Journal of Oral Rehabilitation

Journal of Oral Rehabilitation 2012 39; 226–238

Review Article
Prognosis of implants and fixed restorations after lateral sinus
elevation: a literature review
T. TUNA*, M. YORGIDIS† & J. R. STRUB* *Department of Prosthodontics, Albert-Ludwigs-University, Freiburg
and †School of Dentistry, Albert-Ludwigs-University, Freiburg, Germany

SUMMARY Aim of this review was to investigate the rates were between 75% and 100%, and survival
prognosis of implants inserted in augmented sinuses rates of single crowns, splinted crowns and fixed
and fixed restorations supported by these implants. partial dentures ranged between 96Æ4% and 100%
Special attention was given to the impact of grafting after a follow-up of 12–101 months. Within the
material, time of implant placement, residual bone limits of this review, the prognosis of implants and
height and type of fixed restoration. An electronic fixed restorations seemed not to be influenced by
search in PubMed, the German database medpilot the type of restorations, graft material, residual
and the Cochrane Library was executed followed by bone height and time of implant placement. How-
supplementary manual search in relevant journals. ever, conclusions of this review are based on studies
The search was limited to human studies published with low level of evidence; therefore, careful inter-
up to November 2010. Only publications in English pretation is required. Multicentre randomised con-
and German, in peer-reviewed journals, were con- trolled clinical trials with sufficient statistical power
sidered. After the initial search and application of concentrating on few factors are needed to reach
selection criteria on titles and abstracts, a full-text sound conclusions.
analysis of 67 articles was performed, out of which KEYWORDS: fixed prosthodontics, implant-supported
six prospective and three retrospective studies were fixed restorations, crown, fixed partial denture, oral
finally included in the review. The heterogeneous implant, sinus augmentation, sinus lift, sinus eleva-
properties of the identified articles did not allow tion, sinus graft
systematic analysis of the data. Success rates of
implants were between 96Æ3% and 100%, survival Accepted for publication 6 August 2011

There is a variety of modifications related to surgical

Introduction
technique, and the use of grafting materials related to
Tooth loss in the posterior maxilla is a major reason for the sinus lift procedure (2–7). In general, the imple-
severe horizontal and vertical atrophy of the alveolar mented surgical methods can be divided into two main
ridge and increased pneumatisation of the sinuses. techniques (8): the lateral window technique (1, 9) and
Sinus augmentation, a surgical grafting procedure the crestal osteotome sinus floor elevation technique
introduced in the late 1970s (1), enables the rebuilding (10–13).
of the lost bone volume and placement of oral implants, Concerning the lateral window technique, a window
to support prosthetic restorations. The design of the is prepared into the lateral wall of the sinus after creating
restoration can be either fixed, including single crowns, a mucoperiosteal flap on the buccal site of the sinus.
splinted crowns and fixed partial dentures (FPDs), or After elevation of the Schneiderian membrane, a sinus
removable, including overdentures retained with di- cavity is created and filled with graft material. This
verse anchoring attachment modalities. concept can be combined with simultaneous implant

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 PROGNOSIS OF FIXED IMPLANT RESTORATIONS 227

