Short Communication
ISSN: 2574 -1241 DOI: 10.26717/BJSTR.2021.33.005447
Indirect Sinus Lift: An Overview of Different Techniques
Aruna Wimalarathna*
Consultant in Restorative Dentistry, Department of Prosthetic Dentistry, Faculty of Dental Sciences, Sri Lanka
*Corresponding author: Aruna Wimalarathna, Consultant in Restorative Dentistry, Department of Prosthetic Dentistry,
Faculty of Dental Sciences, University of Peradeniya, Sri Lanka
ARTICLE INFO ABSTRACT
Received: February 01, 2021 The common physiological changes in edentulous posterior maxilla are the
pneumatization of the maxillary sinus and related vertical bone loss. The close proximation
Published: February 08, 2021 of sinus to the crestal bone is a limiting factor for the dental implant placement in the
posterior maxilla. Therefore, numerous techniques were implemented to elevate the
sinus floor to increase the vertical bone height. The indirect sinus lift is one of the safest
Citation: Aruna Wimalarathna. Indirect
and easiest ways of technique that has been introduced in clinical implant dentistry. In
Sinus Lift: An Overview of Different
this article is expressed an overview of different techniques of indirect sinus lifts.
Techniques. Biomed J Sci & Tech Res 33(4)-
2021. BJSTR. MS.ID.005447. Clinical Relevance: The general knowledge of different types of indirect sinus lifts
will help to utilize them according to the case and the available resources.
Keywords: Maxillary Sinus; Sinus Lift;
Dental Implants; Augmentation; Vertical Background: To provide an overall summary of different types of indirect sinus
Bone lift techniques in one article. The indirect sinus lifts are case sensitive therefore this
manuscript will emphasis the indications and limitations of each method when they are
Abbreviations: HySiLift: Hydraulic
applying on patients.
Sinus Lift Technique; β-TCP: Tricalcium
phosphate; PRP: Platelet Rich Plasma
Introduction
should be good quality and quantity of live bone right around the
The maxillary sinus (or antrum of Highmore) is a pyramid-
osteotomy, at least 2mm or more [6].
shaped air-filled space lying within the bilateral maxillae, lateral
to the nasal cavity, superior to the maxillary teeth, inferior to the That fundamental requirement may be compromised in
orbital floors, and anterior to the infratemporal fossa. It is present edentulous posterior maxilla in the vertical direction due to
at birth and develops until around the age of 14 years. Maxillary pneumatization of the maxillary sinus or close proximation of
sinuses are the largest among paranasal sinuses [1], with an sinus floor to the crestal bone. To overcome that limitation, the
average of 12.5 mL in volume [2]. They are lined by a thin bilaminar sinus lift procedure has been invented in the mid-1970s. There
mucoperiosteal membrane known as the Schneiderian membrane. onwards, several techniques and procedures were introduced into
It comprises with a single-cell osteogenic periosteal layer (cambium the implant dentistry. The rationale behind that all the techniques
layer) on the bone side and ciliated pseudostratified columnar was an elevation of the sinus membrane to create a sub-antral
epithelium (respiratory epithelium) on the lumen side. Even space for increasing the vertical bone height. Currently, in order to
though the pneumatization is a poorly understood physiological reconstruct the atrophic maxillae, different bone grafting methods
process, itself causes the expansion of maxillary sinus into the are used as autogenous, homogenous and heterogenous grafts, as
adjacent anatomical structures [3]. In addition, there are some well as synthetic biomaterials [7]. The accurate diagnosis and a
factors such as heredity, craniofacial configuration, nasal mucous better understanding of bone remodeling at posterior maxilla may
membrane pneumatization, sinus surgeries, bone density, air be highly valuable for precise dental implant therapy. Therefore,
pressure within the sinus and growth hormones may influence the proper patient selection can lead to long the success of the sinus
maxillary sinuses pneumatization [4,5]. With the advancement of lifting treatments for the deficient posterior maxilla. There are
implant dentistry, the most popular and predictable modality of many techniques that are available for sinus lifting. Basically, they
replacement of missing teeth is dental implants. But, to achieve can be divided into two broad categories as
better osseointegration after placement of an implant there
Copyright@ Aruna Wimalarathna | Biomed J Sci & Tech Res | BJSTR. MS.ID.005447. 26101
Volume 33- Issue 4 DOI: 10.26717/BJSTR.2021.33.005447
1) The direct method: with lateral antrostomy as a one or for 12 mm, 98.7% for 10 mm, 98.7% for 8 mm and only 47.6% for
two-step procedure and 6 mm implants. This outcome has evidently shown bone height
gain (7.8 mm ± 0.86 mm) which is greater than the average of the
2) The indirect method: with the osteotome technique
osteotome technique [14,15].
with a crestal approach. The indirect sinus lift is also called as
subantral sinus augmentation, subcrestal augmentation, sinus Intralift Technique
floor elevation or transcrestal approach.
