Effectiveness of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic review.

Abstract

CONFLICT-OF-INTEREST STATEMENT: Marco Esposito, Pietro Felice and Paul Coulthard are among the authors of four of the included trials, however, they were not involved in the quality assessment of these trials. This review is based on a Cochrane systematic review entitled 'Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus' published in The Cochrane Library (see http:// www.cochrane.org/ for information). Cochrane systematic reviews are regularly updated to include new research and in response to comments and criticisms from readers. If you wish to comment on this review, please send your comments to the Cochrane website or to Marco Esposito. The Cochrane Library should be consulted for the most recent version of the review. The results of a Cochrane Review can be interpreted differently, depending on people's perspectives and circumstances. Please consider the conclusions presented carefully. They are the opinions of the review authors, and are not necessarily shared by the Cochrane Collaboration.
Insufficient bone volume is a common problem encountered in the rehabilitation of the edentulous posterior maxillae with implant supported prostheses. Bone volume is limited by the presence of the maxillary sinus together with loss of alveolar bone height. Sinus lift procedures increase bone volume by augmenting the sinus cavity with autogenous bone and/or commercially available biomaterials.
To test whether and when augmentation of the maxillary sinus is necessary and which are the most effective augmentation techniques for rehabilitating patients with implant-supported prostheses.
The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were hand searched. The bibliographies of review articles were checked, and personal references were searched. More than 55 implant manufacturing companies were also contacted. The last electronic search was conducted on 7th January 2010.
Randomised controlled trials (RCTs) of different techniques and materials for augmenting the maxillary sinus for rehabilitation with dental implants reporting the outcome of implant therapy at least to abutment connection.
Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and odds ratios for dichotomous outcomes with 95% confidence intervals. The statistical unit of the analysis was the patient.
Ten RCTs out of 29 potentially eligible trials were suitable for inclusion. One trial including 15 patients, evaluated whether 5-mm-long implants with a diameter of 6 mm could be an alternative to sinus lift in bone having a residual height of 4 to 6 mm. Nine trials with 235 patients compared different sinus lift techniques and, of these, four trials (114 patients) evaluated the efficacy of platelet-rich plasma (PRP). Since different techniques were evaluated in different trials, only two meta-analyses evaluating the efficacy of PRP could be performed for implant failures (two trials) and complications (three trials). No statistically significant difference was observed for any of the evaluated interventions.
Conclusions are based on few trials, usually underpowered, having short follow-ups, and often judged to be at high risk of bias, therefore they should be viewed as preliminary and interpreted with great caution. It is still unclear when sinus lift procedures are needed. Short implants (5 mm) can be successfully loaded in maxillary bone with a residual height of 4 to 6 mm, but their long-term prognosis is unknown. Elevating the sinus lining in the presence of 1 to 5 mm of residual bone height without the addition of a bone graft may be sufficient to regenerate new bone to allow rehabilitation with implant-supported prostheses. Bone substitutes might be successfully used as replacements for autogenous bone. If the residual alveolar bone height is 3 to 6 mm, a crestal approach to lifting the sinus lining and placing 8 mm implants may lead to less complications than a lateral window approach and placing implants at least 10 mm long. PRP treatment does not seem to improve the clinical outcome of sinus lift procedures with autogenous bone or bone substitutes.

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SYSTEMATIC REVIEW
Marco Esposito, DDS,
PhD
Senior Lecturer, Oral and
Maxillofacial Surgery and
Editor, Cochrane Oral
Health Group, School of
Dentistry, The University of
Manchester, Manchester,
UK, and Associate Professor,
Department of Biomaterials,
The Sahlgrenska Academy
at Göteborg University,
Göteborg, Sweden
Maria Gabriella
Grusovin, DDS
Senior Clinical Teaching
Fellow in Implant Dentistry,
School of Dentistry,
The University of
Manchester, Manchester,
UK,
and
Private practice, Gorizia,
Italy
Jonathan Rees, DDS
Senior Clinical Teaching
Fellow in Implant Dentistry,
School of Dentistry,
The University of
Manchester, Manchester
and Private practice, UK
Dimitrios Karasoulos
Postgraduate Student in
Dental Implantology,
School of Dentistry,
The University of
Manchester, Manchester,
UK
Pietro Felice, MD,
DDS, PhD
Resident, Department
of Periodontology and
Implantology, University of
Bologna, Bologna, Italy
Rami Alissa, DDS
PhD Student in Oral and
Maxillofacial Surgery,
School of Dentistry,
The University of
Manchester, Manchester,
UK
Marco Esposito, Maria Gabriella Grusovin, Jonathan Rees, Dimitrios Karasoulos, Pietro Felice,
Rami Alissa, Helen Worthington, Paul Coulthard
Effectiveness of sinus lift procedures for dental
implant rehabilitation: a Cochrane systematic
review
Key words bone augmentation, dental implant, randomised controlled clinical trial, sinus lift, sys-
tematic review
Conflict-of-interest statement: Marco Esposito, Pietro Felice and Paul Coulthard are among the
authors of four of the included trials, however, they were not involved in the quality assessment of
these trials.
This review is based on a Cochrane systematic review entitled ‘Interventions for replacing missing
teeth: augmentation procedures of the maxillary sinus’ published in The Cochrane Library (see http://
www.cochrane.org/ for information). Cochrane systematic reviews are regularly updated to include
new research and in response to comments and criticisms from readers. If you wish to comment on
this review, please send your comments to the Cochrane website or to Marco Esposito. The Cochrane
Library should be consulted for the most recent version of the review. The results of a Cochrane
Review can be interpreted differently, depending on people’s perspectives and circumstances. Please
consider the conclusions presented carefully. They are the opinions of the review authors, and are
not necessarily shared by the Cochrane Collaboration.
Background: Insufficient bone volume is a common problem encountered in the rehabilitation of the
edentulous posterior maxillae with implant supported prostheses. Bone volume is limited by the pres-
ence of the maxillary sinus together with loss of alveolar bone height. Sinus lift procedures increase
bone volume by augmenting the sinus cavity with autogenous bone and/or commercially available
biomaterials.
Objectives: To test whether and when augmentation of the maxillary sinus is necessary and which
are the most effective augmentation techniques for rehabilitating patients with implant-supported
prostheses.
Search methods: The Cochrane Oral Health Group’s Trials Register, the Cochrane Central Register
of Controlled Trials (CENTRAL), MEDLINE and EMBASE were searched. Several dental journals were
hand searched. The bibliographies of review articles were checked, and personal references were
searched. More than 55 implant manufacturing companies were also contacted. The last electronic
search was conducted on 7th January 2010.
Selection criteria: Randomised controlled trials (RCTs) of different techniques and materials for aug-
menting the maxillary sinus for rehabilitation with dental implants reporting the outcome of implant
therapy at least to abutment connection.

