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The materials offered in the ITI Treatment Guide are for educational purposes only and intended as a step-by-step guide to treatment of a particular case and patient situation. These recommendations are based on conclusions of the ITI Consensus Conferences and, as such, in line with the ITI treatment philosophy. These recommendations, nevertheless, represent the opinions of the authors. Neither the ITI nor the authors, editors and publishers make any representation or warranty for the completeness or accuracy of the published materials and as a consequence do not accept any liability for damages (including, without limitation, direct, indirect, special, consequential or incidental damages or loss of profits) caused by the use of the information contained in the ITI Treatment Guide. The information contained in the ITI Treatment Guide cannot replace an individual assessment by a clinician, and its use for the treatment of patients is therefore in the sole responsibility of the clinician.

The inclusion of or reference to a particular product, method, technique or material relating to such products, methods, or techniques in the ITI Treatment Guide does not represent a recommendation or an endorsement of the values, features, or claims made by its respective manufacturers.

All rights reserved. In particular, the materials published in the ITI Treatment Guide are protected by copyright. Any reproduction, either in whole or in part, without the publisher’s prior written consent is prohibited. The information contained in the published materials can itself be protected by other intellectual property rights. Such information may not be used without the prior written consent of the respective intellectual property right owner.

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The tooth identification system used in this ITI Treatment Guide is that of the FDI World Dental Federation.

“… to promote and disseminate knowledge on all aspects of implant dentistry and related tissue regeneration through education and research to the benefit of the patient.”

Acknowledgment

We would like to thank Mr Thomas Kiss of the ITI Center for his invaluable assistance in the preparation of this volume of the Treatment Guide series. We would also like to express our gratitude to Ms Juliane Richter (Quintessenz Verlags-GmbH) for the typesetting and the coordination of the production workflow, Mr Per N. Döhler (Triacom Dental) for the editing support and Ms Ute Drewes for the excellent illustrations. We also acknowledge Straumann AG, the corporate partner of the ITI, for their continuing support.

Additionally, we would like to acknowledge the enthusiastic support and valuable contributions received from the following clinicians in the creation of the chapter manuscripts 3, 4 and 7 for this Treatment Guide volume: Dr. Yoji Kamiura

Editors and Authors

Contributors

Continuous advances in the field of implant dentistry have provided clinicians with various treatment options to facilitate the placement of dental implants in patients with vertical bone deficits in the posterior maxilla. Today, one of the most common ways to compensate for inadequate vertical bone height is to elevate the sinus floor. Often employed in combination with bone grafts and bone substitutes, sinus floor elevation procedures are of moderate to high complexity, entailing a significant risk of complications.

In August of 2008, the ITI held the 4th ITI Consensus Conference to discuss a number of current issues in implant dentistry. One focus was on bone augmentation procedures in localized defects and on the clinical efficacy of the different protocols employed with the many grafting materials and techniques available today. The results of this conference were published in a supplement to the International Journal of Oral & Maxillofacial Implants in 2009.

The present fifth volume in the ITI Treatment Guide series summarizes the findings and consensus statements of the 4th ITI Consensus Conference and provides an up-to-date overview of the literature on sinus floor elevation published in the past four years. Reinforced by this scientific evidence, emphasis is placed on clinical recommendations and guidelines for evaluating possible patients for sinus floor elevation and for choosing the appropriate treatment approach and augmentation protocol. All clinical procedures are illustrated and supported by detailed case reports.

As with the preceding four volumes of the ITI Treatment Guide, the authors hope that this fifth volume will prove a valuable resource and reference for clinicians placing implants in patients requiring sinus floor elevation to minimize the risk of complications and to ensure predictable and stable long-term results.

The International Team for Implantology (ITI) is an independent academic organization that brings together professionals from the various fields in implant dentistry and related tissue regeneration. The ITI regularly publishes treatment guidelines based on evidence-based clinical studies supported by long-term clinical results. The ITI Treatment Guides have proven to be an invaluable resource for the clinician active in the field of implant dentistry.

