SINUS GRAFT SURGERY

Implant Dentistry

Jaime L. Lozada, DDS

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

The maxillary posterior edentulous area presents a challenging situation in implant

dentistry when compared to other areas of the mouth. When teeth are extracted in the
posterior maxilla, bone in that area is lost due to inferior expansion of the sinus involving
the residual ridge area. This process is known as pneumatization of the maxillary sinus.
Moreover, bone density in this area also decreases rapidly and is the least dense area of
the maxilla (figure 1). When the maxillary sinus pneumatizes and no bone is available
for dental implants, evaluation and treatment procedures have been developed1-33 that
permit bone to be grafted into the sinus (video clip). The technique was developed by
Tatum in 1977.4 Boyne and James were the first to publish an article and describe the
technique in 1980 (reference 1). Implants can sometimes be placed simultaneous with
the grafting procedure or it may be necessary to perform the grafting first with the
implant placement being a second procedure performed several months later. Both
processes and associated criteria will be described later. When contemplating sinus
grafting, it is important to know the anatomy, be able to evaluate the maxillary sinus,
understand the surgical management procedures and identify data related to long-term
results.

ANATOMY

The maxillary sinus is surrounded by several bony walls. The anterior wall frequently
approximates the first premolar or canine. The superior wall of the maxillary sinus cavity
relates to the orbital floor. The posterior wall of the maxillary sinus corresponds to the
pterygomaxillary fossa. The pterygoid plexus or branches of the internal maxillary artery
are usually located posterior to this wall. The medial wall of the antrum separates the
maxillary sinus from the nasal fossa. The maxillary ostium is located in the most
superior area and is the opening through which the maxillary sinus drains its secretion
into the middle meatus of the nasal cavity. The lateral wall of the maxillary sinus forms
the posterior maxilla and the zygomatic process. This wall is several millimeters thick on
a patient with teeth. However, the extraction of teeth and the expansion or
pneumatization of the sinus reduces the thickness of this lateral bony wall (figure 2).
Vascularization and innervation of the maxillary sinus are shared with the maxillary
teeth, which involves the lateral posterior superior branches of V-2 and the superior
alveolar and intraorbital nerves.
Sinus Membrane

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The lining of the maxillary sinus is consistent with that of the other paranasal sinuses.
The sinuses are normally lined by a mucous membrane composed of pseudostratified or
columnar epithelium. Through the lateral wall of the maxillary sinus, this membrane is
carefully separated and manipulated in order to place graft material without impeding the
drainage of the sinus and without perforating the membrane.

PATIENT EVALUATION

A history of symptoms related to the maxillary sinus like sinusitis requires careful
evaluation as part of implant treatment plans in which sinus grafts are being considered.
Acute, allergic, or chronic maxillary sinusitis might be diagnosed by a patients history
and clinical examination. Other methods of examination might include transillumination,
nasal endoscopy, cytology, and radiography, including CT-scan imaging.
Radiographically, infected maxillary sinuses typically show radiopacities in the area. A
CT scan is currently the modality of choice in the evaluation of the nose and paranasal
sinuses (figure 3). Signs of acute sinusitis, root tips, cysts, or tumors complicate sinus
graft procedures and mandate further evaluation (reference 2).

SURGICAL TECHNIQUES

The surgical approach to the maxillary sinus area varies depending on the degree of
pneumatization of the maxillary sinus and the amount of remaining bone When there is
adequate bone, the implants are placed simultaneous with the sinus grafting. When little
bone is remaining, the sinus is grafted first and then the implants are placed in
conjunction with a second surgery. For both surgical techniques, it is recommended that
the patient have sedation and local anesthesia. The use of an aseptic environment is also
recommended. Threaded, HA-coated implants are preferred for use in grafted maxillary
sinuses.

