Wang.

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Sinus

6–9 mm

≥ 5 mm CEJ ≤ 3 mm

Sinus

≤ 5 mm

≥ 5 mm
CEJ > 3 mm

The International Journal of Periodontics & Restorative Dentistry

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ABC Sinus Augmentation Classification

Hom-Lay Wang, DDS, MSD, PhD* The use of osseointegrated implants

Amar Katranji, DDS** for rehabilitation of an edentulous
space is quickly becoming the treat-
ment of choice in dentistry. Numerous
techniques and treatment protocols
Edentulism in the posterior maxilla can present with compounding variables that have been championed regarding the
make it a difficult region to restore with implants. Pneumatization of the sinus timing and placement of implants.
floor is typically accounted for during surgical treatment planning, but other fac- However, factors such as the quantity
tors such as horizontal ridge deficiency and vertical defects may be overlooked. and quality of the residual host bone
This report reviews the different classifications used to treat the posterior maxilla play important roles in successful treat-
and introduces a new system that incorporates all factors critical for implant suc- ment planning and may shift timing
cess. Class A represents abundant bone with ≥ 10 mm bone height below the sequences associated with the place-
sinus floor and ≥ 5 mm bone width, allowing proper implant placement. Class B ment of implants. Specifically, the
indicates barely sufficient bone with 6 to 9 mm bone height below the sinus floor,
edentulous posterior maxilla poses a
and this can be further subclassified into division h (horizontal defect; < 5 mm bone
number of challenges that can com-
width), division v (vertical defect; > 3 mm away from cementoenamel junction),
plicate implant treatment planning.
and division c (combined horizontal and vertical defect). Class C indicates com-
promised bone with ≤ 5 mm bone height below the sinus floor, and this can also
Cawood and Howell,1 in their classifi-
be subclassified similar to Class B. The ABC classification is a simple system to cation of edentulous jaws, reported
guide clinicians in proper implant treatment of the posterior maxilla. (Int J that the posterior maxilla loses its
Periodontics Restorative Dent 2008;28:383–389.) shape upon tooth loss. This bone loss
in combination with sinus pneumati-
zation often resulted in deficient verti-
cal height, creating a major challenge
for future implant-supported restora-
tions. Misch2 developed a classification
*Professor and Director of Graduate Periodontics, Department of Periodontics and Oral for treatment of the edentulous pos-
Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan. terior maxilla based on the amount of
**Private Practice, Detroit, Michigan. bone below the antrum and the ridge
width. Treatment categories ranged
Correspondence to: Dr Hom-Lay Wang, Department of Periodontics and Oral Medicine,
University of Michigan School of Dentistry, 1011 North University Avenue, Ann Arbor, from SA-1 to SA-4 based on bone
Michigan 48109-1078; fax: 734 936 0374; e-mail: homlay@umich.edu. height and division A (> 5 mm) or B (2.5

Volume 28, Number 4, 2008

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Fig 1 Sinus Class A.

Sinus

≥ 10 mm
≥ 5 mm CEJ ≤ 3 mm

to 5 mm) based on ridge width. Class A: Abundant bone

Recently, Simion et al3 developed a
classification of the maxillary posterior Class A (Fig 1) indicates that the sinus
edentulous region that took into floor is located at least 10 mm from the
consideration the bone crest as it crest, with a width of 5 mm or greater.
relates to the cementoenamel junc- The distance from the bone crest to the
tion (CEJ) of the adjacent teeth. adjacent CEJ is 3 mm or less. In this
Together, these classifications provide clinical scenario, implants can be
complete guidelines for rehabilitation placed without further grafting.
of the edentulous posterior maxilla,
but independently, they are incom-
plete. The following is a classification Class B: Barely sufficient bone
of the edentulous posterior maxilla
that seeks to provide guidelines for In this classification (Fig 2), the sinus
implant therapy. floor is located 6 to 9 mm from the
crest of the bone. The width is at least
5 mm and does not require further
ABC classification horizontal augmentation. The bone
crest is 3 mm or less from the adjacent
The ABC classification is based on the CEJ. In this scenario, the sinus can be
assumption that the implants will be of augmented using either osteotome or
minimum specifications: 4 mm in lateral wall (window) procedures, and
diameter and 10 mm in length. the implant may be placed simultane-
Numerous studies showed higher suc- ously. Class B may have component
cess rates in implants with a length of defects that require grafting prior to,
10 mm or greater.4–10 It is also gener- during, or after sinus elevation and
ally acknowledged that a larger-diam- implant placement. Class B situations
eter implant provides better stability can be subclassified into one of three
and makes clinical success more divisions:
likely.8,9 Although a minimum of 4 mm
is assumed in this classification, a
wider diameter has also been recom-
mended when placing implants into
an augmented sinus.11