The ITI regularly organizes Consensus Conferences to review the current literature on oral implantology and to evaluate the scientific evidence supporting a wide range of clinical procedures, techniques, and biomaterials. The proceedings are published in peer-reviewed journals. The 4th ITI Consensus Conference was held in Stuttgart, Germany in August 2008. For this conference, the ITI Education Committee focused on four topics:

(Proceedings of the 4th ITI Consensus Conference, International Journal of Oral and Maxillofacial Implants 2009. Vol. 24, Supplement.)

A working group was elected for the exploration of each topic. Working Group 4, under the leadership of Stephen Chen, reviewed the literature on surgical techniques. Sinus floor elevation procedures were one of the topics in focus of this group.

The following section presents the consensus statements and recommended clinical procedures for sinus augmentation.

2.1	Consensus Statements

Group 4 was asked to prepare evidence-based review papers on surgical techniques in implant dentistry. Two review papers contained information related to the techniques and biomaterials used in sinus floor elevation:

•Simon Storgård Jensen, Hendrik Terheyden: Bone augmentation procedures in localized defects in the alveolar ridge: clinical results with different bone grafts and bone substitute materials (Jensen and Terheyden 2009)

•Matteo Chiapasco, Paolo Casentini, Marco Zaniboni: Bone augmentation procedures in implant dentistry (Chiapasco et al. 2009)

Definition of terms

The following definitions were adopted from the Glossary of Oral and Maxillofacial Implants (Laney 2007):

•Maxillary sinus floor elevation: An augmentation procedure for the placement of implants in the posterior maxilla where pneumatization of the maxillary sinus and/or vertical loss of alveolar bone has occurred.

•Autograft (synonymous with autologous/autogenous graft): Tissue transferred from one location to another within the same individual.

•Allograft: A graft between genetically dissimilar members of the same species.

•Xenograft: A graft taken from a donor of another species.

•Alloplast: Inorganic, synthetic, or inert foreign material implanted into tissue.

Maxillary sinus floor elevation using the transcrestal technique

Maxillary sinus floor elevation using a transcrestal technique is a predictable procedure for augmenting the bone in the posterior maxilla. A variety of grafting materials can be employed safely and predictably, either alone or in combination. These grafting materials include autografts, allografts, xenografts, and alloplastic materials. At present, it is not clear whether the introduction of a grafting material improves the prognosis.

Maxillary sinus floor elevation using the lateral window technique

Maxillary sinus floor elevation using the lateral window technique is predictable for augmentation of bone in the posterior maxilla. A variety of grafting materials can be used safely and predictably, either alone or in combination. These materials include autografts, allografts, xenografts, and alloplastic materials. The use of autografts does not influence survival rates of rough-surfaced implants but may reduce healing times.

Bone quantity and density in the residual maxilla influence implant survival rates, independently of the type of grafting procedure used.

The survival rates for implants with rough surfaces placed in the augmented maxillary sinus are similar to those of implants inserted in native bone.

2.2	Proposed Clinical Approaches

Maxillary sinus floor elevation using the transcrestal technique

•Sinus floor elevation using the transcrestal technique can be recommended in sites where the alveolar crest is sufficiently wide, initial bone height is 5 mm or more, and the anatomy of the sinus floor is relatively flat.

The main disadvantage of this technique is a risk of sinus membrane perforation, which is difficult to manage. Transcrestal procedures should only be user by clinicians experienced in performing sinus floor elevation using the lateral window technique. Primary implant stability is a prerequisite for this technique.

Maxillary sinus floor elevation using the lateral window technique

•In sites where initial bone height is limited and does not allow implants of the desired length to be placed, sinus floor elevation using the lateral window technique can increase bone height.