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Introduction
n
Missing teeth may result in a functional and cosmetic
deficit and have traditionally been replaced with den-
tures or bridges. Dental implants offer an alternative,
they are inserted into the jawbones and used to sup-
port dental prostheses. Dental implants rely on the
maintenance of a direct structural and functional con-
nection between living bone and the implant surface,
this is termed osseointegration and was first described
by Brånemark1. Osseointegration has undoubtedly
been one of the most significant scientific break-
throughs in dentistry over the past 40 years.
Insufficient bone volume is a common problem
encountered in the rehabilitation of the edentulous
posterior maxilla with implant-supported prostheses.
The bone available for implant placement may be lim-
ited by the presence of the maxillary sinus together
with loss of alveolar bone height. Bone volume may
be increased by augmentation, and the sinus cav-
ity is commonly augmented with auto genous bone
and/or biomaterials.
Implant placement may be combined with sinus
augmentation as a ‘one-stage’ technique. Alterna-
tively, sinus augmentation may be carried out at
some time prior to implant placement, as a ‘two-
stage’ technique which requires an additional surgi-
cal episode.
Techniques of sinus augmentation
(sinus lift)

n
Boyne described the pre-prosthetic surgical tech-
nique of retrograde sinus augmentation, and in some
cases blade implants were placed2. The technique
required a window to be prepared in the lateral wall
of the sinus via a buccal sulcus incision. The mucosal
lining was elevated to create a cavity into which
Helen Worthington,
CStat, PhD
Professor of Evidence Based
Care, and Co-ordinating
Editor, Cochrane Oral
Health Group, School of
Dentistry, The University
of Manchester, Manches-
ter, UK
Paul Coulthard, BDS,
MDS, PhD
Professor, Oral and Maxil-
lofacial Surgery and Editor,
Cochrane Oral Health
Group, School of Dentistry,
University of Manchester,
Manchester, UK
Correspondence to:
Marco Esposito, Oral and
Maxillofacial Surgery,
School of Dentistry,
The University of
Manchester,
Higher Cambridge Street,
Manchester M15 6FH, UK
E-mail: espositomarco@
hotmail.com
Data collection and analysis: Screening of eligible studies, assessment of the methodological quality
of the trials and data extraction were conducted independently and in duplicate. Authors were con-
tacted for any missing information. Results were expressed as random-effects models using mean dif-
ferences for continuous outcomes and odds ratios for dichotomous outcomes with 95% confidence
intervals. The statistical unit of the analysis was the patient.
Results: Ten RCTs out of 29 potentially eligible trials were suitable for inclusion. One trial including 15
patients, evaluated whether 5-mm-long implants with a diameter of 6 mm could be an alternative to
sinus lift in bone having a residual height of 4 to 6 mm. Nine trials with 235 patients compared differ-
ent sinus lift techniques and, of these, four trials (114 patients) evaluated the efficacy of platelet-rich
plasma (PRP). Since different techniques were evaluated in different trials, only two meta-analyses
evaluating the efficacy of PRP could be performed for implant failures (two trials) and complications
(three trials). No statistically significant difference was observed for any of the evaluated interven-
tions.
Conclusions: Conclusions are based on few trials, usually underpowered, having short follow-ups,
and often judged to be at high risk of bias, therefore they should be viewed as preliminary and
interpreted with great caution. It is still unclear when sinus lift procedures are needed. Short implants
(5 mm) can be successfully loaded in maxillary bone with a residual height of 4 to 6 mm, but their
long-term prognosis is unknown. Elevating the sinus lining in the presence of 1 to 5 mm of residual
bone height without the addition of a bone graft may be sufficient to regenerate new bone to
allow rehabilitation with implant-supported prostheses. Bone substitutes might be successfully used
as replacements for autogenous bone. If the residual alveolar bone height is 3 to 6 mm, a crestal
approach to lifting the sinus lining and placing 8 mm implants may lead to less complications than a
lateral window approach and placing implants at least 10 mm long. PRP treatment does not seem to
improve the clinical outcome of sinus lift procedures with autogenous bone or bone substitutes.

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particulate bone from the iliac crest was placed and
allowed to heal for about 6 months or more before
placing the implants.
Tatum described five tissue incisions (crestal, pal-
atal, split-thickness palatal, vertical and horizontal
vestibular), three types of bone access (crestal, buc-
cal wall and Le Forte I) and the use of autogenous
bone, allografts and alloplasts. In addition, Tatum
described sinus augmentation and implant place-
ment as a one-stage and a two-stage technique3.
The technique known as a lateral window sinus
lift is widely used today and is considered reliable
particularly when autogenous bone is used4,5. Sum-
mers described a less invasive one-stage technique
for sinus floor elevation with simultaneous implant
placement called the osteotome sinus floor eleva-
tion. Summers considered it necessary to have at
least 6 mm of residual bone to ensure primary sta-
bility of the implant. Concave-tipped osteotomes of
increasing diameter applied via a crestal approach
advanced a mass of bone beyond the level of the
original sinus floor, elevating the mucosal lining.
Summers combined this procedure with the addi-
tion of a bone graft material6. For cases of less than
6 mm of residual bone height, Summers proposed a
two-stage approach. A bone plug is defined with a
trephine and displaced superiorly with the use of a
broad osteotome. Hydrostatic pressure elevates the
mucosal lining of the sinus. The resultant osteotomy
is filled with a bone graft material and the implant
placed after a period of healing7.
Cosci modified the crestal approach technique
utilising an atraumatic lifting drill to reduce the risk
of perforation of the mucosa lining the sinus using a
one-stage technique with as little as 3 mm of residual
bone8. Bone can be collected with a trephine directly
from the osteotomy site to be used as grafting mate-
rial, a bone substitute can be used or the implant tip
can hold up the sinus membrane that will work as
a natural barrier for bone regeneration. While the
crestal approach is less invasive and is a one-stage
technique, there are some disadvantages associated
with it. The amount of bone which can be gained
using a crestal approach is usually less than what can
be obtained with the lateral window technique, and
a minimal amount of crestal bone height of about
3 mm is generally recommended to stabilise the
implant at placement8.
In order to obtain simultaneous vertical bone
augmentation with a sinus lift procedure, Canniz-
zaro proposed a technique that is a combination of
a sinus lift and an onlay graft. Implants are placed
in the ulna, bone blocks containing the implants are
retrieved with a trephine, inserted into the sinus via
a crestal approach and left protruding occlusally for
some mm in order to obtain simultaneous vertical
bone gain9.
Materials used in sinus lift procedures
n
Autogenous bone has long been considered the gold
standard. Intra-oral donor sites (chin and ramus)
are convenient but yield limited volume. Extra-oral
donor sites (iliac crest, tibia, ulna, rib and calvarium)
increase surgical complexity and are associated with
significant (and under-reported) morbidity and scar-
ring, therefore alternative grafting materials (bone
substitutes) are used.
Allografts consist of ‘same species’ tissue. Cadav-
eric bone is harvested and various techniques (freeze
drying and irradiation) reduce antigenicity. The grafts
are then sterilised and supplied by specially licensed
tissue banks.
Xenografts consist of ‘different species’ tissue.
Anorganic bovine and equine bone predominate.
Chemical removal of the organic component creates
a mineral scaffold.
Alloplasts are synthetic bone substitutes. There
are many types classified in terms of porosity as
dense, macro-porous, micro-porous, and either
crystalline or amorphous. The structure influences
performance. Some examples are beta-tricalcium
phosphate, bio-active glass and calcium sulphate.
All of these grafts can be delivered in various con-
venient ways such as bone particles or large blocks,
can be mixed with autogenous bone and can be very
stable over time or highly resorbable, depending on
their chemical characteristics.
Bone formation may be promoted by the use of
biologically active molecules such as bone morpho-
genic proteins (BMPs), growth factors, platelet rich
plasma (PRP) and other molecules.
Urist found that cell-free, decalcified bone
implanted into extra-skeletal sites stimulated new
bone formation10. The molecules responsible belong
to the growth factor B family and are called BMP’s11.