placement, the so called one-stage procedure, or with technique (4–7) as well as the clinical outcome of the
delayed implant placement after healing of the grafted respective implant-supported restorations is poorly
sinus, which is called the two-stage procedure (4). It is documented.
generally reported that simultaneous implant placement Therefore, the aim of this review was to investigate
requires at least 4–5 mm of residual bone height (14– the prognosis of implants inserted in augmented sinuses
18). The osteotome technique involves the elevation of and the fixed restorations supported by these implants.
the sinus floor via crestal approach. A channel is drilled Special attention was given to the impact of the grafting
into the bone until a short bony distance to the sinus material, the time of implant placement, the residual
membrane is achieved. Graft material is plugged by bone height and the type of fixed restoration.
special designed osteotome instruments through the
channel so that the undrilled slim bone area prior to the
Materials and methods
sinus membrane is pushed into the sinus, which is being
elevated successively (4). A residual bone height of at A literature search with a specific set of inclusion and
least 5–6 mm is required according to the literature (3, exclusion criteria was undertaken to identify articles
10). In comparison with the lateral technique, this evaluating the outcome of implants and their fixed
approach is less invasive, requires less graft material and restorations in augmented sinuses.
is associated with reduced operative time and post-
operative discomfort (8).
Search strategy
Various graft materials have been implemented for
sinus augmentation, including the autogenous bone, An electronic search through MEDLINE (PubMed), the
allografts, xenografts, alloplasts or combinations of German database medpilot and the Cochrane Library
them (7). Autogenous bone is harvested from the including studies in the dental literature published from
same individual. It counts as gold standard for sinus 1970 to November 2010 was executed. Only publica-
augmentation owing to its osteoinductive and osteo- tions in English and German in peer-reviewed journals
conductive properties that are considered to promote were considered. Following keywords and their com-
fast healing (2, 4, 19). Autogenous bone can be binations were used: sinus lift, sinus graft, sinus
harvested from intraoral sites such as chin or ramus, augmentation, sinus elevation, sinus floor lift, sinus
but in a limited amount, or from extraoral sites, such floor graft, sinus floor augmentation, sinus floor eleva-
as iliac crest or tibia offering more bone quantity. tion, fixed reconstruction or crown or fixed partial
However, this involves a more complex surgical treat- denture, oral implant or endosseous implant, elevation
ment of the patient under general anaesthesia and or augmentation or graft, or lift or bone graft or bone
higher morbidity and scarring of the patients at the transplant or bone remodel, sinus or sinus floor or
donor sites (4). maxillary sinus or maxillary antrum or alveolar ridge.
Allograft material is bone material of the same species For German publications, combinations of search terms
tissue but from another person (4). The bone is like ‘Sinuslift’, ‘Implantat’, ‘Maxilla’, ‘Krone’ and
prepared by either freeze-drying or irradiation and ‘Brücke’ were used. In addition, a supplementary
sterilisation. Xenograft is from other species tissue, e.g. manual search was carried out on high-yield journals.
of bovine origin. Alloplast materials are synthetic bone Subsequently, the reference lists of articles selected for
substitutes consisting of molecules similar to that of inclusion in this review were screened.
human bone. Their structures vary in consistence and
porosity. All graft materials can be used as particular
Inclusion criteria
pieces or in the form of blocks (4).
Although sinus augmentation is a very frequently Eligible for this review were clinical studies on humans
used procedure (6, 20), it has been debated that with a minimum number of 10 patients, prospective
qualitatively satisfying and sufficient long-term clinical studies, retrospective studies, randomised controlled
evidence provided from randomised controlled clinical studies, controlled clinical trials or comparative studies
trials is lacking regarding performance of oral implants reporting on success and survival rates of implants in
placed in augmented sinuses. In particular, the clinical augmented sinuses using the lateral window technique
outcome of implants placed using the lateral window and fixed restorations.

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228 T . T U N A et al.