•Atrophy of the maxilla occurs three-dimensionally. The edentulous posterior maxilla should not only be evaluated in terms of initial bone height below the maxillary sinus but also in terms of vertical and horizontal deficiencies of the ridge. If a relevant vertical or horizontal intermaxillary discrepancy is present, onlay bone augmentation may be considered to create sufficient bone volume and a proper intermaxillary relationship in order to optimize implant placement and related prosthetic restoration.

•Data related to the initial clinical situation should be reported and defects classified according to well-defined criteria.

•If the initial bone height allows primary implant stability, simultaneous implant placement (one-stage) can be recommended. Where primary stability cannot be achieved, the sinus floor should be elevated in a separate procedure, followed by delayed implant insertion (staged approach).

•Implants should have rough surfaces. Covering the access window with a membrane may be considered.

2.3	Literature Review
	Simon Storgård Jensen

Maxillary sinus floor elevation was comprehensively reviewed as a major topic at the 4th ITI Consensus Conference in August 2008. The following is a summary of the literature that was reviewed during that conference and of additional papers of significance published subsequently.

2.3.1Maxillary Sinus Floor Elevation – Lateral Window Technique

Note: To improve readability, extensive lists of references (referred to by superscript numbers in brackets) are presented separately in Chapter 8.1.

Implant survival

Maxillary sinus floor elevation using the lateral window technique is a well-documented and reliable procedure to increase bone height in the posterior maxilla to allow the placement of dental implants of optimal length. Follow-up data for one year or more after prosthetic loading were included in 85 studies. These studies reported on 4,807 patients with 14,944 implants inserted in augmented sinuses.[1]

Survival rates were 61.2% to 100% (mean: 94.2%; median: 95%) after 12 to 107 months (mean: 31.2 months; median: 29 months) of prosthetic loading. Survival rates of rough-surface implants (plasma-sprayed, acid-etched and/or sandblasted titanium, or HA-coated) were 88.6% to 100% (mean: 97.7%; median: 98.8%), compared to implants with machined implant surfaces, whose survival rates were 61.2% to 100% (mean: 87.9%; median: 89%). Rough-surface implant survival rates are comparable to those of implants in non-augmented maxillary bone. However, success rates determined by established and well-defined success criteria are rarely reported (Chiapasco et al. 2009).

Subantral bone height

The vertical distance between the floor of the maxillary sinus and the crest of the posterior maxillary alveolar process constitutes the subantral bone height (also called initial bone height or residual bone height). The subantral bone height is often used to determine whether implants can be placed simultaneously with sinus floor elevation or whether a staged approach should be preferred. Judging from the data in the literature, the mean subantral bone height before grafting was calculated to be 3.8 mm. For simultaneous and two-stage implant placements, it was 4.4 mm and 2.9 mm, respectively. In two-stage procedures, the mean healing time between grafting and implant placement was 6.0 months. The mean healing time between implant placement and loading was 6.3 months.

Grafting protocols

A bone substitute material only was used in 19 studies (740 patients, 2,481 implants).[2]

Autograft material only or a combination of autograft material and a bone substitute was used in 36 studies (1,210 patients, 4,128 implants).[3]

The mean subantral bone heights for the two groups were 3.3 mm and 4.0 mm, respectively. For two-stage procedures, the mean healing times before implant placement were 6.6 months and 5.6 months, respectively. In the bone substitute only group, survival rates after 12 to 107 months of loading were 82% to 100% (mean: 96.3%; median: 97.5%). By comparison, the survival rates in the autograft group were 61.2% to 100% (mean: 92.0%; median: 94.4%) after up to 60 months of loading. Excluding studies using smoothsurface implants, survival rates were 88.6% to 100% (mean: 96.6%; median: 96.8%) with a bone substitute alone after up to 42 months of loading, compared to 96% to 100% (mean: 99.4%; median: 100%) when particulated autograft material was included after up to 60 months of loading.

Eight grafting protocols for sinus floor elevation were documented in three or more studies.

Deproteinized bovine bone mineral (DBBM) only was used for sinus floor elevation in 11 studies (565 patients, 1,771 implants).[4]

The initial bone height was reported in 4 of these studies with an average of 2.8 mm (70 patients, 215 implants).