Sinus Graft with Simultaneous Implant Placement Part 1

(One-Stage Approach)
Patients suitable for the one-stage approach can be identified radiographically by the
presence of 3-5 millimeters of bone below the maxillary sinus floor (partial
pneumatization) (figure 4). After careful radiographic evaluation and location of the
maxillary sinus cavity boundaries, an incision is made on the crest of the edentulous area
with two vertical release incisions anterior and posterior to the maxillary sinus cavity.
The mucoperiosteal flap is carefully elevated to gain access to the lateral aspect of the
maxillary sinus cavity.

A lateral access antrostomy window is formed to gain access to the sinus. It is created by
first scoring the outline of the window into the bone with a round bur. The size of the
window is related to the required surgical access and size of the antrum. This antrostomy
resembles the shape of a rectangle with rounded corners. Once the lateral access window
is delineated, the rotary bur is used to continue the careful removal of bone using a
paintbrush stroke approach under copious irrigation, until a bluish hue is observed. This
bluish color observed through the thin bone is an indication of approximation to the sinus

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membrane (figure 5). The patient should be told there will be some tapping on the bone.
A blunt-handled instrument is then used to inwardly tap on the bone and separate the
lateral window from the surrounding bone by fracture of the thin bone, while still
maintaining attachment of the bony window to the underlying thin sinus membrane.
Curettes of different shapes are then used to facilitate the sinus membrane elevation. One
of these curettes is introduced along the margin of the window. The free lateral wall of
the maxillary sinus cavity is then carefully pushed into the sinus while the separation of
the maxillary sinus membrane is performed (figure 6). Careful separation of the
membrane from the sinus cavity is continued until there is sufficient space for the
placement of the graft material and a 16 millimeter long implant. Careful inspection of
the maxillary sinus membrane is performed to ensure no tears are present that might
complicate the grafting procedure. At this point, the graft material can be carefully
positioned in the created cavity (figure 7). Once the graft material has been completely
placed into the recently created cavity, the implants are placed following the conventional
placement protocol and utilizing a surgical template for best implant positioning. The
only modification to the implant placement protocol is that it is not necessary to extend
the osteotomy to the full length of the implant. The osteotomy is only extended through
the existing bone located at the crest of the alveolar ridge and not through the graft
material. A more delicate insertion technique of the implants is necessary, usually with a
handpiece following a self-tapping protocol (figure 8). Once the implants have been
fully seated, and the cover screws placed on each implant (figure 9), the mucoperiosteal
flap is repositioned and closed with continuous horizontal mattress and single interrupted
sutures (figure 10). The borders and flanges of any dentures are aggressively relieved to
eliminate pressure against the lateral wall and the recently placed implants. For implants
placed simultaneously with a sinus graft procedure and based on the graft material used, a
six to ten month healing time is recommended.

Sinus Graft with Delayed Implant Placement

(Two-Stage Approach)
Patients who have little or no bone available between the maxillary sinus floor and the
crest of the ridge are treated using a two-stage approach. The surgical procedure outlined
for the one-stage approach is similar for these patients, with the exception that no
implants will be placed at the first-stage surgery (video clip). Due to the complete
pneumatization of the maxillary sinus cavity and the impossibility of placing the implants
simultaneously to this procedure, the recently placed graft material will be allowed to
heal for approximately six to eight months before the second-stage surgery takes place
(figure 11).

During the second stage, denser bone is found in the grafted area which allows for the
placement of the implants in the planned positions. The implants placed into the
maxillary sinus graft during the second stage will be allowed to heal for an additional six
months before they are uncovered and the prosthodontic procedures initiated.