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A number have been discovered, and their use
requires a delivery system that mimics the physical
properties and release kinetics of bone.
Some authors have proposed sinus augmenta-
tion without the use of a graft material, with coagu-
lated blood acting as a scaffold for bone formation.
Lundgren proposed maintaining a space by suturing
the sinus lining to the lateral wall12. The implant apex
may be used to support the sinus membrane13-18.
Some bone regeneration does occur though the
actual clinical benefit remains in doubt since this
method has not been compared to appropriate con-
trol procedures.
Alternative techniques to sinus lift
n
When anatomical conditions permit, there are a few
alternative techniques to sinus augmentation. Onlay
bone grafts may be used for horizontal or vertical
augmentation. These procedures are evaluated in
another Cochrane systematic review19.
Implants can also be placed with an angulated
direction in order to avoid the maxillary sinus20.
These implants are called ‘tilted’ or ‘angulated’
implants and they can only be used when anatomi-
cal conditions permit.
Zygomatic implants offer an alternative to sinus
augmentation. Long implants pass through the
sinus21 or laterally from the sinus into the zygo-
matic process. Zygomatic implants are evaluated in
another Cochrane review22. In some situations, angled
implants may be placed into the pterygomaxilla23.
Another alternative to sinus lift procedures is the
use of short implants. Current research is focused
on evaluating short implants placed without aug-
mentation, offering the option of a less complex,
cheaper and faster alternative to augmentation.
There are few comparative studies evaluating the
efficacy of short implants19. Implants with lengths
of 5 to 8 mm are currently used and may be defined
as short implants24, though this is controversial as
some authors consider implants of 7 to 10 mm to be
short25. A review of the literature suggested a failure
rate of around 10% for implants 7 mm long25. The
design of the included studies requires this figure
to be viewed with caution, it may represent a gross
underestimation. Nevertheless, these figures suggest
that shorter implants may have a poorer prognosis
than longer ones. Since it is commonly believed that
shorter implants (8 mm or less) have a poorer prog-
nosis than longer implants, clinicians place longer
implants if bone allows. When bone height is 5 to
8 mm clinicians must decide whether to augment
or place short implants. New and possibly improved
implant surface modifications and designs, with thus
far no reliable evidence of their superiority having
been documented26, together with improved surgi-
cal techniques may shift the balance in favour of
short implants when the alternative is a more com-
plex augmentation procedure.
Several ‘systematic’ reviews have been published
on the outcome of sinus-lift procedures4,5,27-32,
however, since those findings were not based on
the most reliable clinical studies, a systematic review
based on the most reliable evidence would be useful
to summarise the current scientific knowledge.
Objectives
n
The objectives of the present review were to test the
null hypothesis of no difference in the success, func-
tion, complications and patient satisfaction of aug-
menting or not and between different maxillary sinus
lift techniques for dental implant treatment against the
alternative hypothesis of a difference. This included,
in particular, testing (a) whether and when sinus lift
procedures are necessary and (b) which is the most
effective augmentation technique for sinus lift.
Materials and methods
n
Criteria for considering studies
in the present review

n
Randomised controlled clinical trials (RCTs) including
patients with missing teeth and an atrophic posterior
maxilla who may require augmentation of the maxil-
lary sinus prior or at placement of dental implants
were included in the present review.
The following interventions/comparisons were
considered: any bone augmentation technique,
active agent (such as BMPs, PRP) or biomaterials
used in relation with osseointegrated, root-formed
dental implants. For trials to be considered in the

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present review, implants had to be placed and the
outcome of the implant therapy had to be reported
at least at the endpoint of the abutment connection
procedure. The following time points were consid-
ered: abutment connection, prosthetic loading, up
to 1 year, 3 and 5 years after loading.
The following outcome measures were considered:
Prosthesis failure: planned prosthesis which could ??
not be placed due to implant failure(s) and loss of
the prosthesis secondary to implant failure(s).
Implant failure: implant mobility and removal of ??
stable implants dictated by progressive marginal
bone loss or infection (biological failures). Bio-
logical failures were grouped as early (failure to
establish osseointegration) and late failures (fail-
ure to maintain the established osseointegration).
Failures that occurred before prosthesis placement
were considered early failures. Implant mobility
could be assessed manually or with instruments
such as Periotest (Siemens AG, Benshein, Ger-
many) or resonance frequency (Osstell, Integra-
tion Diagnostics, Göteborg, Sweden).
Augmentation procedure failure: failure of the ??
augmentation procedure not affecting the suc-
cess of the implant.
Major complications at treated sites (e.g. sinusi-??
tis, infection, haemorrhage, etc.).
Major complications at bone donor sites (e.g. ??
nerve injury, gait disturbance, infection, etc.).
Patient satisfaction. ??
Patient preference (only in split-mouth trials).??
Bone gain expressed in mm or percentage.??
Duration of the treatment time starting from the ??
first intervention to the functional loading of the
implants.
Treatment costs. ??
Trials evaluating only histological outcomes were not
considered in the present review.
Search strategies for identification
of studies

n
For the identification of studies included or consid-
ered for this review, detailed search strategies were
developed for each database searched. For more
details see the original Cochrane review33. The fol-
lowing databases were searched:
The Cochrane Oral Health Group’s Trials Register
(to 7th January 2010)
The Cochrane Central Register of Controlled
Trials (CENTRAL) (The Cochrane Library 2009,
Issue 4)
MEDLINE via OVID (1950 to 7th January 2010)
EMBASE via OVID (1980 to 7th January 2010).
??
??
??
??
The most recent electronic search was undertaken
on 7th January 2010 and there were no language
restrictions.
The British Journal of Oral and Maxillofacial
Surgery, Clinical Implant Dentistry and Related
Research, Clinical Oral Implants Research, Euro-
pean Journal of Oral Implantology, Implant Den-
tistry, International Journal of Oral and Maxillo-
facial Implants, International Journal of Oral and
Maxillofacial Surgery, International Journal of Peri-
odontics and Restorative Dentistry, International
Journal of Prosthodontics, Journal of Clinical Peri-
odontology, Journal of Dental Research, Journal of
Oral Implantology, Journal of Oral and Maxillofa-
cial Surgery, Journal of Periodontology, and Journal
of Prosthetic Dentistry were hand searched up to
January 2010.
All of the authors of the identified RCTs were
contacted, the bibliographies of all identified RCTs
and relevant review articles were checked, and per-
sonal contacts were used in an attempt to identify
unpublished or ongoing RCTs. In the first version of
this review, more than 55 oral implant manufacturers
were written to through an Internet discussion group
(implantology@yahoogroups.com) for information on
trials, however it was discontinued due to poor yield.
Study selection
n
The titles and abstracts (when available) of all reports
identified through the electronic searches were
scanned independently by two review authors. For
studies appearing to meet the inclusion criteria, or
for which there were insufficient data in the title
and abstract to make a clear decision, the full report
was obtained. The full reports obtained from all
of the electronic and other methods of searching
were assessed independently by two review authors
to establish whether the studies met the inclusion
criteria or not. Disagreements were resolved by