Survival rates after 12 to 68 months in function were 85% to 100% (mean: 96.2%; median: 97%).

DBBM and particulated autograft material were used in another 11 studies.[5]

However, 4 studies reported on the same pool of patients at different times (Hallman et al. 2001, 2002a, 2004, 2005). Therefore, only clinical data from the latest follow-up were included (Hallman et al. 2005). There were 411 patients receiving 1,061 implants. Initial ridge height was presented as an average of 4.4 mm for 5 patient pools. Survival rates were 89% to 100% (mean: 95.6%; median: 94.9%) with a follow-up of 12 to 60 months after loading.

Autologous block grafts were used for augmenting the maxillary sinus in 10 studies, all harvested from the iliac crest.[6]

In 5 studies (155 patients), 560 implants were placed simultaneously with the grafting procedure, whereas 4 studies (85 patients, 351 implants) documented a staged approach (1 study did not differentiate between staged and simultaneous implant placement). The overall survival rates after up to 58 months in function were 61.2% to 94.4% (mean: 83.5%; median: 84.9%). For simultaneous and staged implant placements in autologous bone blocks, the corresponding survival rates were 61.2% to 92.2% (mean: 78.7%; median: 79%) and 76.9% to 94.4% (mean: 87.4%; median: 89.1%), respectively.

Data on sinus floor elevations using particulated autografts from different donor sites was presented in 7 studies (205 patients, 850 implants).[7]

The survival rates after 12 to 54 months of loading were 82.4% to 100% (mean: 95.1%: median: 99.5%).

A composite graft consisting of particulated autograft and allograft was presented in 4 studies on 94 patients with 338 implants (2 studies did not report the number of patients; Peleg et al. 1998; Mazor et al. 1999; Peleg et al. 1999; Kan et al. 2002). All 4 studies reported 100% survival rates after loading for up to 42 months.[8]

Alloplastic particulate in the form of hydroxyapatite was used as grafting material for sinus floor elevation in 3 studies by the same group (56 patients, 135 implants; Mangano et al. 2003, 2006, 2007). After up to 36 months in function, survival rates were 96% to 100% (mean: 98.7%; median: 100%).[9]

A combination of DFDBA and DBBM was used in 3 studies (Valentini and Abensur 1997; Kan et al. 2002; Valentini and Abensur 2003) reporting on the augmentation of 113 maxillary sinuses (the number of patients was not reported by Kan et al.) and the placement of 283 implants. After up to 107 months in function, survival rates were 82.1% to 96.8% (mean: 90.1%; median: 90.7%).[10]

Three case series (63 patients, 110 implants) presented data on sinus floor elevation without grafting material. Instead, the simultaneously placed implants acted as tent poles for the elevated Schneiderian membrane, allowing a coagulum to occupy the space created (Lundgren et al. 2004; Chen et al. 2007; Thor et al. 2007). After 12 to 27.5 months of loading, survival rates were 97.7% to 100% (mean: 99.2%; median: 100%).[11]

Membrane over lateral window

A barrier membrane was used to cover the lateral window in 16 studies (660 patients, 1975 implants).[12]

No membrane was used in 28 studies (1,020 patients, 3,185 implants).[13]

Survival rates with and without the use of a membrane were 92% to 100% (mean: 97.8%; median: 99.1%) and 61.2% to 100% (mean: 92.9%; median: 94.9%) after loading periods of up to 60 and 107 months, respectively. Excluding studies using smooth surface implants, survival rates were 92% to 100% (mean: 98.5%; median: 100%) with a barrier membrane after up to 60 months of loading compared to 93% to 100% (mean: 98.5%; median: 100%) without a membrane after up to 36 months of loading.