POSTOPERATIVE INSTRUCTIONS

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Postoperative instructions after sinus grafting procedures include restrictions. The patient
should be told to avoid blowing of the nose and/or creating negative pressure by sucking
through a straw for about one week following surgery. Sneezing, if it occurs, should be
done with the mouth open to relieve pressure. Swelling of the region is common, but
pain is usually less severe than other surgical procedures. Postoperative medications
should be taken as directed. The antibiotic of choice should be one such as Amoxicillin
that is effective against the bacterial spectrum, non-toxic, and bactericidal. Patients with
a history of allergic reaction to penicillin might take Clindamycin as a good alternative.
If postoperative inflammation and edema of the sinus mucosa obstructs the ostium, it
might quickly become secondarily infected by common pathogens. Additional foreign
bodies such as graft material particles might also cause an obstruction. Therefore, agents
to reduce membrane swelling and repair are prudent to decrease the risk. Systemic
decongestants are useful in reopening a blocked sinus and facilitating drainage.

SINUS GRAFT MATERIALS

Several graft materials have been studied which include autogenous bone, allografts,
xenografts, and combinations of these (reference 3). Multiple tests have been used to
demonstrate that bone growth occurs into a variety of graft materials (reference 4). Bone
formation is fastest and most complete with autogenous bone followed by the
combination of porous HA and allograft. A bone biopsy study of a combined allogenic-
zenogenic bone graft showed there was uniform bone formation throughout the sinus.
The study also followed the mineralization process over time and compared the
percentage of bone present in the graft compared to the residual ridge bone (reference 5).

COMPLICATIONS

The most common complication that occurs during sinus graft surgery is tearing or
creation of an opening in the sinus membrane. If membrane perforation occurs, the
surgeon should consider altering the surgical technique (figure 12). The recommended
procedure usually consists of releasing more of the sinus membrane from its bony
attachment so it can collapse on itself and close the small tears. Another recommended
procedure to reduce sinus membrane complications is to carefully position a resorbable
collagen membrane over the opening to ensure continuity before the graft material is
placed.

Bony septums are also often found in the sinus cavity. The bony projections might
complicate the procedure of separation of the membrane from the sinus walls.

Swelling and discomfort are the most common postsurgical complications. Infection,
acute postoperative sinusitis (reference 6) and other related problems can occur in
conjunction with sinus graft procedures and represent the most common short-term
postsurgical complications. These types of complications occur in about 3% of the
patients treated.
CLINICAL SUCCESS DATA

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The primary method of long-term evaluation of sinus grafts has been implant survival.
Since various graft materials have been used in the sinus cavity along with dental
implants of various shapes, surface coatings and placement protocols, the results reported
varied among different authors. Overall, implants placed into the maxillary sinus area
provide similar or slightly superior results than those placed in the same area without the
sinus grafting procedure. Tidwell et al reported a high level of success when implants
were placed into grafted sinuses (reference 7).

The data from studies of implants placed into grafted sinuses presents higher success
rates than the long-term implant success rates reported for implants placed in the
posterior maxilla, which usually consists of type IV bone.

Cigarette smoking has been associated with factors that have a negative impact on dental
health. The results of a study conducted by Kan et al suggest that cigarette smoking
might compromise the success of implants placed in grafted maxillary sinuses (reference
8).

A meta-analysis has been performed on available papers where implants were placed into
maxillary sinuses grafted with various materials (reference 9). The authors of the paper
did not combine all the data from the studies they included in their meta-analysis3,7,10-17
because their purpose was to compare the survival of implants placed into different graft
materials. However, it is of interest to combine the data from the selected studies to
determine an overall failure rate. There were 1092 implants placed in the 10 studies and
76 failed (7%), documenting a high level of success.

REFERENCES

1. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autologous marrow
and bone. J Oral Surg 1980;38:613-616.

The authors reported on 14 patients where sinus grafting was performed. An incision
was made over the edentulous ridge and the mucoperiosteum reflected superiorly. A
large round bur was used to create an antrostomy in the lateral bony wall of the sinus
without tearing the sinus membrane. A large Molt curet was used to gently elevate the
sinus membrane from the lateral and inferior borders. The membrane was then elevated
from the entire floor of the sinus extending to the posterior border of the tuberosity using
a specially modified curet which is illustrated in the paper. Bony septa encountered in
the antral floor are cut with a narrow bone chisel and the bone segments removed with a
hemostat. The antral membrane was then elevated superiorly and autogenous bone from
the iliac crest was packed into the inferior portion of the sinus. The antral membrane was
allowed to gently settle on top of the grafted bone and the flap sutured over the
antrostomy.