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discussion. Where resolution was not possible, a third
review author was consulted. All studies meeting the
inclusion criteria then underwent validity assessment
and data extraction. Studies rejected at this or subse-
quent stages were recorded in the table of excluded
studies, and reasons for exclusion were recorded.
Quality assessment
n
The quality assessment of the included trials was
undertaken independently and in duplicate by two
review authors as part of the data extraction process.
In cases where the paper to be assessed had one or
more review authors in the authors list, it was inde-
pendently evaluated only by those review authors
not involved in the trials.
Three main quality criteria were examined:
allocation concealment, recorded as (a) adequate, ??
(b) unclear or (c) inadequate
treatment blind to outcome assessors, recorded ??
as (a) yes, (b) no, (c) unclear or (d) not possible
completeness of follow up (is there a clear expla- ??
nation for withdrawals and dropouts in each
treatment group?) assessed as (a) yes or (b) no.
In cases where clear explanations for dropouts
were given, a further subjective evaluation of the
risk of bias assessing the reasons for the dropout
was made.
After taking into account the additional information
provided by the authors of the trials, studies were
grouped into the following categories:
low risk of bias (plausible bias unlikely to seriously ??
alter the results) if all criteria were met
high risk of bias (plausible bias that seriously ??
weakens confidence in the results) if one or more
criteria were not met.
Further quality assessment was carried out to assess
sample size calculations, definition of exclusion/
inclusion criteria, and comparability of control and
test groups at entry. The quality assessment criteria
were pilot tested using several articles.
Data extraction
n
Data were extracted independently by two review
authors using specially designed data extraction
forms. The data extraction forms were piloted on
several papers and modified as required before use.
Any disagreement was discussed and a third review
author consulted where necessary. All authors were
contacted for clarification or missing information.
Data were excluded until further clarification was
available if agreement could not be reached.
For each trial, the following data were recorded:
year of publication; country of origin and source of
study funding; details of the participants including
demographic characteristics, source of recruitment
and criteria for inclusion; details of the type of inter-
vention and details of the outcomes reported, includ-
ing method of assessment and time intervals.
For dichotomous outcomes, the estimate of the
effect of an intervention was expressed as odds
ratios (OR) together with 95% confidence intervals
(CIs). For continuous outcomes, mean differences
and standard deviations were used to summarise
the data for each group using mean differences and
95% CIs. Appropriate data were extracted from the
split-mouth studies34. The statistical unit was the
patient and not the augmentation procedure or the
implants. In split-mouth studies the augmentation
procedures or the prostheses within each pair were
the unit of analysis34.
The significance of any discrepancies in the esti-
mates of the treatment effects from the different
trials was to be assessed by means of Cochran’s test
for heterogeneity, and heterogeneity would have
been considered significant if P < 0.1. The I2 statis-
tic, which describes the percentage total variation
across studies that is due to heterogeneity rather
than chance, was used to quantify heterogeneity,
with I2 over 50% being considered moderate to high
heterogeneity.
A meta-analysis was conducted only if there
were studies of similar comparisons reporting the
same outcome measures. Odds ratios were com-
bined for dichotomous data, and mean differences
for continuous data, using random-effect models
provided there were more than three studies in the
meta-analysis. Data from split-mouth studies were
to be combined with data from parallel group trials
with the method outlined by Elbourne35, using the
generic inverse variance method in RevMan.

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Results
n
Of the 29 potentially eligible trials36-63, 19 had to
be excluded for various reasons such as: reported
only histological outcomes without presenting any
implant related outcomes37-48; problems with study
design and data reporting49-52; too short of a follow-
up53, data of only 4 out of 16 patients treated were
presented36; and not an RCT54.
Of the 10 included trials, three were conducted
in Italy55-57, two in Sweden58,59, one in Spain60, one
in Germany61, one in France62, one in The Nether-
lands63 and one was a multicentre trial conducted in
four European centres (Belgium, Hungary, UK and
Italy)64.
Two trials had a parallel group study design55,58,
six had a split-mouth design56,57,59,62-64 and two
had a mixed split-mouth/parallel group design60,61,
but only data from their split-mouth portion could be
used in the present review.
For six trials, it was declared that support was
received from industry directly involved in producing
the product being tested in the form of free mate-
rial56-59,63,64, but for one study57 the discounted
implants were not under evaluation. The authors
of four trials declared that no support was received
from commercial parties whose products were being
tested in the trials55,60-62.
Seven trials were conducted at universities or spe-
cialist dental clinics and three trials in private prac-
tices55,56,65. One of the centres (Brugge, Belgium) of
the multicentre trial64 was also a private practice. The
interventions that follow were tested.
Is sinus lift necessary?
(1 trial with 15 patients)
This trial examined one to three 5-mm-long implants
of 6 mm in diameter versus one to three 10 mm or
longer implants of 4 mm in diameter placed in sinuses
augmented with 100% bovine anorganic bone (Bio-
Oss®, Geistlich Pharmaceutical, Wolhusen, Switzer-
land) with lateral windows sealed using a resorbable
collagen membrane (OsseoGuard®, Biomet 3i, Palm
Beach, FL, USA) 4 months before56. All augmenta-
tion procedures were performed under local anaes-
thesia. All implants were left to heal submerged for
4 months. Rescue™ implants (MegaGen, Gyeong-
buk, South Korea) as short implants and EZ Plus
(MegaGen) as long implants, with internal connec-
tion, were used. Implant site preparation was also
different since a 5 mm diameter trephine was used
initially to prepare the osteotomy sites for Rescue
implants. Provisional screw-retained reinforced resin
prostheses were replaced after 4 months by defini-
tive screw-retained metal-ceramic prostheses.
Which is the most effective sinus lift
procedure? (9 trials with 235 patients)
One trial examined one-stage lateral sinus lift with
monocortical iliac bone blocks fixed in most cases
with two implants and left to heal for 6 months ver-
sus two-stage lateral sinus lift with particulate bone
from the iliac crest left to heal for 6 months with
two implants (in most cases) inserted into the healed
graft and left to heal for an additional 6 months58.
All of the augmentation procedures were performed
under general anaesthesia. All implants were turned
titanium self tapping (Nobel Biocare, Göteborg,
Sweden) and were rehabilitated with screw-retained
cross-arch implant supported prostheses.
A study was conducted on two-stage lateral
sinus lift with autogenous particulate bone from the
mandibular ramus versus two-stage lateral sinus lift
with a mixture of 80% Bio-Oss and 20% particulate
bone from the mandibular ramus, left to heal for 6
months in a split-mouth trial59. A fibrin glue (Tisseel®
Duo Quick, Immuno, Wien, Austria) was added to
the grafts after thrombin (Immuno) for both inter-
ventions. A third treatment group was composed
of patients who refused to provide autogenous
bone but accepted the treatment with a two-stage
sinus lift with 100% Bio-Oss. For the latter group,
a resorbable porcine-derived collagen barrier (Bio-
Gide, Geistlich Pharmaceutical) was used to cover
the sinus defect and the healing time was prolonged
to an average of 8.5 months (range 8 to 9.5). Pro-
cedures were performed under local anaesthesia and
oral sedation. All implants were turned titanium self
tapping (Nobel Biocare): the Mark II implant type
was used in the former two groups and Mark III in
the latter. All patients were rehabilitated with screw-
retained metal-ceramic fixed prostheses.
Another study examined a two-stage lateral
sinus lift with autogenous particulate bone from the