Complications

Perforation of the Schneiderian membrane was the most common intraoperative complication and was reported in 10% to 20% of the cases (range: 0% to 58%; Pjetursson et al. 2008; Chiapasco et al. 2009). The procedure had to be aborted due to the size of the perforation in less than 1% of the cases. A few studies demonstrated a correlation between the size of the perforation and subsequent implant loss, while others failed to observe this link. Other intraoperative complications, including excessive bleeding, displacement of implant or grafting material into the sinus cavity, and damage to the infraorbital nerve were reported in only a few cases. Postoperative infectious complications were reported in 3% of the cases, with partial or complete loss of the grafting material in less than 1% of the cases. Wound dehiscence is another, less commonly reported postoperative complication.

2.3.2Maxillary Sinus Floor Elevation – Transcrestal Technique

Implant survival

The transcrestal elevation of the sinus floor (also referred to as the osteotome technique) was documented in 18 studies.[14]

The number of implants placed was 1,744, in 1,096 patients. The survival rates were 83% to 100% (mean: 95.9%; median: 97.3%) after 12 to 64 months of prosthetic loading (mean: 27.1 months; median: 24 months).

Subantral bone height

The mean initial subantral bone height was reported in 14 studies with a mean of 6.4 mm. All studies but one (Stavropoulos et al. 2007) placed the implants simultaneously with transcrestal sinus floor elevation.[15]

Grafting protocol

Results after elevating the sinus floor without grafting material in 249 patients (443 implants) with a mean initial bone height of 5.8 mm were reported in 8 studies.[16] Survival rates were 91.4% to 100% (mean: 95.6%; median: 96.5%) after 12 to 36 months of loading (mean: 23.3 months; median: 23 months).

DBBM only was used as grafting material in 4 studies (Zitzmann and Schärer 1998; Deporter et al. 2005; Rodoni et al. 2005; Krennmair et al. 2007) on 122 patients with a mean initial bone height of 7.5 mm, in whom 195 implants were placed. Survival rates were 95% to 100% (median: 99%) after a follow-up period of 12 to 45 months after loading.[17]

The highest number of patients (489) was grafted with autologous bone in which 771 implants were placed in subantral bone with a mean initial height of 6.6 mm and followed for 20 to 54 months after loading (Fugazzotto and De Paoli 2002; Ferrigno et al. 2006). Survival rates were 93.8% to 97.8% (median: 94.8%).[18]

3	Preoperative Assessment and Planning for Sinus Floor Elevation Procedures
	S. S. Jensen, H. Katsuyama

Careful patient selection is critical to the long-term success of implant treatment in cases requiring sinus floor elevation (SFE). For proper evaluation, clinicians need in-depth knowledge of the anatomy both of the maxillary sinus with its adjacent structures and of the pattern of bone modeling that takes place after tooth extraction. Relevant aspects of each medical history need to be assessed to determine the patient’s suitability for SFE. There is a need for clinicians to understand in detail the indications and contraindications, the various treatment options available, and the implications of different radiographic techniques. Only with this information can they select appropriate cases for treatment and consider non-grafting alternatives to SFE.

3.1

Anatomy

Fig 1aFrontal view of the maxillary sinus.

Fig 1bLateral view of the maxillary sinus with limited extension of the sinus floor in an anterior and inferior direction.

Fig 1cLateral view of the maxillary sinus with the sinus floor extending around the apices of the maxillary molars and second premolar.

Fig 2Panoramic radiograph showing the maxillary sinus bilaterally extending to the regions of the central incisors.

The maxillary sinus is a pyramid-shaped cavity within the maxillary bone (Figs 1a-c)

The base of this pyramid is formed by the lateral nasal wall and the tip within the maxillary zygomatic buttress. The roof (i.e. the cranial wall) of the maxillary sinus is also the floor of the orbit and accommodates the infraorbital canal. A communication with the nasal cavity (the semilunar hiatus) is located in the posterosuperior area of the sinus cavity just below the concha nasalis media. To minimize the risk of postoperative infective complications, this communication should be kept intact and clear of any grafting material. Anteriorly, the maxillary sinus will normally extend to the canine or premolar region, although this may vary considerably (Fig 2).