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2. Zinreich SJ et al. Paranasal sinuses CT imaging requirements for endoscopic surgery.
Radiology 1987;163: 769-775.

Radiographic identification of the small structures in this area along with endoscopic
examination provides preoperative details about morphology and pathology.
Radiologists must be prepared to interpret minute aspects of sinus anatomy and
communicate with otolaryngologists so the most appropriate therapy can be determined.
Radiographic information has facilitated subsequent surgery, producing more focused
endoscopic surgical procedures, thereby dramatically reducing patient morbidity.

3. Wheeler SL, Holmes R, Calhoun CJ. Six-year clinical and histologic study of sinus-
lift grafts. Int J Oral Maxillofac Implants 1996;11:26-34.

Thirty-six sinus graft procedures were performed and 66 implants were placed in the
posterior maxilla where vertical bone height was less than ideal. Grafts were
accomplished using porous hydroxyapatite (HA) alone, porous HA mixed with
autogenous bone from the iliac crest, and HA combined with autogenous bone from the
mouth. Nineteen core biopsies were taken from different grafts at time intervals ranging
from 4 to 36 months from the time of grafting. The cores were evaluated using
histomorphometric analysis to permit a comparison of the volume fractions of bone
formation. Grafts using porous HA alone produced a mean of 16% bone by volume after
6 months. After the same healing time, grafts using HA and bone produced a mean of
19% bone by volume compared with an 11% bone volume when using HA and bone
harvested intraorally. Cores taken at 19 and 36 months revealed greater bone formation.
Recommendations based on clinical and histologic results are discussed in detail in the
complete paper.

4. Smiler DG, Johnson PW, Lozada JL, Misch C, Rosenlicht JL, Tatum OH, Wagner
JR. Sinus lift grafts and endosseous implants: treatment of the atrophic posterior
maxilla. Dent Clin North Am 1992:36;151-186.

Patients from multiple clinical centers were treated using sinus lift operations and the
placement of implants. Surgical procedures healed uneventfully with minimum pain,
swelling, or morbidity. Grafts healed with few complications or failures. Implants were
placed into the grafts to support prosthetic reconstruction and were found to provide
predictable results over time. The question of what graft material to use is discussed.
Grafts of non-resorbable HA (Interpore 200), bovine cortical HA (Bio-0ss), resorbable
HA (OsteoGen), and freeze-dried demineralized bone powder and granules are presented.
Results of biopsy, histometry, backscattered electron microscopy, cell labeling, and
special stain suggest consistent bone growth into a variety of graft materials. In the
authors opinion, further investigation should be performed in order to determine the
following: 1) determine the healing time for different graft materials. At present,
anecdotal evidence suggests that sinus grafts of autogenous bone should heal for 4 to 6
months; freeze-dried demineralized bone heals for 12 to 16 months; and alloplastic

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materials with freeze-dried demineralized bone heal for 9 to 11 months; 2) evaluate
histologic evidence of bone growth into different bone replacement graft materials; 3)
evaluate the long-term follow-up and success of implants placed within sinus grafts; and
4) determine the remodeling potential of different graft materials when placed under
functional loads.

5. Hanisch O, Lozada JL, Holmes RE, Calhoun CJ, Kan JY, Spiekermann H. Maxillary
sinus augmentation prior to placement of endosseous implants: A histomorphometric
analysis. Int J Oral Maxillofac Implants 1999;14:329-336.