Piezoelectric technology is proposed by Torrella et al for the
Here onwards described the evidence available in literature on lateral osteotomy surgeries [16]. Based on the use of piezoelectric
different techniques in indirect sinus lift that are used for implant surgery, sinus lift technique becomes simplified and less
placement in the pneumatized posterior maxilla. intervention as atraumatic as possible. Troedhan and colleagues
have developed the Intralif technique to elevate the sinus floor by
Inflatable Catheter Technique
using piezoelectric surgery based on a specific set of tips for the
The first maxillary sinus lift procedure was performed by application of ultrasound. The high-power ultrasonic instruments
Oscar Hilt Tatum Jr, in 1974 [8]. This was followed by placement allow the osteotomies to be made even, in thicker compact cortical
of two endosteal implants and their restorations. During the year bone. The advantage of this system is that it does not cut the soft
1975–1979, much of the sinus floor elevation was performed using tissues. Therefore, this surgical instrument can be used to elevate
inflatable catheters. Tatum first presented this novel concept at The the sinus membrane without perforating it. The piezoelectric
Alabama Implant Congress in Birmingham in 1976 and published surgical sets consist of many different inserts from osteotomies, to
an article describing the procedure in 1986. Dr Philip Boyne was diamond-cutting inserts. Immediately after the window is made the
introduced to the procedure by Tatum in 1977 or 1978. The first sinus membrane is separated from the bone, and a hydropneumatics
publication on the technique was authored by Boyne and James in pressure of the physiologic saline solution is subjected to the
1980 when they published case reports of autogenous grafts placed piezoelectric cavitation [17]. Vercellotti and colleagues [18] in Italy
into the sinus and allowed to heal for 6 months, which was followed performed 21 bony window osteotomies by using Piezo surgery
by the placement of blade implants8. Trans crestal sinus lift using System on 15 patients. The inserts were used with a vibration 60-
the sinus balloon is a minimally invasive procedure involving 210 mm with power exceeding 5W. Autogenous bone grafts and
few intraoperative complications. Peñarrocha Diago M, et al. [9] platelet-rich plasma were used for all the sinus augmentations in
revealed that they were able to perform trans crestal sinus lift from this study. Of the 21 osteotomies, only one resulted in membrane
3 mm of residual bone, gaining a mean height of up to 8.7 mm, and perforation and there was a 95% success rate.
with a 100% implant success rate one year after prosthetic loading.
Hydraulic Sinus Lift Technique
Summers Osteotome Technique
In this method, the sinus membrane is lifting through a crestal
In 1994 Summers introduced the sinus lift technique with approach, characterized by the hydraulic detachment of the
the use of osteotomes to elevate the membrane. It was eliminated mucosa through injection of a liquid by its spontaneous expulsion
hammering and making the technique more comfortable for the or aspiration, and simultaneous filling of the sub Schneiderian
patient combined with graft material around the implant [10]. This space, with solid or semisolid grafting material. But this is involved
was also known as bone-added osteotome sinus floor elevation in prolonging the operating procedure. Furthermore, during this
technique [11]. This is conceded as a less traumatic and minimally conventional method, a single-use syringe is used which it is not
invasive method. The main limiting factors of this technique are the possible to check exactly the progression of the membrane position
availability of >5mm residual bone height to prevent the membrane [12]. In 2013, Andreasi et al. introduce a new method with the
perforation and low primary stability of the implant11. On the other advancement of hydraulic pressure exercised on a semisolid graft
hand, this technique was a well-validated surgical option when the material to detach the sinus membrane and simultaneously fill the
residual bone height was ≥ to 5-6 mm [10,12]. The survival rate of augmented space created this way [19]. This technique is called as
implants placed simultaneously with indirect sinus lift with bone HySiLift. There were three components of instruments have used
graft material ranges between 93.5% and 100% [13]. Further, the this purpose:
survival rate of the osteotome-installed implants after a mean
follow-up time of 3.2- years was 97.4% in Pjetursson study. There 1) a titanium syringe equipped with a micrometric control