The sinus floor will usually take a downward convex route with the deepest point in the first-molar region. The cavity does not occupy any significant space before the permanent teeth erupt and becomes increasingly larger throughout life. Ongoing pneumatization is seen throughout adolescence, and secondary pneumatization may follow the loss of posterior maxillary teeth. Conical elevations projecting into the cavity, reflecting the roots of the maxillary molars and premolars, are frequently observed. Bony walls or septa may project into the cavity from the sinus floor and lateral wall (Figs 3a-b).

Fig 3aPanoramic radiograph of an edentulous patient with bilateral septa in the posterior third of the maxillary sinus.

Fig 3bCoronal section of a CT scan of the same patient confirming the presence of septa. At this level, the septae completely divide the sinus into two compartments in the orofacial dimension.

In fact, septa may divide the entire sinus into two or more almost completely separated entities. Their incidence varies between 16% and 58%, most commonly taking the form of a single unilateral septum (Koymen et al. 2009). Septa are classified as primary or secondary, the former being developmental in nature, while the latter are caused by irregular pneumatization following the loss of posterior teeth. It is essential that any irregularities of the maxillary sinus floor be identified preoperatively, as such irregularities will increase the risk of sinus membrane perforation during surgery.

The mucosal lining of the maxillary sinus (also known as the sinus or Schneiderian membrane) consists of normal ciliated respiratory epithelium covering a thin layer of connective tissue. It ranges in thickness between 0.45 and 1.40 mm. As a thin membrane increases the risk of intraoperative perforation, any preoperative findings that can help predict membrane thickness are potentially useful when preparing for the surgical procedure. A number of factors are commonly associated with increased membrane thickness: thick gingival biotype and a history of chronic sinus inflammation. In contrast, smokers tend to have reduced membrane thickness (Aimetti et al. 2008; Hadar et al. 2009). SFE procedures are contraindicated if membrane thickness is increased due to existing sinus pathology (e.g. sinusitis or mucosal cysts). Conditions of this type should be treated in a separate session before the procedure.

The lateral bony wall of the maxillary sinus may also vary considerably in thickness. The normal range is between 0.5 and 2.5 mm, with values generally being somewhat higher in men than women (Neiva et al. 2004; Yang et al. 2009). Preoperatively, this information can only be obtained from coronal sections of a cone-beam or traditional CT scan.

Illustrations:	Ute Drewes, CH-Basel, www.drewes.ch
Copyediting:	Triacom Dental, D-Barendorf, www.dental.triacom.com
Graphic Concept:	Wirz Corporate AG, CH-Zurich
Production:	Juliane Richter, D-Berlin