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iliac crest versus a two-stage sinus lift with 1.5 to
2 g of beta-tricalcium phosphate (Cerasorb®,
Curasan AG, Kleinostheim, Germany) and left to heal
for 6 months64. In 10 of the 20 patients, the alveolar
crest was also widened with cortical bone blocks
fixed with microscrews. No membranes were used to
cover the bone. All of the augmentation procedures
were performed under general anaesthesia. Patients
were instructed not to wear their upper dentures for
30 days. In 16 patients, Ankylos® (Dentsply Fria-
dent, Mannheim, Germany) implants were used,
whereas in four patients Protetim (Hódmezo ” vásár-
hely, Hungary) implants were used. The authors did
not provide any explanation for using two different
implant systems. Two implants were placed in each
augmented sinus.
One trial studied one-stage sinus lift using one to
three 8-mm-long implants placed in simultaneously
crestally augmented sinus with autogenous particu-
late bone, harvested from the implant site, versus
one to three 10 mm or longer implants placed in
simultaneously augmented sinuses using the lateral
approach with a mixture of 50% particulate autog-
enous bone from the tuberosity area and 50% Bio-
Oss55. A modified ‘Cosci technique’ was used to cre-
stally augment the sinus. In brief, implant sites were
prepared with a 2.5 mm trephine drill up to about
1 mm of the sinus cortical wall, to collect autog-
enous bone, and with a 3.1 mm diameter atraumatic
lifting drill. Resorbable barriers (Biomend® Extend,
Sulzer Dental, Carlsbad, CA, USA) were used to seal
the lateral windows. All augmentation procedures
were performed under local anaesthesia. All implants
were left to heal submerged for 45 days and were
functionally loaded within 1 week after abutment
connection. All implants were tapered Screw-Vent®
MP-1 HA Dual Transition Selective Surface Implants
(Zimmer Dental) inserted in underprepared osteot-
omy sites with a torque of at least 35 Ncm.
A study analysed two-stage sinus lift with lateral
window approach using either a synthetic resorbable
barrier (GTR™ Biodegradable Membrane System,
Inion, Tampere, Finland) to keep the sinus mem-
brane or 100% granular Bio-Oss57. Inion barriers
were used to seal the lateral windows. Inion barriers
are made of a synthetic co-polymer (trimethylene
carbonate l-lactide polyglycolide) that needs to be
softened in a plasticising solution, allowing the mem-
brane to be cut and moulded to exactly fit the space.
The barrier then hardens in the new position main-
taining the new shape and the space. This material
should biodegrade in situ after 8 to 12 weeks. All
augmentation procedures were performed under
local anaesthesia. After 6 months, one to 3 implants
were placed per side and submerged for 4 months.
All implants were Way® (Geass, Pozzuolo del Friuli,
Italy) with a laser-treated surface and internal con-
nection. Provisional screw-retained reinforced resin
prostheses were replaced after 4 months by defini-
tive screw-retained metal-ceramic prostheses.
Trials evaluating the efficacy of PRP with
grafts (4 trials with 114 patients)
One trial examined two-stage lateral sinus lift with
autogenous blocks and particulate bone together
with buccal onlays and monocortico-cancellous bone
grafts, to reconstruct the width of the maxilla, fixed
with titanium screws harvested from the iliac crest
with or without PRP and left to heal for 3 months
in a split-mouth trial63. Barriers were not used. PRP
was made using the Platelet Concentration Collec-
tion System kit (PCCS® kit, 3i Implant Innovations,
Palm Beach Gardens, FL, USA). A total of 54 ml of
blood was mixed with 6 ml of anticoagulant (citrate
dextrose) and processed with the platelet concen-
tration system. To promote the release of growth
factors from the platelets, a 10% calcium chloride
(CaCl2) solution and the patient’s serum, as a source
of autologous thrombin, were added before actual
reconstruction of the defect with the bone graft.
The resulting gel was mixed with the bone graft and
some gel was applied at the closure of the wound
at the side treated with PRP. Three implants were
inserted into the healed graft of each side and were
left to heal for an additional 6 months. All of the
augmentation procedures were performed under
general anaesthesia. Surgical templates were used to
optimise implant insertion. All implants were turned
titanium self tapping (Nobel Biocare) and were reha-
bilitated with two implant-supported prostheses.
A study analysed two-stage sinus lift with lat-
eral window approach using either autogenous
particulate bone from the iliac crest alone or the
same graft plus PRP61. All sites were also horizontally
augmented with cortico-spongeous blocks from the

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iliac crest fixed with screws. PRP was produced at a
university institute of clinical immunology and trans-
fusion medicine under transfusion medical stand-
ards. Autologous platelet concentrate from PRP was
derived from 450 ml of citrate phosphate dextrose-
anticoagulated blood. The PRP was concentrated
using differential centrifugation, then stored for
24 h and adjusted up to 1010 platelets/ml. The con-
centrations obtained were 11 to 12 times above the
baseline level of whole blood. All augmentation pro-
cedures were performed under general anaesthesia.
After 4 months of healing, different implant systems
(no details provided) were inserted and left to heal
submerged for 6 months.
Another trial examined two-stage lateral sinus lift
with autogenous cortico-cancellous blocks from the
iliac crest versus granules of bone with platelet con-
centrates (APCs) and a biological glue (Tissucol, Bax-
ter, Maurepas, France), left to heal for 6 months in
a split-mouth trial62. Plateletphoresis was conducted
at least 3 days before surgery on a plateletpheresis
collection system (Trima Accel, Version 5.1, Gambro
BCT, Lakewood, CO), a single-needle continuous-
flow separation system. The targeted concentration
was a post-donation platelet count of more than
100 × 106 per ml. Citrate (ACD-A) was used for
anticoagulation. APCs were delivered by the cell-
processing laboratory in a 20 ml transfer bag that
was centrifuged for 15 minutes. The plasma was
removed with a plasma extraction device to reach
the target volume of 8 to 15 ml. Two ml of cancellous
bone was mixed with half of the APC volume and
1 ml of Tissucol. The remaining APCs were mixed with
0.5 ml Tissucol to obtain a membrane for covering
the grafted area. Sites treated with bone blocks were
covered by 1 ml of Tissucol. Implants were placed
6 months after the augmentation procedure.
One trial compared one or two-stage sinus lift
procedures using a lateral window technique and
100% granular Bio-Oss with or without PRP, left to
heal for 6 months with a hybrid split-mouth parallel
design trial60. Patients having up to 4 mm of residual
bone height were augmented first and implants were
placed after 6 months, whereas patients with residual
bone more than 4 mm and up to 7 mm received
implants during the sinus lift procedures. Implants
were left to heal unloaded for 6 months. Ten to 20 ml
of venous blood were collected 30 minutes prior to the
surgery and mixed with a 3.8% sodium citrate solu-
tion at a 5:1 ratio, achieving anticoagulation through
calcium binding. The blood was then centrifuged and
separated into 3 layers: red blood cells (RBCs), PRP
and poor plasma. Flow cytometry was used for plate-
let counting. Platelet counts were 2.97 ± 0.7-fold
greater than peripheral blood. PRP was activated with
a 30% CaCl2 solution and a PRP gel was obtained
and mixed with Bio-Oss. The entire bone of the buc-
cal window was removed, and, after the sinus was
filled with the bone substitute, no barrier was used to
seal the window. Patients were instructed not to wear
their upper dentures for 2 to 3 weeks after surgery.
Osseotite® (Biomet 3i) implants were used.
Characteristics of outcome measures
n
Prosthesis failure
Implant failure by individual implant stability
assessment with removed prostheses (with the
exception for single implants)55-64.
Augmentation procedure failure
Major complications at treated sites: perfora-
tion of the sinus membrane only (though not
a major complication)57, various complica-
tions55-57,59-64.
Major complications at bone donor site
In the present review, complications at treated
and donor sites were combined when appropri-
ate.
Patient satisfaction: no trial.
Patient preference (only in split-mouth trials)
Data for one trial56 were reported, however they
might be biased because of the study design. All
augmentation procedures were performed first
and, after 4 months, test and control implants
were placed bilaterally in the same surgical ses-
sion. The potential advantage of having the pros-
theses on the short implants loaded 4 months
earlier was lost with this study design.
Bone gain expressed in mm or percentage: verti-
cal bone gain was measured in mm by direct
measurement in three trials57,61,62, however, for
two trials61,62 data were presented in a way that
could not be used.
Duration of the treatment period starting from
the first intervention to the functional loading of
the implants: all trials.
??
??
55-60,63,64.
??
??
55-64.
??
55,59,63,64.
??
??
56,57.
??
??