Table 1. Excluded studies and reasons for exclusion

Exclusion criteria

Excluded studies were in vitro studies, animal studies Combined Missing

success & success ⁄
and case reports. In addition, studies reporting on the
survival rates survival No
osteotomy technique, onlay grafts and on immediately of various rates of restorations
loaded implants or implants supporting removable No. Author restorations restorations mentioned
restorations were not considered.
1 Johansson x
et al. (40)
2 Garlini et al. (41) x
Study selection and data extraction
3 Bae et al. (42) x
The obtained titles and abstracts of the electronic and 4 Tetsch et al. (43) x x
5 Ferreira x x
manual search were screened and evaluated for eligi-
et al. (44)
bility according to the inclusion and exclusion criteria.
6 Ferri et al. (45) x
Studies not meeting the inclusion criteria were 7 Bornstein x
excluded from further evaluation. Upon identification et al. (46)
of abstracts for possible inclusion, the full reports were 8 Kahnberg x
obtained and assessed independently. Disagreements et al. (47)
9 Minichetti x
were resolved by an inter-reviewer discussion. At the
et al. (48)
same stage, the search was narrowed by excluding 10 Cannizaro x x
studies with inadequate data on survival rates of the et al. (49)
restorations and studies reporting on combined survival 11 Peleg et al. (50) x x
rates of different prosthetic treatment options on 12 Lindenmuller and x x
Lambrecht (51)
implants. Articles that were excluded through the
13 Karabuda x
application of these criteria were listed in the table of
et al.(52)
excluded studies (Table 1), and reasons for exclusion 14 Herzberg x x
were recorded. et al. (53)
Reports considered to fulfil all inclusion criteria were 15 Tetsch et Tetsch x x
analysed, and obtained data were included in a data (54)
16 Zijderfeld et al. x x
extraction form (Table 2). Recorded variables were the
(55)
author names, the year of publication, the study design, 17 Maiorana x x
the number of patients and number of inserted et al. (56)
implants, the type of graft material, the time of implant 18 Wallace x
placement, the residual bone height, the healing time et al. (57)
19 Sjöström x x
of implants, the observation time of loaded implants,
et al. (58)
the type of denture and the success and survival rates of
20 Leick et al. (59) x
implants and their fixed restoration. 21 Wiltfang x x
For further evaluation of the results of the identified et al. (60)
studies, success and survival rates of implants and fixed 22 Schlegel x
restorations were examined related to the aspects graft et al. (61)
23 Shlomi x x
material, time of implant placement, residual bone
et al. (62)
height and type of fixed restoration. 24 Becktor x
et al. (63)
25 Iturriaga and x
Results Ruiz (64)
26 Hallmann and x
The initial search resulted in 4352 titles. After screening
Nordin (65)
the titles and abstracts, 67 articles were selected for full-
27 Lundgren x x
text analysis. Finally, nine publications (21–29) fulfilled et al. (66)
the inclusion criteria (Table 2). Eight of these were case
studies, three of them being retrospective (21, 26, 28)

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 PROGNOSIS OF FIXED IMPLANT RESTORATIONS 229

Table 1. (Continued) Table 1. (Continued)

Combined Missing Combined Missing

success & success ⁄ success & success ⁄
survival rates survival No survival rates survival No
of various rates of restorations of various rates of restorations
No. Author restorations restorations mentioned No. Author restorations restorations mentioned

28 Stricker x 56 Chiapasco and x x

et al. (67) Ronchi (93)
29 Pinholt (68) x 57 Keller et al. (94) x x
30 Rodriguez x x 58 Small et al. (95) x
et al. (69)
31 Mangano x
et al. (70) and five prospective (22–24, 27, 29). One study was a
32 Valentini x x
prospective comparative study (25). No randomised
et al. (71)
33 Hallman x x
controlled clinical trials were identified.
et al. (72) Main focus of eight articles was to evaluate the
34 Kan et al. (73) x clinical outcome of implants placed in augmented
35 Tawil et Mawla x x sinuses (21–25, 27–29). Apart from the implant out-
(74) come, seven studies evaluated the outcome of the
36 Raghoebar x
implant-supported restorations such as splinted crowns
et al. (75)
37 Hising et al. (76) x and ⁄ or FPDs (21–26, 28). Two studies investigated the
38 Kahnberg x outcome of single implants in augmented sinuses and
et al.(77) their single crown restorations (26, 27). Additionally,
39 Engelke (78) x several studies dealt with the radiologic evaluation of
40 Valentini x x
the bone stability around implants (21, 23–25) and ⁄ or
et al. (79)
41 Wannfors x x
the histology of bone grafts (22, 28).
et al. (80) Four of the identified articles were using life table
42 Olson et al. (81) x x analysis to demonstrate cumulative survival or success
43 Maiorana x x rates of implants (21, 23–25) and restorations (25). In
et al. (82) several cases, restorations’ survivals were reported very
44 Lorenzoni x x
briefly (21, 22, 27–29). In three articles, authors were
et al. (83)
45 Peleg et al. (14) x x focusing mainly on the description of the treatment
46 Johansson x process, particularly the surgical (27, 28) and the
et al. (84) restorative technique (29). All studies showed a variety
47 Khoury x x of considerable differences in graft materials used,
et al. (85)
residual crestal bone height and type of fixed restora-
48 Raghoebar x
et al. (86)
tions.
49 van den Bergh x One study reported on the use of autogenous bone
et al. (87) as graft material alone (21). Seven studies used
50 Zitzmann and x x mixtures of autogenous bone with either xenograft
Scharer (18) bone (23, 24, 26), or allograft bone (27, 28), or
51 Watzek et al. x x
allograft bone and alloplastic material (29) or allo-
(88)
52 Block and x plastic material alone (22). Another study used five
Kent (89) different materials or combinations of materials such
53 Raghoebar x x as xenograft, alloplast, combinations of xenograft with
et al. (90) alloplast, alloplast with autogenous bone from the
54 Wheeler et al. (91) x x
iliac crest or alloplast with autogenous bone from
55 Triplett and x x
Schow (92)
the chin (Table 2) (25). The authors of this study
could not find any statistical difference in treatment