1	Introduction H. Katsuyama, S. S. Jensen
2	Proceedings of the 4th ITI Consensus Conference and Literature Review: Sinus Floor Elevation Procedures
2.1	Consensus Statements
2.2	Proposed Clinical Approaches
2.3	Literature Review S. S. Jensen
2.3.1	Maxillary Sinus Floor Elevation – Lateral Window Technique
2.3.2	Maxillary Sinus Floor Elevation – Transcrestal Technique
3	Preoperative Assessment and Planning for Sinus Floor Elevation Procedures S. S. Jensen, H. Katsuyama
3.1	Anatomy
3.2	Medical History
3.2.1	General Health Status
3.2.2	Concomitant Medications
3.2.3	Allergies
3.2.4	Tobacco and Alcohol
3.2.5	Compliance
3.3	Clinical Examination
3.3.1	Indications and Contraindications for SFE
3.3.2	Local Risk Factors
3.3.3	Informed Consent
3.4	Radiography, Cone-Beam CT, and Conventional CT for Implant Treatment Involving the Maxillary Sinus
3.4.1	Radiographic Techniques and Radiation Exposure
3.4.2	Characteristics of Various Examination Techniques
3.4.3	Clinical Application of CT Images
3.5	Non-Grafting Alternatives to SFE
3.5.1	Short Implants
3.5.2	Angled/Tilted Implants
3.5.3	Zygomatic Implants
3.6	Lateral Window Versus Transcrestal SFE
3.7	Simultaneous Versus Staged SFE
4	Treatment Options for Sinus Floor Elevation H. Katsuyama, S. S. Jensen
4.1	Diagnosis and Treatment Planning
4.1.1	Diagnosis
4.1.2	Classification and Treatment Options
4.2	Materials and Instrumentation
4.2.1	Instrumentation for SFE
4.2.2	Biomaterials
4.2.3	Implant Design
4.3	Surgical Techniques
4.3.1	Transcrestal Technique
4.3.2	Lateral Window Technique
4.3.3	Timetable
4.3.4	Harvesting Site
4.3.5	Managing Septa and Compromised Cases
5	Guidelines for Choosing the Surgical Technique and Grafting Protocol for Sinus Floor Elevation S. S. Jensen
6	Clinical Case Presentations
Transcrestal Protocols
6.1	Implant Placement with Simultaneous SFE: Transcrestal Technique with DBBM S. S. Jensen
6.2	Implant Placement with Simultaneous SFE: Transcrestal Technique with DBBM B. E. Pjetursson
Lateral Window Protocols
6.3	Implant Placement with Simultaneous SFE: Lateral Window Technique with a Composite Graft V. Chappius
6.4	Bilateral Implant Placement with Simultaneous SFE: Lateral Window Technique with a Composite Graft A. Tahmaseb
6.5	SFE with BCP using a Staged Approach C. ten Bruggenkate
6.6	SFE with a Composite Graft using a Combined Simultaneous and Staged Approach ... D. Buser
6.7	Bilateral SFE with Transcrestal and Lateral Window Technique using Various Composite Grafts R. A. Levine
6.8	SFE with a Composite Graft using a Staged Approach P. Casentini
6.9	Combined SFE and Horizontal Ridge Augmentation with Autologous Block Grafts, BCP, and GBR using a Staged Approach L. Cordaro
6.10	SFE with Particulated Autografts Combined with Vertical Ridge Augmentation using Onlay Block Grafts and a Staged Approach W. D. Polido, E. Marini
6.11	Bilateral SFE in the Edentulous Maxilla with DBBM using a Staged Approach S. Umanjec-Korac
6.12	SFE with Particulated Autografts Combined with Vertical Ridge Augmentation using Onlay Grafts and a Staged Approach T. W. Head
6.13	SFE with a Composite Graft Combined with Vertical Ridge Augmentation using Onlay Grafts and a Staged Approach M. Chiapasco
7	Complications with Sinus Floor Elevation Procedures H. Katsuyama
7.1	Intraoperative Complications
7.2	Postoperative Complications
7.3	Case Presentations of Failures and Complications
7.3.1	Membrane Perforation E. Lewis
7.3.2	Soft Tissue Dehiscence and Correction after SFE with Vertical and Horizontal Bone Grafting H. Katsuyama
7.3.3	Sinusitis after Undetected Membrane Perforation during Surgery H. Katsuyama
7.3.4	Bilateral Sinus Infection after Perforation due to Residual Non-resorbable Barrier Fragments H. Katsuyama
7.3.5	Implant Loss due to Unsuccessful Osseointegration H. Katsuyama
7.4	Conclusions
8	References
8.1	References for Literature Review (Chapter 2.3)
8.2	Literature/References

Preface

Acknowledgment

Editors and Authors

Contributors

Table of Contents

Maxillary sinus floor elevation using the transcrestal technique

Maxillary sinus floor elevation using the lateral window technique

Maxillary sinus floor elevation using the transcrestal technique

Maxillary sinus floor elevation using the lateral window technique

S. S. Jensen, H. Katsuyama

Stephen Chen	Daniel Buser	Daniel Wismeijer