This prospective study histomorphometrically evaluated the status of mineralization

when an allogenic-zenogenic bone graft was used for sinus augmentation (1:1 volumetric
combination of demineralized freeze-dried cortical bone and bovine hydroxyapatite).
One biopsy was taken from 20 patients at either 6, 8, 10 or 12 months after sinus
augmentation and then an implant was immediately placed into the biopsy site. Using
backscattered electron image analysis, the specimens were analyzed to determine the
volume fractions of residual cancellous bone, newly formed bone, soft tissue, bovine
hydroxyapatite, and remineralized freeze-dried demineralized bone allograft. There
was no significant difference between newly formed bone in the inferior, central, and
superior aspects of the grafted areas. The mineralization process was incomplete after 6
months and new bone continued to form up to 12 months following surgery. However,
there was less percentage of bone in the graft (21%) than in the residual ridge (33%) after
12 months.

6. Sandler NA, Johns FR, Braun TW. Advances in the management of acute and
chronic sinusitis. J Oral Maxillofac Surg 1996;54:1005-1013.

Management of the symptoms of sinusitis has changed markedly. The symptoms of

maxillary sinusitus include fever, facial pain that increases on leaning or bending forward
and clear to cloudy, thin, yellow to green purulent drainage. There may be
accompanying fatigue and malaise, nausea, muffled hearing and halitosis. Management
changes have occurred as a result of advances in diagnosis and treatment and also
because of changes in the microbiology of the disease. A coronal CT is considered to be
the gold standard for radiographic evaluation of inflammatory sinus disease. These scans
readily identify minor or major inflammatory changes. Treatment alternatives include
antibiotics, decongestants, and occasionally intranasal vasoconstrictors. Since the
introduction of potent antibiotics and precise laboratory and endoscopic diagnostic
methods, complications from maxillary sinusitis have become rare. More aggressive
treatment measures include antral aspiration and irrigation with or without nasal
antrostomy. For more specific details, read the complete article which provides treatment
algorithms.

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7. Tidwell JK, Blijdorp PA, Stoelinga PJ, Briybs HB, Gubderks F. Composite grafting
of the maxillary sinus for placement of endosteal implants: a preliminary report of 48
patients. Int J Oral Maxillofac Surg 1992;22:204-9.

The maxillary sinuses in 48 patients were grafted with dense, non-resorbable

hydroxyapatite (HA) particles combined with autologous, cancellous bone. After 3
months of healing, HA-coated titanium endosteal implants were placed in the maxilla.
Following an additional 3-5 month healing period, prostheses were placed. After a mean
follow-up period of 17 months (range from 12 to 32 months), 13 (6.4%) of the 203
implants placed in the grafted floor of the sinus failed, and 5 (7.8%) of the 64 implants
placed in the anterior maxilla failed. Simultaneous lateral and anterior onlay grafting of
the alveolar process was required in 36 (75%) patients because the width of the alveolar
process was considered insufficient for placement of endosseous implants.

8. Kan JY, Rungcharassaeng K, Lozada JL, Goodacre CJ. Effects of smoking on

implant success in grafted maxillary sinuses. J Pros Dent 1999;82(3):309-11.

This retrospective study evaluated the effect of smoking and the amount of cigarette
consumption on the success of implants placed in grafted maxillary sinuses. Sixty
patients (16 smokers and 44 nonsmokers) were evaluated. Eighty-four maxillary sinuses
were grafted and a total of 228 endosseous root form implants were placed. Seventy
implants were placed in 26 maxillary sinuses in smokers, and 158 implants were placed
in 58 sinuses in nonsmokers. After a mean follow-up period of 42 months (range of 2 to
60 months), there was a significantly higher cumulative implant success rate in
nonsmokers (82.7%) than in smokers (65.3%) (P = .027). There was no correlation
between implant failures and the amount of cigarette consumption (P > .99).

9. Tong DC, Rioux K, Drangsholt M, Beirne OR. A review of survival rates for
implants placed in grafted maxillary sinuses using meta-analysis. Int J Oral
Maxillofac Implants 1998;13:175-182.