were 3 implants lost before loading and another three were lost in piston on which it is possible to assemble disposable syringes
the first and second year. According to the residual bone height, of various volumes;
the survival rate was 91.3% for implant sites with 4 mm residual 2) a surgical steel dispenser available in two forms (conical
bone height, and 90% for the sites with 4-5 mm bone height, when and cylindrical) and four diameters (two cylindrical of ø 3.2 and
compared with that of 100% in sites with the bone height of above 4.0 mm and two conical of ø 2.8–4.0 and 3.5–4.6 mm) and;
5 mm. According to implant length, the survival rates were 100%
Copyright@ Aruna Wimalarathna | Biomed J Sci & Tech Res | BJSTR. MS.ID.005447. 26102
Volume 33- Issue 4 DOI: 10.26717/BJSTR.2021.33.005447
3) a needle in surgical steel, with a Luer lock attachment, connected to the implant via the tubing port. Saline solution (2 cc)
complementary to that of the single-use syringe. was gently injected through the implant and into the sinus. After
retracting the saline, the syringe was disconnected from the tubing
The single-use syringes can be pre-loaded with the desired
port and flowable bone graft syringe was then connected. The
amount of graft material that, in our experience, was represented
bone graft material was then slowly injected through the implant
by nanocrystalline hydroxyapatite in an aqueous medium or
into the sinus. After that, the bone graft syringe and the tubing
the syringe containing the graft material as provided by the
port were disconnected from the implant [21]. Biphasic calcium
manufacturer. The tip of the titanium injector is semi-spherical
phosphate in the suspension of a soluble polymer or β tricalcium
shaped so that to penetrate nearly 3 mm in the sub-Schneiderian
phosphate granulate suspended in a hyaluronic acid matrix were
space without damaging the overlying mucosa while the lateral
used as injectable bone grafting materials. Then the implant was
openings allow uniform distribution of the paste-like graft material
fully inserted through the osteotomy until the implant aligned with
while forming a dome precisely in correspondence to the future
the alveolar crest [21].
implant site. The threaded portion of the dispenser extends for an
about 6 mm length, thus indicated for ridges of 3-6 mm thickness According to the study done by Chaushu, et al. [21], the mean
to ensure the sufficient stability of the tool during the injection initial bone height was 4.21 ± 0.5 for the control and 5.44 ± 0.76
maneuver. for the study group (p < 0.01). The mean bone gain for the study
group was 7.80 ± 0.5 mm and 9.3 ± 0.5 mm for the control group
Sinu-Lift System (p < 0.01) and all the implants were placed during the study were
This is a minimally invasive two-staged indirect sinus lift osseointegrated at second-stage surgery.
procedure called a “Sinu-Lift system” that utilizing beta-tricalcium
phosphate in conjunction with platelet-rich plasma20. The Discussion
disposable kit consists of starter drill, curettes, and bone packer. The sinus lifting is a mandatory element in managing atrophic
The starter drill (ø 3.2-mm) makes osteotomy towards the sinus edentulous posterior maxilla. The sinus augmentation procedures
membrane which disengages upon contact with the sinus membrane have been well established in clinical implant dentistry with many
to avoid the rupture. The 3-mm yellow and 4.2mm blue curettes are techniques and modifications. In 1980 Boyne and James performed
used to gently separate and additional elevation of the membrane. >10mm bone augmentation through lateral approach in the
The curettes with colour codings allow the accurate control of atrophic maxilla with a significant higher post-surgical morbidity
the working length providing the desired membrane elevation by and an increased risk of membrane perforation. Therefore, Crestal
minimizing the risk for membrane perforation and post-surgery approach, sinus lift surgery, may be performed with different
infections. The bone packer is used to fill the space incrementally bone-grafting materials, such as allograft, autogenous bone or
with pure phase synthetic β-TCP (Tricalcium phosphate) sized 500- heterologous materials, and platelet derivatives themselves
1000 µm mixed with PRP (Platelet Rich Plasma) was obtained by or combined with grafting materials, in order to combine the
adding 1ml Batroxobin and 1ml of 10% Calcium gluconate). Mean properties of the growth factors that allow a better force control
duration of the procedure was 22.6±7.5min and the mean bone during the sinus floor elevation [12]. Compared to the lateral open