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Treatment costs: no trials. However, this out-
come measure was indirectly extrapolated in the
present review for all trials.
Duration of follow-up (including unpublished
data kindly provided by the investigators):
– to the abutment connection61,62,64
– 4-month post-loading56,57
– 1-year post-loading55,59
– 2-year post-loading57,63
– 3-year post-loading58.
??
??
Risk of bias in included studies
n
The final quality scoring after having incorporated
the additional information kindly provided by the
authors of the trials is summarised in Table 1. It was
assessed whether each trial was at low or high risk
of bias. Six studies were judged to be at high risk of
bias, and four at low risk of bias.
Main inclusion criteria
n
Severely resorbed maxillae (classes V and VI)
with maxillary sinuses having <5 mm in height of
residual alveolar bone with reduced stability and
retention of upper dentures63.
1 to 5 mm in height of residual alveolar bone in
the floor of the edentulous sinus57.
2 to 7 mm in height of residual alveolar bone in
the floor of the edentulous sinus58.
3 to 6 mm in height of residual alveolar bone in
the floor of the edentulous sinus55.
4 to 6 mm in height of residual alveolar bone in
the floor of the edentulous sinus56.
??
66
??
??
??
??
Less than 5 mm in height of residual alveolar
bone in the floor of the edentulous sinus59,64.
Less than 8 mm in height of residual alveolar
bone in the floor of the edentulous sinus62.
Severe atrophy of the edentulous or partially
edentulous posterior maxilla, and intention to
treat with onlay bone blocks and sinus floor
augmentation61. Residual bone height values
appeared to be in the range of 1 to 12 mm
according to the measurements kindly provided
by the authors.
1 to 7 mm in height of residual alveolar bone in
the floor of the edentulous sinus69.
??
??
??
??
Main exclusion criteria
n
Smokers
Bone metabolic diseases
Medication interfering with bone metabolism
(i.e. corticosteroids, bisphosphonates, etc.)55-58.
Sinusitis
History of maxillary sinusitis or sinus sur-
gery60,62.
History of reconstructive, pre-prosthetic surgery
or previous oral implantology63.
Edentulous period less than 1 year
Severe systemic disease (ASA III and IV)
None specified
??
??
??
62.
58.
??
??
55-58,62.
??
??
??
??
63.
60.
59,64.
An a priori calculation for the sample size was under-
taken in only two trials55,56, however in one trial55
the number of included patients did not reach the
calculated sample size.
Study Allocation
concealment
Outcome assessor blindWithdrawalsRisk of
bias
Wannfors 200058
Unclear NoNoneHigh
Hallman 200259
Adequate NoNone
Raghoebar 200563
UnclearYesNone
Szabó 200564
UnclearNoNone High
Schaaf 200861
InadequateYesNoneHigh
Bettega 200962
UnclearUnclearYes, explanations givenHigh
Cannizzaro 200955
AdequateYesNoneLow
Felice 2009a56
AdequateNot possible, but independent asses-
sor
NoneLow
Felice 2009b57
Adequate YesNoneLow
Torres 200960
Adequate YesNone Low
Table 1 Risk of bias
assessment after hav-
ing included additional
explanations provided
by the authors of the
examined trials.

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Baseline comparability between
treatment groups

n
No apparent major baseline differences
Unclear whether major baseline differences
existed59,61,62,64.
??
??
57,58,60,63.
The following major baseline differences existed:
more large diameter implants were placed in the sites
treated with 8-mm-long implants and crestal sinus
lift55, and short 6 mm diameter implants were com-
pared to longer implants with a 4 mm diameter56.
Effects of interventions
n
Is sinus lift necessary?
(1 trial with 15 patients)
One trial compared 5-mm-long implants of 6 mm
diameter versus different implants at least 10 mm
long with a diameter of 4 mm placed in laterally aug-
mented sinuses with 100% Bio-Oss56. The original
trial included a second group of 15 patients treated
according to a split-mouth design in the mandible
that was of no interest for the present review. Only
patients having 4 to 6 mm of residual alveolar bone
height with a thickness of 8 mm or more below the
sinus were included. Fifteen patients were treated
according to a split-mouth design. All patients were
followed up to 4 months after loading, therefore
there were no dropouts. One prosthesis could not
be placed when planned in the short implant side
because one implant was found to be mobile at
abutment connection. This was not statistically sig-
nificant (McNemar P = 1.00, exact odds ratio [Stata
‘epitab’ procedure] was 0 [95%CI 0 to 39]; unable to
calculate SE to display data in RevMan). The implant
was successfully replaced by an implant placed more
distally and loaded. Four perforations of the sinus
lining occurred: one in the augmented group versus
3 in the 5-mm-long implant group. The difference
was not statistically significant (McNemar P = 0.50,
exact odds ratio [Stata] was 0 [95% CI 0 to 5.3];
unable to calculate SE to display data in RevMan).
All patients expressed no preference for either of
the two procedures, judging both of them as accept-
able. However, this measurement was considered
to be biased as previously described in ‘Character-
istics of outcome measures’. With respect to cost
and treatment time, the long implant group required
one additional surgical intervention for placing the
implants (two-stage procedure) plus the cost of the
bone substitute with the barrier and 4 additional
months to complete the treatment. The trial was
judged to be at low risk of bias.
Which is the most effective sinus lift
procedure? (9 trials with 235 patients)
One trial compared two techniques for augmenting
atrophic maxillary sinuses58 (Fig 1). Only patients
having 2 to 7 mm of residual alveolar bone in the
floor of the edentulous sinus were included. Twenty
patients were treated with a one-stage sinus lift
with monocortical iliac bone blocks, and the other
20 patients were treated with a two-stage sinus lift
with particulate bone from the iliac crest. All patients
were followed up to 3 years after loading, therefore
there were no dropouts. However, data were pre-
sented in a way which could not be used for all of the
time points intended for evaluation. Three patients
refused to have their prostheses removed and x-ray
examination at the 3-year follow up. The only com-
plications reported were 11 perforations of the sinus
membrane in nine patients of the one-stage group
versus 11 perforations in 10 patients of the two-
stage group. At the time of abutment connection,
11 implants in eight patients were found to not be
osseointegrated in the one-stage group versus seven
implants in six patients of the two-stage group. At
1 year, an additional five implants were lost in the
one-stage group versus one in the two-stage group.
At 3 years, one additional implant was lost in the
one-stage group versus two in the two-stage group.
Two patients of the one-stage group had problems
with the fixed prostheses at 1 year. In one patient,
the prosthesis was lost due to four implant failures
whereas in another patient the prosthesis had to be
redesigned due to lack of space for the tongue (the
present review did not consider this as a prosthesis
failure in the calculations, since it was independent
of the bone grafting technique). One prosthesis was
lost due to the failure of a strategically positioned
implant at 1 year in the two-stage group. There was
no statistically significant difference for any of the
outcomes considered in the review. With respect to