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Table 2. Success and survival rates of implants and fixed restorations

T . T U N A et al.

Follow-up Success Survival Success Survival

Time of Pre-operative Healing of loaded rate rate rate fixed rate fixed
Study No. of No. of Augmentation implant residual bone period implants Type of implants implants restoration restoration
No. Author design patients implants material placement height, (mm) (month) (month) denture (%) (%) (%) (%)

1 Becktor RS 5 12 Corticocancellous bone 1 £5 6–12 29–101 B NR 75 NR 100

et al. (21) 12 36 block of the iliac crest 2 94Æ4
2 Hallman and PS 20 79 80% Bio-Oss & 20% 2 <5 6–8 60 B NR 88Æ6 NR 96Æ4
Zetterqvist autogenous bone from
(24) chin mixed with fibrin
glue (4:1)
3 Hallman PS 20 79 2 <5 6–8 12 B NR 92Æ4 NR 100
et al. (23)
4 Cordioli PS 12 27 Bioactive glass 1 £5 9–12 12 B 96Æ3 96Æ3 NR 100
et al. (22) (Biogran!) &
autogenous bone (4:1)
5 Peleg et al. RS 20 55 Demineralised 1 <5 9 15–39 B NR 100 NR 100
(28) freeze-dried bone
allograft (DFDBA) &
autogenous bone (1:1)
6 Zinner and PS 50 215 Mixture of 1 <5 9 60 B NR 98Æ6 NR 100
Small (29) demineralised
freeze-dried cortical
bone powder with
porous non-resorbable
hydroxyapatite
[Interpore 200] (1:1)
& corticocancellous
bone from maxillary
tuberosity and ⁄ or
mandibular symphysis
& surgical site

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 Table 2. (Continued)

Follow-up Success Survival Success Survival

Time of Pre-operative Healing of loaded rate rate rate fixed rate fixed

ª 2011 Blackwell Publishing Ltd

Study No. of No. of Augmentation implant residual bone period implants Type of implants implants restoration restoration
No. Author design patients implants material placement height, (mm) (month) (month) denture (%) (%) (%) (%)

7 Hürzeler PS 133 235 5 groups: Bio-Oss only 1 <4 6 12–60 B 95Æ2 98Æ8 100 100
et al. (25) 105 Allogen (Interpore) 2 4–6 88Æ3
only Bio-Oss & 6–8 72Æ4
Interpore (1:1) >8 65Æ1
Interpore & CSR: 90Æ3
autogenous bone from
iliac crest (1:3)
Interpore mixed with
bone from chin (1:1)
8 Krennmair RS 25 28 Bio-Oss & mixture of 1 >5 6–9 44Æ5 A NR 100 NR 100
et al. (26) 12 12 autogenous bone graft 2 £5 100 NR
(from maxillary
tuberosity and ⁄ or
collected bone
particles from drilling)
9 Mazor et al. PS 10 10 Demineralised 1 ‡5 9 36 A 100 NR NR 100
(27) freeze-dried cortical
bone powder [DFDB]
& autograft from
maxillary
tuberosity (1:1)