height at the desired area of sinus augmentation was 4.4mm which approach, the indirect sinus lift technique has many advantages
is also statistically significant (p < 0.01). Thus, it is appropriate even though it is performed blindly. The advantages are, more
to conclude that sinus-floor elevation using the “sinu-lift system” conservative, less frequent of sinus membrane rupture, the
is definitely a reliable tool in achieving maximum sinus lift for possibility of simultaneous implantation, good bone healing, better
augmentation [20]. positioning of bone grafting material, no subjected to resorption
and high predictable implant survival rate [15]. Further, the 5-year
Sinus Augmentation with Simultaneous Implant
survival rate of implants more to 92.7% in less than 5 mm ridge
Placement height and 94.9% for implants placed in more than 5mm ridge
An osteotomy was started with a 2.8 mm drill to a depth of 3 height after the indirect sinus lift technique [15]. The height bone
mm using a stopper and guided with radiographs. The osteotomy in between crest of the alveolar bone and the floor of the sinus is
was widened with two diameters under drilling off to the desired the most important factor that influences the survival rate of the
width (e.g. 3.2 mm for 4.2 mm; 3.65 mm for 5 mm). The sinus floor implants which placed in sinus augmented sites.
was opened by specially designed diamond tips with automatically
That fact is similarly important for the primary stability of the
prevent the Schneiderian membrane penetration. The length of the
implants too. According to the literature the amount of available
implant was selected based on the bone height: (a 13-mm for 5mm
bone directly proportionates to the survival rate. Rosen, et al. [22]
bone, 14.5-mm for 6.5 mm bone, and a 16-mm for 8 mm bone).
concluded that the survival rates are strictly linked to the residual
Then the implant was inserted into the osteotomy until it reached
bone height, starting from 96% when 5 mm or more of bone is
the end of the prepared osteotomy and slowly advanced until the
present and dropping it into 85% when 4 mm or less bone is
sinus floor was penetrated (<1 mm). A normal saline syringe was
Copyright@ Aruna Wimalarathna | Biomed J Sci & Tech Res | BJSTR. MS.ID.005447. 26103
Volume 33- Issue 4 DOI: 10.26717/BJSTR.2021.33.005447
present. A reduction of the grafted material has been evident over References
the first 3 months of bone remodeling and remained stable over 1. Stern A, Green J (2012) Sinus lift procedures: An overview of current
the whole follow-up period (60 months)15. Regarding the grafting techniques. Dent Clin North Am 56(1): 219-233.
materials, several authors describing a consistent bone formation 2. Gosau M, Rink D, Driemel O (2009) Maxillary sinus anatomy: A cadaveric
(6.51 mm ± 2.49 mm) even when no grafting material was used study with clinical implications. Anat Rec (Hoboken) 292(3): 352-354.
after a minimum of 1-year follow-up. On the other hand, some 3. Sharan A, Madjar D (2008) Maxillary sinus pneumatization following
extractions: A radiographic study. Int J Oral Maxillofac Implants 23(1):
authors have suggested their necessity as the use of a blood clot 48-56.
or platelet concentrates alone may lead to unpredictable results
4. Shapiro R, Schorr S (1980) A consideration of the systemic factors that
[11]. The autologous bone grafting materials were representing the influence frontal sinus pneumatization. Invest Radiol 15(3): 191-202.
gold standard, however, might be subjected to extensive resorption 5. Thomas A, Raman R (1989) A comparative study of the pneumatization
and endosinusal contamination due to intraoral pathogens [11]. of the mastoid air cells and the frontal and maxillary sinuses. AJNR Am J
However, the successful predictability of the indirect sinus lifting Neuroradiol 10(5): S88.
procedures are depending on several factors such as the amount of 6. Elian N, Bloom M, Dard M, Cho SC, Trushkowsky RD, et al. (2011) Effect
of Interimplant Distance (2 and 3 mm) on the Height of Interimplant
the remaining bone height, primary stability, the ability to elevate Bone Crest: A Histomorphometric Evaluation. J Periodontol 82(12):
the Schneiderian membrane without any tearing, a low membrane 1749-1756.
detachment force, elasticity and deformation capacity, the amount 7. Cardoso CL, Curra C, Santos PL, Rodrigues MFM, Ferreira Junior O, et
of elevation, and number of implant insertion sites. al. (2016) Current considerations on bone substitutes in maxillary sinus
lifting. Rev Clin Periodoncia Implantol Rehabil Oral 9(2): 102-107.