The International Journal of Periodontics & Restorative Dentistry

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Fig 2a (left) Sinus Class B.

Fig 2b (right) Sinus Class B-h.

Sinus Sinus

6–9 mm 6–9 mm
≥ 5 mm CEJ ≤ 3 mm < 5 mm
CEJ ≤ 3 mm

Fig 2c (left) Sinus Class B-v.

Fig 2d (right) Sinus Class B-c.

Sinus Sinus

6–9 mm 6–9 mm
≥ 5 mm
≥ 5 mm
CEJ > 3 mm CEJ > 3 mm

1. Division h (horizontal defect): cent CEJ and requires vertical

Sinus floor is 6 to 9 mm from the augmentation. In this scenario,
crest of the bone, and the width is the bone crest is elevated through
less than 5 mm and requires hor- grafting procedures to maintain
izontal augmentation such as proper crown-to-implant ratio.
guided bone regeneration (GBR) Following augmentation, implants
to achieve proper width. The can be placed using the Class B
bone crest is 3 mm or less from protocol.
the adjacent CEJ. In this scenario, 3. Division c (combined defect): Sinus
the width should be augmented floor is 6 to 9 mm from the crest of
(eg, GBR, onlay graft, or ridge the bone, the width is less than 5
split/expansion) to at least 5 mm mm, and the bone crest is greater
so that the Class B protocol can than 3 mm from the adjacent CEJ.
be followed. In this scenario, a combined verti-
2. Division v (vertical defect): Sinus cal and horizontal component
floor is 6 to 9 mm from the crest requires grafting procedures.
of the bone with normal bone Following augmentation, implants
width (≥ 5 mm). The bone crest is can be placed using the Class B
more than 3 mm from the adja- protocol.

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386
Fig 3a (left) Sinus Class C.
Fig 3b (right) Sinus Class C-h.
Sinus
≤ 5 mm
≥ 5 mm CEJ > 3 mm
Fig 3c (left) Sinus Class C-v.
Fig 3d (right) Sinus Class C-c.
Sinus
≤ 5 mm
≥ 5 mm
CEJ > 3 mm
Class C: Compromised bone
In Class C situations (Fig 3), the bone
crest is 5 mm or less from the sinus
floor, the bone width is 5 mm or more,
and the bone crest is 3 mm or less
from the adjacent CEJ. Lateral wall
sinus augmentation is often recom-
mended for a more predictable out-
come. If implant stability is achieved,
then immediate implants may be
placed in a two-stage approach. If
implant stability cannot be achieved, a
sinus graft should be allowed to heal
for at least 6 months. Implants are
placed after the healing period. Class
C situations can be subclassified into
one of three divisions:
1. Division-h (horizontal): Sinus floor
is 5 mm or less from the crest of
bone, and the width is less than 5
mm. The bone crest is 3 mm or
The International Journal of Periodontics & Restorative Dentistry
Sinus
≤5 mm
< 5 mm
CEJ ≤ 3 mm
Sinus
≤ 5 mm
< 5 mm
CEJ > 3 mm
less apical to the adjacent CEJ.
The lateral window sinus aug-
mentation procedure is often rec-
ommended, and implants are
placed after sinus grafting.
Horizontal augmentation is per-
formed as indicated.
2. Division v (vertical defect): Sinus
floor is 5 mm or less from the alve-
olar bone crest with normal bone
width (≥ 5 mm). The bone crest is
more than 3 mm from the adja-
cent CEJ. The bone crest is ele-
vated via grafting procedures to
maintain proper crown-to-implant
ratio. Following augmentation,
implants can be placed using the
Class B protocol. Nonetheless,
the patient should be informed
that an unfavorable crown-to-
implant ration may exist after the
definitive restoration is placed.
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387