Abbreviations and trademarks for Tables 1–2: PS, prospective study; RS, retrospective study; 1, one-stage; two, two-stage; A, single crowns; B, fixed partial dentures, C, splinted
crowns; CSR, cumulative success rate; NR, not reported.; Bio-Oss (Geistlich, Wohlhusen, Switzerland), bioactive glass: Biogran! (Orthovita, Malvern, PA, USA), demineralised
freeze-dried bone allograft: DFDBA (Pacific Coast Tissue Bank, Los Angeles, CA, USA), demineralised freeze-dried cortical bone (University of Miami Bone Bank), non-resorbable
hydroxyapatite: Interpore 200 (Interpore International, Irvine, CA, USA).
PROGNOSIS OF FIXED IMPLANT RESTORATIONS
231
232 T . T U N A et al.

outcome between the uses of various types of graft (26). These events were described as minor complica-
material. tions, but success rates or even criteria for success were
In four studies, implants were placed simultaneously not provided. The survival rates of implants and
to sinus augmentation (22, 27–29). In three of them, restorations in that study were reported 100%.
residual bone height was <5 mm (22, 28, 29). In two Altogether, eight studies presented 100% survival of
studies, which were reporting on the same patient the fixed prosthetic restorations including two studies
groups, but with different follow-up times, implants on implant-supported single crowns (26, 27) and six
were placed at a second-stage surgery after sinus studies on implant-supported splinted crowns and ⁄ or
augmentation (23, 24). Residual bone height in these implant-supported FPDs (21–23, 25, 28, 29). Only one
two studies was <5 mm. study reported a survival rate of 96Æ4% of implant-
In three studies, both one- and two-stage procedures supported FPDs and ⁄ or implant-supported splinted
were conducted (21, 25, 26). The residual bone heights crowns after 60-month follow-up (24).
varied; for example, in one of these studies, residual Other considerable differences in study design could
bone height was <5 mm (21), and in another study, the be detected in patient numbers, healing and follow-up
one-stage procedure was used when bone height was times, the use (22, 25–29) and non-use (21, 23, 24) of
higher than 5 mm and the two-stage procedure when different types of membranes to cover the buccal
bone height was <5 mm (26). The authors of the third window of the sinus, the type of used implants, implant
study divided the residual bone height into four groups: surfaces, implant lengths and patient selection: smokers
up to 4, 4–6, 6–8 and more than 8 mm (25). The time of or patients with history of smoking were included in
implant placement depended on the availability of three investigations (23, 24, 29) and excluded in one
primary stability. There were no statistically significant study (22). In contrast, other studies did not report on
differences in terms of implant survival (21, 26) and smoking habits (21, 25–28). One study included
success (21) using the one- and two-stage approaches. patients with partially dentate maxillae alone, three
Also, the success rates of implants were not influenced studies included partially and fully edentulous patients,
by the residual bone height according to one research two studies did not differentiate between partially
group (25). Further variations in study design, data dentate and fully edentulous maxillae and two studies
reporting and the criteria used for reporting reported on single implants. Owing to such heteroge-
implant ⁄ restoration success ⁄ survival could be found neity in the design of the different studies, it was not
among the studies. possible to perform a statistical analysis of the data.
Four studies presented success rates of implants (22,
25, 27, 28), out of which one was not taken into
Discussion
consideration as the data referred to the time of
abutment connection surgery and not to the end of Several reviews have evaluated the outcome of sinus
the follow-up of prosthetic loading (28). The lowest lift procedure and implant rehabilitation. However, the
success rate of implants was 96Æ3% after 12 months clinical outcome of the implant-supported restorations,
(22), and the highest rate was 100% after 36 months which is the major concern of the patient, has not been
(27). extensively examined so far. Therefore, the purpose of
Eight studies reported on survival rates of implants this literature review was to investigate the prognosis of
(21–25, 27–29). The lowest survival rate of implants implants inserted in augmented sinuses and the fixed
was 75% after 29–101 months (21), and the highest restorations supported by these implants. Furthermore,
rate was 100% after 15–39 (28) or 44Æ5 months (26). the influence of the type of graft material, the time of
Only one study provided data about success rates of implant placement, the degree of residual bone height
prosthetic treatment (25). The authors of that investi- and the type of fixed restoration on the success and
gation reported 100% success because no fixed pros- survival rates has been critically evaluated.
theses were lost during the entire follow-up period, The nine identified studies of the present review
misquoting the survival rate as success rate (25). showed high implant success rates (90Æ3–100%),
Data like crown loosening owing to cement washout implant survival rates (75–100%) and restoration sur-
(7Æ4%), abutment screw loosening (5Æ5%) and porce- vival rates (96Æ4–100%), although surgical methods,
lain fracture (3Æ7%) were reported in another study graft materials, anatomic circumstances or the types of