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cost and treatment time, all of the procedures were
performed under general anaesthesia. However, the
two-stage group required one additional surgical
intervention for placing the implants whereas implants
were placed simultaneously with the augmentation
procedure in the one-stage group. The healing period
was 6 months longer in the two-stage group. The trial
was judged to be at high risk of bias.
One trial compared three two-stage tech-
niques for augmenting atrophic maxillary sinuses59
(Fig 2). Only patients with less than 5 mm of alveolar
bone height in the sinus floor and fixed dentition
on the opposite jaw were included. The trial was
designed as a sort of split-mouth/parallel-preference
trial. Eleven patients willing to provide autogenous
bone from the mandibular ramus were treated with
a split-mouth approach (autogenous bone versus
80% Bio-Oss and 20% autogenous bone), whereas
10 patients who refused to have their bone har-
vested from the mandible were treated with 100%
Bio-Oss. All patients were followed up to 1 year after
loading, therefore there were no dropouts. During
the post-operative phase, no complications occurred
either in the augmented sites or in the donor sites.
However, a severe resorption of the autogenous
bone graft occurred in two patients. At abutment
connection, six implants failed in five patients in the
group treated with autogenous bone only and two
implants failed in two patients in the group treated
with 80% Bio-Oss. No implants or prostheses were
lost at the 1-year evaluation. The author confirmed
that additional implants were lost at the 2-year fol-
low up in two patients, causing the failure of the
fixed prostheses. The complete information should
be published in a future 5-year follow-up report.
There was no statistically significant difference for
any of the outcomes considered in the review. With
respect to cost and treatment time, the only differ-
ence in cost was the use of the bone substitute. The
healing period was 6 months. The trial was judged
to be at high risk of bias.
One trial compared two techniques for augment-
ing atrophic maxillary sinuses64. Only patients with
less than 5 mm of alveolar bone height in the sinus
floor were included. Twenty patients were treated
with a split-mouth approach with a two-stage sinus
lift and particulate bone from the iliac crest on one
side and and a two-stage sinus lift with 100% Cera-
sorb (a beta-tricalcium phosphate bone substitute)
on the contralateral sinus. In 10 patients, an addi-
tional autogenous onlay bone block was placed to
widen the alveolar crest. All patients were followed
Study or Subgroup
1.1.1 Prosthetic failure (1 year)
Wannfors 2000
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 0.00 (P = 1.00)
1.1.2 Early implant failure
Wannfors 2000
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 0.66 (P = 0.51)
1.1.3 Complication (perforation of sinus membrane) at augmented site
Wannfors 2000
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 0.32 (P = 0.75)
Events
1
1
8
8
9
9
Total
20
20
20
20
20
20
Events
1
1
6
6
10
10
Total
20
20
20
20
20
20
Weight
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
M-H, Fixed, 95% CI
1.00 [0.06, 17.18]
1.00 [0.06, 17.18]
1.56 [0.42, 5.76]
1.56 [0.42, 5.76]
0.82 [0.24, 2.84]
0.82 [0.24, 2.84]
1-stage 2-stageOdds RatioOdds Ratio
M-H, Fixed, 95% CI
0.010.11 10 100
Favours 1-stage Favours 2-stage
Fig 1 Forest plot comparing one-stage sinus lift with monocortical iliac bone blocks versus two-stage sinus lift with particulate bone from the iliac crest.
No statistically significant differences were observed.

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Esposito et al Effectiveness of sinus lift procedures for dental implant rehabilitation
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up to implant loading and there were no dropouts.
No serious post-operative complications occurred at
the implant sites. Three complications occurred at
the bone graft donor sites: one permanent sensory
loss of the lateral femoral cutaneous nerve and two
had prolonged wound drainage (2 to 3 weeks). At
abutment connection two implants failed, one in
each group. They both had to be replaced in order
to place the prosthesis and this caused a delay of 3
to 6 months (these were not considered prosthesis
failures in the calculations). There was no statisti-
cally significant difference for any of the outcomes
considered in the review. With respect to cost and
treatment time, the only difference was the cost of
the bone substitute. The trial was judged to be at
high risk of bias.
One trial compared two one-stage techniques for
augmenting maxillary sinuses55 (Fig 3). Only patients
having 3 to 6 mm of bone height at the sinus floor
were included. Twenty patients were treated with
Study or Subgroup
1.2.1 Implant failure (1 year)
Hallman 2002
Subtotal (95% CI)
Heterogeneity: Not applicable
Test for overall effect: Z = 1.67 (P = 0.10)
log[Odds Ratio]
-5
SE
3
Total
11
11
Total
11
11
Weight
100.0%
100.0%
IV, Fixed, 95% CI
0.01 [0.00, 2.41]
0.01 [0.00, 2.41]
Bone Bio-Oss Odds RatioOdds Ratio
0.0010.11 101000
Favours Bio-Oss Favours Bone
Fig 2 Forest plot comparing autogenous bone from the mandibular ramus versus 80% Bio-Oss and 20% autogenous bone. No statistically significant
differences were observed though trends for implant failures favoured 80% Bio-Oss and 20% autogenous bone.
Fig 3 Forest plot comparing sinus lift through a crestal approach with autogenous bone and 8-mm-long implants versus sinus lift through a lateral
window approach with a mixture of 50% particulate autogenous bone from the tuberosity area and 50% Bio-Oss and at least 10-mm-long implants.
One year after loading, no statistically significant differences were observed though trends favoured the less invasive procedure, i.e. crestal sinus lift with
8-mm-long implants.
Study or Subgroup
1.4.1 Prosthesis failure (1 year)
Cannizzaro 2009
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 0.59 (P = 0.56)
1.4.2 Implant failure (1 year)
Cannizzaro 2009
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 1.01 (P = 0.31)
1.4.3 Graft failure (1 year)
Cannizzaro 2009
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 1.08 (P = 0.28)
1.4.4 Complications at treated and donor sites (1 year)
Cannizzaro 2009
Subtotal (95% CI)
Total events
Heterogeneity: Not applicable
Test for overall effect: Z = 1.33 (P = 0.18)
Events
1
1
1
1
0
0
1
1
Total
20
20
20
20
20
20
20
20
Events
2
2
3
3
2
2
4
4
Total
20
20
20
20
20
20
20
20
Weight
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
M-H, Fixed, 95% CI
0.47 [0.04, 5.69]
0.47 [0.04, 5.69]
0.30 [0.03, 3.15]
0.30 [0.03, 3.15]
0.18 [0.01, 4.01]
0.18 [0.01, 4.01]
0.21 [0.02, 2.08]
0.21 [0.02, 2.08]
Crestal lift Lateral window lift Odds Ratio Odds Ratio
M-H, Fixed, 95% CI
0.001 0.1
Favours crestal lift
1 10 1000
Favours lateral lift