Table 1 ABC classification and recommended treatment options

Class Recommended procedure(s) Immediate/delayed
A Implant placement Immediate
B Osteotome Immediate
B-h Osteotome and ridge expansion Immediate
GBR/onlay graft Delayed
B-v GBR followed by osteotome Delayed
B-c GBR and/or onlay graft followed by osteotome Delayed
C Lateral wall sinus elevation Immediate with implant stability
Delayed without implant stability
C-h Lateral wall sinus elevation and GBR/onlay graft Delayed
C-v Lateral wall sinus elevation and GBR, followed by onlay graft if indicated Delayed
C-c Lateral wall sinus elevation and GBR, followed by onlay graft if indicated Delayed
GBR = Guided bone regeneration.

3. Division-c (combined): Sinus floor Discussion

is 5 mm or less from the crest of
bone, and the width is less than 5
mm. The bone crest is more than
3 mm apical to the adjacent CEJ.
The lateral window sinus aug-
mentation procedure is per-
formed. Horizontal and vertical
bone augmentation is required for
proper implant placement and
restoration. Implants are placed
after successful sinus and bone
grafting.
Table 1 summarizes the ABC sinus
augmentation classification and the
proposed treatment procedure(s) for
each individual classification and sub-
classification.
Proper treatment planning is necessary
to ensure a successful outcome when
using implant therapy. The posterior
maxilla is especially difficult to treat
because of the dynamic nature of the
sinus cavity. Specifically, pneumatiza-
tion of the sinus may be present, and
should be addressed by sinus lifting
past the apical position of the implant.
The decision to place an implant dur-
ing the lifting process is left to the sur-
geon, but this decision is limited by the
achievability of implant stability. In a
study by Peleg et al,12 the failure rate of
implants stabilized in 5 mm or less of
residual bone was shown to be signifi-
cantly higher than those placed in more
than 5 mm of residual bone height.
However, the success achieved in all
groups was very high and attributed to
proper stabilization of the implants.

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388
Still, a minimum residual bone
height of 6 mm should be considered
for immediate placement of implants.
Implants adjacent to natural den-
tition in the posterior maxilla should be
placed approximately 3 mm from the
CEJ to maintain adequate crown-to-
implant ratios and reduce vertical can-
tilevers. Reducing crown length has
been shown to decrease stress around
implants and should be a goal during
implant placement.13 An edentulous
maxilla may present with horizontal,
vertical, or combined alveolar ridge
deficiencies. Wang and Al-Shammari14
developed a classification and treat-
ment guide to treat these defects. In
this classification, the vertical alveolar
ridge defect is classified according to
the position of the crest in relation to
the adjacent CEJ, as in the Simion et
al classification.3 The horizontal classi-
The International Journal of Periodontics & Restorative Dentistry
fication is referenced based on the
minimum width needed to place a 4-
mm implant, similar to the Misch clas-
sification.2 Here, all factors are consid-
ered and used for treatment planning
in the edentulous posterior maxilla.
Conclusion
This article presented a new classifica-
tion for treatment planning in the
edentulous posterior maxilla. All
aspects of implant placement were
considered, including the location of
the sinus floor, alveolar ridge resorp-
tion, and location of the bone crest. It
is a simple system to guide clinicians in
proper implant treatment of the pos-
terior maxillary area.
Acknowledgments
The authors would like to thank Mr Chris Jung
for his expertise in drawing all of the diagrams.
This paper was partially supported by the
University of Michigan Periodontal Graduate
Student Research Fund.
Wang.qxd 8/4/08 9:56 AM Page 389
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