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 PROGNOSIS OF FIXED IMPLANT RESTORATIONS 233

restorations and their manufacturing techniques varied Unfortunately, no controlled studies were found using
considerably in the identified studies (Table 2). Pros- split mouth designs to compare the outcomes of single
thetic rehabilitation on implants placed in augmented crowns and splinted crowns or FPDs.
sinuses was considered a predictable treatment modal- A noticeable observation was that in the majority of
ity (22, 26) with good short- and long-term results for the identified studies (21–25, 29), authors reported
single crowns (26, 27) and splinted crowns or FPDs (21– implant failures, most of them occurring before pros-
25, 28, 29). thetic loading (21, 23, 24, 29) or during the prosthetic
However, it should be taken into consideration that phase (22). These failure events were attributed to poor
all treatments have been implemented in institutional patient compliance regarding smoking habits (23, 24)
environments like universities or specialists’ clinics. It or post-operative instructions, e.g. early wearing of the
would be wrong to generalise such results to the daily interim removable partial dentures after surgery caus-
work of a routine private practice (2). Another possible ing pressure and subsequent micro movements of the
explanation for such positive results can be publication underlying implants (29). Denture stability, fit, occlu-
bias (30) which means that studies with positive results sion, bite force and opposing dentition bearing an
are published in the literature while negative results are overload of the bone graft and submerged implants
being retained. were other potential reasons for early failures in grafted
Comparing the outcomes of the present review with patients (21). Partially dentate patients who did not
other reviews that have been published mostly relating wear dentures during the healing phase might have less
to outcome of implants in augmented sinuses, similar failure risk in comparison with edentulous patients
good findings in implant survival (between 81% and because of the use of a temporary prosthesis during the
95Æ6%) could be observed (2–8, 19, 31). healing period (21).
In the identified studies of the present review, a In contrast to the incidence of implant failures prior
surprising finding was that the survival of fixed resto- to prosthetic loading, the incidence of implant failures
rations was generally higher than the survival of after prosthetic loading decreased (22–24, 29). In one
implants (Table 2; 21–23, 25, 29). Apparently, the study where further implant loss after prosthetic load-
more abutments ⁄ implants used to support the fixed ing was observed, the impact of smoking was discussed
restoration, the less is the risk of failure of the as an important factor. However, the authors had to
restoration once an implant is lost. relativise the influence of smoking because 45% of
In terms of splinted crowns and FPDs, only one study their patients were smokers and only two of them lost
defined the types of superstructures and classified them 10 from altogether 15 of the failed implants in the
into four groups depending on the type and position of whole patient sample (23, 24).
abutments (25). Accordingly, abutments of a restora- According to the good survival and success data of
tion were supported by implants either in the aug- implants and fixed restorations in each of the nine
mented sinus alone, implants in the augmented sinus identified studies, all kind of graft materials seemed to
combined with natural teeth in or outside the grafted provide good function for implant placement and
area, as well as implants with implants outside the prosthetic loading in grafted sinuses. A 5-year investi-
grafted region, yielding 51Æ3%, 84%, 100% and 71% gation with a sample size of 340 implants in 133
estimated 5-year success rates, respectively (25). patients and the use of five different grafting materials
Despite the considerable differences, the authors or combinations (25) reported similarly high success
concluded that the type of superstructure had no effect rates for implants, which are in agreement with the
on treatment failure in their study (25). previous published studies on implants placed in non-
It has been suggested that the adjacent dentition grafted partially dentate (32–34) and on implants placed
plays an influential role in facilitating force distribution in fully edentulous maxillae (35, 36). Owing to the good
and thus protecting the implant (21, 26). For instance, long-term results with bone substitutes alone or in
owing to the extent of the occlusal surface, implant- combination with autogenous bone, it was suggested
supported single crowns in a full surrounding natural that harvesting of autogenous bone could be avoided
dentition were thought to be exposed to less occlusal (25). Although autogenous bone was considered to
load than FPDs in partially dentate patients or full-arch provide best osteogenic potential and biomechanical
fixed restorations in edentulous patients (21, 26). properties of the regenerated bone (37–39), reasons