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a sinus lift through a crestal approach, autogenous
bone and 8-mm-long implants, and 20 patients were
treated with a sinus lift through a lateral window
approach with a mixture of 50% particulate autog-
enous bone from the tuberosity area and 50% Bio-
Oss and implants at least 10 mm long. All patients
were followed up to 1 year after loading, therefore
there were no dropouts. Four complications occurred
in four sinuses laterally augmented (one abscess and
one sinusitis, both determining the failure of the graft
and the implants), versus one peri-implant infection
in the short implant group. One implant failed in the
short implant group at abutment connection and five
implants (four in the immediate post-operative phase
and one at abutment connection) in three patients
in the long implant group. Two prostheses could not
be placed in the long implant group versus one in
the short implant group because of implant failures.
There was no statistically significant difference for
any of the outcomes considered in the review. The
additional cost of the bone substitute in the group
with the lateral approach should be considered. All
implants were loaded 7 weeks after sinus lift. The
trial was judged to be at low risk of bias.
One trial compared two two-stage techniques
for augmenting maxillary sinuses using a lateral win-
dow approach57 (Fig 4a and b). Only patients having
1 to 5 mm of bilateral bone height at the sinus floor
were included. Ten patients were treated with a split-
mouth approach. After elevation of the sinus lining,
one side was filled with granular Bio-Oss whereas an
Inion resorbable rigid barrier was used to maintain
space to allow bone regeneration in the contralateral
site. All patients were followed up to 4 months after
loading, therefore there were no dropouts. After 6
months, both interventions gained bone (14.4 mm
for Inion versus 14.1 mm for Bio-Oss) with no sig-
nificant differences between the procedures. There
were no differences in complications between
groups (two perforations of the maxillary lining at
the Inion treated sites versus one at Bio-Oss site).
However, in one of the patients where a perforation
occurred at the Inion site, at implant placement, the
sinus was two-thirds filled with soft tissue. Implants
were placed anyway and the site was successfully
retreated with Bio-Oss. No implant failed. The cli-
nician preferred Bio-Oss because it was simpler to
handle. There were no statistically significant differ-
Fig 4a Forest plot comparing two two-stage lateral window sinus lift procedures: granular bone substitute (Bio-Oss) versus a resorbable rigid barrier
(Inion) to maintain space for bone regeneration. No statistically significant differences in complications were observed.
Study or Subgroup
1.5.1 Complications (4 months)
Felice 2009b
Subtotal (95% CI)
Heterogeneity: Not applicable
Test for overall effect: Z = 0.46 (P = 0.65)
Test for subgroup differences: Not applicable
log[Odds Ratio]
-0.69
SE
1.51
Total
10
10
Total
10
10
Weight
100.0%
100.0%
IV, Fixed, 95% CI
0.50 [0.03, 9.68]
0.50 [0.03, 9.68]
Inion Bio-Oss Odds RatioOdds Ratio
IV, Fixed, 95% CI
0.0010.1
Favours Bio-Oss
1 101000
Favours Inion
Fig 4b Forest plot comparing two two-stage lateral window sinus lift procedures: granular bone substitute (Bio-Oss) versus a resorbable rigid barrier
(Inion) to maintain space for bone regeneration. No statistically significant differences in vertical bone gain were observed.
Study or Subgroup
1.6.1 Bone gain
Felice 2009b
Subtotal (95% CI)
Heterogeneity: Not applicable
Test for overall effect: Z = 0.44 (P = 0.66)
Test for subgroup differences: Not applicable
Mean Difference
0.26
SE
0.59464
Total
10
10
Total
10
10
Weight
100.0%
100.0%
IV, Fixed, 95% CI
0.26 [-0.91, 1.43]
0.26 [-0.91, 1.43]
Inion Bio-OsslMean DifferenceMean Difference
IV, Fixed, 95% CI
-10-50510
Favours Bio-OssFavours Inion

Page 15

Copyright byNot for
Quintessence
Not for Publication
IV, Fixed, 95% CI
Esposito et al Effectiveness of sinus lift procedures for dental implant rehabilitation
n 21
Eur J Oral Implantol 2010;3(1):7–26
ences in patient preference 1 month after surgery
and 1 month after delivery of definitive prostheses:
eight patients had no preference while two preferred
the Bio-Oss treated side. With respect to cost, the
bone substitutes and the barrier in one group and
the cost of the barrier alone in the other should be
considered. There was no significant difference in
time to complete the augmentation procedure (19.8
minutes for Inion versus 20.5 for Bio-Oss) and all
implants were loaded 11 months after sinus lift. The
trial was judged to be at low risk of bias.
Trials evaluating the efficacy of PRP with
grafts (4 trials with 114 patients)
One trial compared two techniques for augment-
ing resorbed maxillae including atrophic maxillary
sinuses63. Only patients with less than 5 mm of alve-
olar bone height in the sinus floor were included. Five
patients were treated with a split-mouth approach
with a two-stage sinus lift and autogenous bone
together with buccal onlay grafts, harvested from
the iliac crest. One side was treated with platelet-rich
plasma (PRP) and the other without. All patients were
followed for 2 years after implant loading and there
were no dropouts. No serious complications occurred
at the grafted sites: one sinus membrane was perfo-
rated during surgery but healing was uneventful. A
small incision breakdown occurred in the first week
at the non-PRP side of one patient. A seroma which
healed uneventfully was the only complication that
occurred at the donor sites. During the prosthetic
phase, one implant failed in the PRP side, but no
prosthesis failed. There was no statistically significant
difference for any of the outcomes considered in the
review (Fig 5). The difference in cost and treatment
time was the use of PRP. Prostheses were inserted
about 10 months after augmentation. The trial was
judged to be at high risk of bias.
One trial compared a two-stage sinus lift with a
lateral window approach using either autogenous
particulate bone from the iliac crest alone or the
same graft with PRP in fully edentulous patients61
(Fig 5). All sites were also horizontally augmented
with cortico-spongeous blocks and left to heal for 4
months. A total of 34 patients treated according to
a split-mouth design and 19 patients treated accord-
ing to parallel group design were included in the first
publication but no clinical data were provided67. In
the second publication, the clinical data of the 34
patients treated with a split-mouth approach were
presented, and only the data of those patients is
Fig 5 Forest plot illustrating meta-analyses of trials evaluating the efficacy of platelet rich plasma (PRP) in conjunction with sinus lift procedures. No
statistically significant differences were observed.
Study or Subgroup
1.7.1 Implant failure
Schaaf 2008
Torres 2009
Subtotal (95% CI)
Heterogeneity: Chi² = 0.02, df = 1 (P = 0.89); I² = 0%
Test for overall effect: Z = 0.49 (P = 0.62)
1.7.2 Complications
Raghoebar 2005
Schaaf 2008
Torres 2009
Subtotal (95% CI)
Heterogeneity: Chi² = 0.04, df = 2 (P = 0.98); I² = 0%
Test for overall effect: Z = 0.27 (P = 0.79)
1.7.3 Partial graft loss
Torres 2009
Subtotal (95% CI)
Heterogeneity: Not applicable
Test for overall effect: Z = 0.34 (P = 0.73)
Test for subgroup differences: Chi² = 0.34, df = 2 (P = 0.84), I² = 0%
log[Odds Ratio]
-0.4
-0.69
0
0
0.4
-0.4
SE
1.18
1.81
2.22
2.22
1.18
1.18
Total
34
57
91
5
34
57
96
57
57
Total
34
57
91
5
34
57
96
57
57
Weight
70.2%
29.8%
100.0%
18.1%
18.1%
63.9%
100.0%
100.0%
100.0%
IV, Fixed, 95% CI
0.67 [0.07, 6.77]
0.50 [0.01, 17.42]
0.61 [0.09, 4.27]
1.00 [0.01, 77.57]
1.00 [0.01, 77.57]
1.49 [0.15, 15.07]
1.29 [0.20, 8.20]
0.67 [0.07, 6.77]
0.67 [0.07, 6.77]
No PRP PRPOdds Ratio Odds Ratio
0.0010.11 10 1000
Favours PRP Favours no PRP