Conclusion 8. https://en.wikipedia.org/wiki/Sinus_lift#History
Gaining additional bone height in atrophic maxilla through 9. Peñarrocha Diago M, Galán Gil S, Carrillo García C, Peñarrocha Diago
D, Peñarrocha Diago M (2012) Transcrestal sinus lift and implant
sinus augmentation is a well-established clinical procedure in
placement using the sinus balloon technique. Med Oral Patol Oral Cir
implant dentistry. Compared to the lateral approach technique the Bucal 17(1): e122-e128.
vast varieties of indirect sinus lifting techniques are available with 10. Summers RB (1994) A new concept in maxillary implant surgery: The
more safety and predictable success rates when selecting the cases osteotome technique. Compendium 15: 152-158.
appropriate to the specific techniques. 11. Sathvik N, Nessapan T, Ganapathy D (2019) Indirect sinus lift techniques:
A literature review. Drug Invention Today 11(2): 90-93.
Declarations 12. Emmerich D, Att W, Stappert C (2005) Sinus floor elevation using
osteotomes: A systematic review and meta-analysis. J Periodontol 76(8):
Ethical Approval and Consent to Participate 1237-1251.
Not applicable 13. Krennmair G, Krainhofer M, Schmid Schwap M, Piehslinger E (2007)
Maxillary sinus lift for single implant-supported restorations: A clinical
study. Int J Oral Maxillofac Implants 22(3): 351-358.
Consent for Publication
14. Pjetursson BE, Rast C, Urs Brägger, Schmidlin K, Zwahlen M, et al. (2009)
Not applicable Maxillary sinus floor elevation using the (transalveolar) osteotome
technique with or without grafting material. Part I: implant survival and
Availability of Supporting Data patients’ perception. Clin Oral Impl Res 20: 667–676.
15. Lo Giudice G, Iannello G, Terranova A, Lo Giudice R, Pantaleo G, et al.
All the gathered information were presented in the text. (2015) Transcrestal sinus lift procedure approaching atrophic maxillary
ridge: A 60-month clinical and radiological follow-up evaluation. Int J
Competing Interests Dent 2015: 1-8.
16. Torrella F, Pitarch J, Cabanes G, Anitua E (1998) Ultrasonic ostectomy for
The author is declared that there is no conflict of interests on the surgical approach of the maxillary sinus: A technical note. Int J Oral
any materials or products which were described in the manuscript. Maxillofac Implants 13(5): 697-700.
17. Troedhan AC, Kurrek A, Wainwright M, Jank S (2010) Hydrodynamic
Funding ultrasonic sinus floor elevation an experimental study in sheep. J Oral
Maxillofac Surg 68: 1125-1130.
Not applicable
18. Vercellotti T, De Paoli S, Nevins M (2001) The piezoelectric bony
window osteotomy and sinus membrane elevation: Introduction of a
Authors’ Contributions
new technique for simplification of sinus augmentation procedures. Int
J Periodontics Restorative Dent 21(6): 561-567.
Single author article
19. Andreasi B, Lopez MA, Confalone L, Fanali S, Carinci F (2013) Hydraulic
Acknowledgements sinus lift technique: Description of a clinical case. Ann Oral Maxillofac
Surg 1(2): 18.
Not applicable
Copyright@ Aruna Wimalarathna | Biomed J Sci & Tech Res | BJSTR. MS.ID.005447. 26104
Volume 33- Issue 4 DOI: 10.26717/BJSTR.2021.33.005447
20. Parthasaradhi T (2015) An alternative maxillary sinus lift technique 22. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, et al.
sinu lift system. J Clin Diagn Res 9(3): ZC33-ZC37. (1999) The bone-added osteotome sinus floor elevation technique:
multicenter retrospective report of consecutively treated patients. Int J
21. Chaushu L, Chaushu G, Better H, Sarit Naishlos, Roni Kolerman, et Oral Maxillofac Implants 14(6): 853-858.
al. (2020) Sinus Augmentation with Simultaneous, Non-Submerged,
Implant Placement Using a Minimally Invasive Hydraulic Technique.
Medicina (Kaunas) 56(2): 75.
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