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234 T . T U N A et al.

against the use of autogenous bone alone were the favourable integration of implants in the residual bone
quantitative limitations from intraoral sites (22) and the and in well-incorporated bone grafts compared to the
high morbidity in extraoral (29) and intraoral sites such one-stage group.
as the mandibular symphysis (23, 24). There seems to The remaining bone height seemed to have no effect
be conformity in the aim of reducing morbidity as much on implant success (25). In the majority of the studies,
as possible either in preferring donor sites such as the it was underlined that primary stability was an indis-
ramus of the mandible with less post-surgical compli- pensable prerequisite for simultaneous implant place-
cations (23, 24) and ⁄ or mixing autogenous bone with ment in augmented sinuses (22, 25, 26, 28, 29).
bone substitutes (22, 24, 25, 29) or in using bone Interestingly, one study negated the relationship
substitutes alone (24, 25). Leading to good results, all between primary stability and residual bone height
kinds of bone substitutes appear to be a real alternative (28). Implants were simultaneously placed in residual
to autogenous bone alone accepted by most of the bone heights of 1–2 mm with meticulous condensation
author groups (22–29). This was in accordance with a of grafting material, achieving 100% implant success
review in which no major differences between grafting and 100% restoration survival. Nevertheless, a correla-
materials were found (6). Another review did not find tion was noted between implant failure and poor initial
significant differences between the use of particulate stability of implants owing to poor bone quality (28).
autogenous bone and particulate bone substitutes but In contrast, in one study, simultaneous placement of
statistically significant lower survival rates for the use of implants was performed only when the residual bone
block grafts (83Æ3%) compared to all particulate grafts height was at least 5 mm, thus suggesting an indirect
combined (92Æ3%; 31). However, the worse perfor- correlation between residual bone and primary stability
mance of the implants in the block grafts was discussed (26). Again, others conducted the delayed approach
as a result of possible covariable effect of the use of when primary stability could not be attained (22, 25).
machined surfaced implants in 6 of seven studies (31). As far as results from review articles are concerned,
Similar findings were reported in other reviews (2, 7). It no differences in implant outcome between simulta-
was generally adopted that bone substitutes may be a neous and delayed implant placement were observed,
viable substitute for autogenous bone (4, 6, 7, 31). and it was concluded that the time of implant place-
Additionally, donor site morbidity was mentioned to be ment did not affect survival rates of implants (2, 7, 31).
a major reason to question the use of autogenous bone Owing to a lack of sufficient clinical data, the timing of
(19), but a definite statement concerning their superi- implant placement and a possible correlation among
ority compared to 100% autogenous bone could not be primary stability, residual bone height and bone quality
made owing to insufficient data and low level of remain controversial issues according to two review
evidence in the current literature (4, 5, 7, 19). authors (19, 31). In contrast, the delayed approach was
The identified articles reported on one- and ⁄ or two- recommended when residual bone height was not
stage surgery techniques in various residual alveolar sufficient to provide adequate initial stability (7).
bone heights, both yielding favourable clinical results Recently, a positive association between the initial
with respect to implants and restorations. From the alveolar bone height and implant survival rates by
biological point of view, the two-stage procedure is to meta-regression analysis could be shown (8).
prefer because maturation and incorporation of the In agreement with previously published review
graft is completed before implant placement. On the articles, a general observation of the present review
other hand, one-stage surgery is less invasive, more was the low level of evidence seen in the majority of
cost-effective and shortens treatment time (21, 22). included articles. A comparison of the retrieved results
One study reported 100% implant survival for both was difficult owing to considerable variation of param-
procedures (26). Another study reported better implant eters in the study designs (2, 4–7, 19, 31). Following
survival in the two-stage grafting group (49 ⁄ 52, 94%) variables playing a role in the outcome of implants and
compared with the one-stage grafting group (14 ⁄ 17, restorations in augmented sinuses should be taken into
82%) (21). Although no significant differences in consideration for future studies: quality of bone, heal-
implant survival between both techniques could be ing time, patient selection (gender, age, health condi-
shown (21), the higher survival rate observed in the tions, habits), graft material (autogenous bone,
two-stage group was ascribed to a potentially more block ⁄ particular, bone substitutes), time of implant

