
sinus. The lateral swing door technique of Tatum (1) is
now the most commonly used and best-documented
surgical intervention for increasing alveolar bone height
prior to placement of endosseous implants in the pos-
terior maxilla. Other procedures, such as the osteotome
sinus elevation technique, were summarized in recent
systematic reviews (70, 74) and showed quite promising
results (implant success range 88.6–100%). However,
clinical reports concerning other techniques to app-
roach the maxillary sinus are still too scarce to allow a
statistically adequate analysis on their efficacy. For
this reason, only studies where the lateral approach
technique was performed were considered in the present
Overall implant survival rates according to implant placement timing
< 36 months
> 36 months
< 36 months
> 36 months
Total 4,020* 13,162100.00840
NC, not classifiable.
*One patient in the study by T. Testori (unpublished data) underwent two separate sinus augmentation procedures: in one case the
simultaneous protocol was adopted; in the other case the delayed protocol was adopted.
Implant survival after sinus lift procedure
Limitations of the review
Because of great variability in study design, inclusion
and exclusion criteria, patient age and gender, smoking
habits, implant types (surface, shape, length, and width),
ranges in follow-up, use or non-use of a membrane to
cover the graft, and amount of residual bone height
between the sinus floor and alveolar crest, a direct
comparison of published reports was impossible. This
situation highlights the difficulties encountered when
attempting to draw conclusions from non-controlled
studies as a result of the presence of many additional
confounding variables that may influence the outcome of
the sinus graft procedure. As a consequence, it was not
possible to isolate all these separate variables in the
present review because data reporting was heterogeneous
and specific information on each patient was rarely
As a matter of fact, the conclusions of this review are
based mainly on the results of studies having a low level
of evidence, such as case series or retrospective studies.
These types of study design indeed could be appropriate
to determine the prognosis of a given treatment, but
should not be used when a comparison between treat-
ments (or between materials) has to be made. This poses
a strong limitation to the evaluation of the efficacy of any
In the present review, implant survival was investi-
gated as the main outcome because it is simple to
determine, whereas implant success is more valuable but
has to be determined using specific criteria. Unfortu-
nately, these criteria were rather heterogeneous among
studies that evaluated implant success, and most of the
selected studies only assessed implant survival.
Sinus augmentation procedures are highly predictable,
with many studies reporting over 95% success. This type
of surgery may be significantly influenced by the choice
of graft material and the implant surface micromor-
phology. Within the limits of this review, the following
conclusions can be drawn:(i) Rough-surfaced implants
displayed a higher survival rate than smooth-surfaced
implants when placed in grafted sinuses and this was
independent of graft type. (ii) Similar survival rates were
observed between simultaneous and delayed implant
placement. (iii) Grafts using bone-substitute materials
were as effective as those using particulate autogenous
bone, either when used alone or in combination with
autogenous bone, for supporting dental implants. How-
ever, it must be considered that in most cases bone
substitutes were used in association with textured sur-
faces. (iv) Long-term reports on sinus floor elevation
using non-autogenous grafting materials are still scarce,
as a result of their relatively recent introduction, com-
pared with the numerous reports on the use of auto-
Further studies of a high level of evidence are needed
to assess the individual performance of the various bone
substitutes and to evaluate the influence of other vari-
ables, such as the amount of residual crestal bone in the
posterior maxilla, the patient?s systemic condition, and
smoking habits, on the survival of implants placed in the
grafted maxillary sinus.
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