A MEDLINE search of the English literature revealed 28 papers. Ten of the studies3,7,10-17
met the inclusion criteria.

There were 6 studies10-13,15,17 that evaluated 484 implants placed into 130 patients where
the graft material was autogenous bone. There were 47 implant failures (10% failure
rate).

Three studies3,7,14 used a combination of autogenous bone and hydroxyapatite (HA) for
the graft material. In this group, 363 implants were placed in 104 patients and 22 failed
(6% failure rate).

One of the previous studies3 also placed 30 implants into 11 patients using only
hydroxyapatite and 4 implants failed (3% failure rate).

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There was one study16 that also used a combination of hydroxyapatite and demineralized
freeze-dried bone. There were 215 implants placed into 50 patients and 3 implants failed
(2% failure rate).

The studies document a high level of success when implants are placed into grafted
sinuses.

REFERENCE LIST

1. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autologous marrow
and bone. J Oral Surg 1980;38:613-616.
2. Zinreich SJ, Kennedy DW, Rosenbaum AE, Gayler BW, Kumer AJ, Stammberger H.
Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology
1987;163:769-775.
3. Wheeler SL, Holmes R, Calhoun CJ. Six-year clinical and histologic study of sinus-
lift grafts. Int J Oral Maxillofac Implants 1996;11:26-34.
4. Smiler DG, Johnson PW, Lozada JL, Misch C, Rosenlicht JL, Tatum OH, Wagner
JR. Sinus lift grafts and endosseous implants: Treatment of the atrophic posterior
maxilla. Dent Clin North Am 1992:36;151.
5. Hanisch O, Lozada JL, Holmes RE, Calhoun CJ, Kan JY, Spiekermann H. Maxillary
sinus augmentation prior to placement of endosseous implants: A histomorphometric
analysis. Int J Oral Maxillofac Implants 1999;14:329-336.
6. Sandler NA, Johns FR, Braun TW. Advances in the management of acute and
chronic sinusitis. J Oral Maxillofac Surg 1996;54:1005-1013.
7. Tidwell JK, Blijdorp PA, Stoelinga PJ, Briybs HB, Gubderks F. Composite grafting
of the maxillary sinus for placement of endosteal implants: A preliminary report of
48 patients. Int J Oral Maxillofac Surg 1992;22:204-209.
8. Kan JY, Rungcharassaeng K, Lozada JL, Goodacre CJ. Effects of smoking on
implant success in grafted maxillary sinuses. J Pros Dent 1999;82(3):309-311.
9. Tong DC, Rioux K, Drangsholt M, Beirne OR. A review of survival rates for
implants placed in grafted maxillary sinuses using meta-analysis. Int J Oral
Maxillofac Implants 1998;13:175-182.
10. Kent JN, Block MS. Simultaneous maxillary sinus floor bone grafting and placement
of hydroxyapatite-coated implants. J Oral Maxillofac Surg 1989;47:238-242.
11. Hall HD, McKenna SJ. Bone graft of the maxillary sinus floor for Brnemark
implants. Oral Maxillofac Surg Clinics North Am 1991;3:869-874.
12. Raghoebar GM, Brouwer TJ, Reintsema H, Van Oort RP. Augmentation of the
maxillary sinus floor with autogenous bone for the placement of endosseous implants:
A preliminary report. J Oral Maxillofac Surg 1993;51:1198-1203.
13. Keller EE, Eckert SE, Tolman DE. Maxillary antral and nasal one-stage inlay
composite bone graft: Preliminary report on 30 recipient sites. J Oral Maxillofac
Surg 1994;52:438-447.
14. Chiapasco M, Ronchi P. Sinus lift and endosseous implants preliminary surgical
and prosthetic results. Eur J Prosthodont Rest Dent 1994;3:15-21.