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 PROGNOSIS OF FIXED IMPLANT RESTORATIONS 235

placement, residual bone height, type of restoration, maxillary sinus. Int J Periodontics Restorative Dent. 2004;
type of loading, implant system (material, surface), 24:565–577.
8. Chao YL, Chen HH, Mei CC, Tu YK, Lu HK. Meta-regression
implant form, length, width and ⁄ or use of membranes.
analysis of the initial bone height for predicting implant
Multicentre randomised controlled clinical trials with survival rates of two sinus elevation procedures. J Clin
sufficient statistical power concentrating on few factors Periodontol. 2010;37:456–465.
with homogenous groups are needed to reach sound 9. Boyne PJ, James RA. Grafting of the maxillary sinus floor with
conclusions. autogenous marrow and bone. J Oral Surg. 1980;38:613–616.
10. Summers RB. The osteotome technique: part 3 – Less invasive
methods of elevating the sinus floor. Compendium.
Conclusions 1994;15:698. 700, 2–4 passim; quiz 10.
11. Summers RB. A new concept in maxillary implant surgery:
Within the limits of this review the prognosis of the osteotome technique. Compendium. 1994;15:152. 4–6, 8
implants and fixed restorations seems not to be influ- passim; quiz 62.
enced by the type of restorations, graft material, 12. Summers RB. The osteotome technique: part 4 – Future site
development. Compend Contin Educ Dent. 1995;16:1090. 2
residual bone height and time of implant placement.
passim; 4–6, 8, quiz 9.
However, the conclusions of this review are based on 13. Summers RB. Sinus floor elevation with osteotomes. J Esthet
studies with low level of evidence; therefore, careful Dent. 1998;10:164–171.
interpretation is required. Multicentre randomised 14. Peleg M, Mazor Z, Garg AK. Augmentation grafting of the
controlled clinical trials with sufficient statistical power maxillary sinus and simultaneous implant placement in
patients with 3 to 5 mm of residual alveolar bone height. Int
concentrating on few factors with homogenous groups
J Oral Maxillofac Implants. 1999;14:549–556.
are needed to reach sound conclusions.
15. Toffler M. Minimally invasive sinus floor elevation procedures
for simultaneous and staged implant placement. N Y State
Dent J. 2004;70:38–44.
Conflicts of interest 16. Toffler M. Osteotome-mediated sinus floor elevation: a clinical
The authors declare no conflicts of interest. report. Int J Oral Maxillofac Implants. 2004;19:266–273.
17. Woo I, Le BT. Maxillary sinus floor elevation: review of
anatomy and two techniques. Implant Dent. 2004;13:28–32.
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