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15. Lundgren S, Moy P, Johansson C, Nilsson H. Augmentation of the maxillary sinus
floor with particulate mandible: A histological and histomorphometric study. Int J
Oral Maxillofac Implatns 1996;11:760-766.
16. Zinner ID, Small SA. Sinus-lift graft: Using the maxillary sinuses to support
implants. J Am Dent Assoc 1996;127:51-57.
17. Bloomqvist JE, Alberius P, Isaksson S. Retrospective analysis of one-stage maxillary
sinus augmentation with endosseous implants. Int J Oral Maxillofac Implants
1996;11:512-521.
18. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am
1986;30:207-229.
19. Smiler DG, Holmes RE. Sinus lift procedure using porous hydroxyapatite: A
preliminary clinical report. J Oral Implantol 1987;13:239-253.
20. Jensen J, Simonsen EK, Sindet-Pedersen S. Reconstruction of the severely resorbed
maxilla with bone grafting and osseointegrated implants: a preliminary report. J Oral
Maxillofac Surg 1990;48:27-32.
21. Jensen OT, Greer R. Immediate placement of osseointegrated implants into the
maxillary sinus augmented with mineralized cancellous allograft and Gore-Tex:
Second-stage surgical and histological findings. In: Laney WR, Tolman DE (eds).
Tissue Integration in Oral, Orthopedic, and Maxillofacial Reconstruction. Chicago:
Quintessence Publishing Co., Inc., 1990:321-333.
22. GaRey DJ, Whittaker JM, James RA, Lozada JL. The histologic evaluation of the
implant interface with heterograft and allograft materials an eight-month autopsy
report, part II. J Oral Implantol 1991;17:404-408.
23. Wagner JR. A 3_ year clinical evaluation of resorbable hydroxylapatite OsteoGen
(HA Resorb) used for sinus lift augmentation in conjunction with the insertion of
endosseous implants. J Oral Implantol 1991;17:152-164.
24. Hochwald DA, Davis WH. Bone grafting in the maxillary sinus floor. In:
Worthington P., Brnemark P-I (eds). Advanced Osseointegration Surgery:
Application in Maxillofacial Region. Chicago: Quintessence Publishing Co., Inc.,
1992:pp 175-181.
25. Moy PK, Lundgren S, Holmes RE. Maxillary sinus augmentation:
Histomorphometric analysis of graft materials for maxillary sinus floor augmentation.
J Oral Maxillofac Surg 1993;51:857-862.
26. Small SA, Zinner ID, Panno FV, Shapiro HJ, Stein JI. Augmenting the maxillary
sinus for implants: Report of 27 patients. Int J Oral Maxillofac Implants 1993;8:523-
528.
27. Fugazzotto PA. Maxillary sinus grafting with and without simultaneous implant
placement: Technical considerations and case reports. Int J Periodont Rest Dent
1994;14:544-551.
28. Nishibori M, Betts NJ, Salama H, Listgarten MA. Short-term healing of autogenous
and allogenic bone grafts after sinus augmentation: A report of 2 cases. J
Periodontol 1994;65:958-966.
29. Summers RB. The osteotome techinque: Part 3 Less invasive methods of elevating
the sinus floor. Compendium 1994;15:698, 700, 702-704 passim;quiz 710.

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30. Hurzeler MB, Kirsch A, Ackermann KL, Quinones CR. Reconstruction of the
severely resorbed maxilla with dental implants in the augmented maxillary sinus: A
5-year clinical investigation. Int J Oral Maxillofac Implants 1996;11:466-475.
31. Zitzmann NU, Scharer P. Sinus elevation procedures in the resorbed posterior
maxilla. Comparison of the crestal and lateral approaches. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1998;85:8-17.
32. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus
Conference of 1996. Int J Oral Maxillofac Implants 1998;13 Suppl:11-45. Review.
33. Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC. Histologic and clinical
comparison of bilateral sinus floor elevations with and without barrier membrane
placement in 12 patients: Part 3 of an ongoing prospective study. Int J Periodont
Rest Dent 2000;20:117-125.

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