Volume 81 • Number 1

Case Series
Transcrestal Sinus Floor Elevation With a Minimally
Invasive Technique
Leonardo Trombelli,* Pasquale Minenna,† Giovanni Franceschetti,* Luigi Minenna,*
and Roberto Farina*

Background: Recently, we proposed a minimally

M
axillary sinus floor elevation represents a sur-
invasive technique to limit the postoperative morbid- gical procedure to vertically enhance the
ity of transcrestal sinus floor elevation procedures. available bone, thus permitting the position-
The technique is based on the use of specially ing of implants with an adequate length in the
designed drills and osteotomes. The purpose of the edentulous posterior maxilla. At present, sinus floor
present study is to present data on the clinical out- elevation techniques require either a lateral ap-
comes and postoperative morbidity of sinus floor ele- proach, that is, opening a ‘‘window’’ through the
vation procedures performed using the proposed lateral wall of the alveolar ridge,1 or a transcrestal (or
technique. transalveolar) approach, in which access to the sinus
Methods: Fourteen implants were placed in the cavity through the edentulous bone crest is cre-
posterior portions of the maxilla areas of 11 patients ated.2-4 For both procedures, bone augmentation is
using the proposed technique. Postoperative pain generally provided by grafting the sinus cavity with
and discomfort were assessed using a 100-mm visual autogenous bone, bone substitutes, or the combina-
analog scale (VAS). The incidences of intra- and post- tion of the two.5-9
operative complications were recorded. The position The transcrestal approach was first presented in
of the grafted sinus floor with respect to the implant 1977 by Tatum and published in 1986.2 The tech-
apex was assessed on periapical radiographs 6 nique consisted of preparing the implant site with
months post-surgery. a ‘‘socket former,’’ selected according to the implant
Results: The augmented sites had a presurgery re- size to be placed. A ‘‘green-stick fracture’’ of the si-
sidual bone height of 6.1 mm, whereas the mean nus floor was performed by hand tapping the socket
length of the implants inserted in augmented sites former in a vertical direction until a fracture of the si-
was 10.3 – 0.9 mm. Immediately after surgery, VAS nus floor was obtained. In 1994, Summers modified
scores for pain and discomfort were 9.4 – 13.4 and this technique suggesting the use of a specific set
17.0 – 22.2, respectively. The 7-day VAS score for of osteotomes for preparing the implant site and ele-
pain was 2.1 – 4.9. No complications were observed vating the sinus floor.3,4 In 2002, Fugazzotto10 sug-
during or after the surgical procedure. Six months af- gested that the pristine bone at sites of implant
ter surgery, a newly formed mineralized tissue was placement could be drilled up to the sinus floor with
found at or beyond the level of the implant apex in a trephine bur and used to fracture the sinus floor by
all cases. hydraulic pressure through osteotomes. Since then,
Conclusion: The proposed technique represents many surgical techniques with specially designed in-
a suitable option to elevate the sinus floor due to a struments for the transcrestal approach were re-
predictable displacement of the sinus floor and a lim- ported in the literature.11-19 Systematic reviews6,8,9
ited post-operative morbidity. J Periodontol 2010;81: showed that sinus augmentation procedures using
158-166. the transcrestal approach were associated with con-
siderable long-term implant stability. Wallace and
KEY WORDS
Froum8 reported an implant survival rate ranging
Bone regeneration; dental implants; maxillary sinus; from 93.5% to 98.3% based on the technique used
outcome assessment (health care); surgical to access the sinus floor, similar to the survival rate
procedures, minimally invasive. observed for implants inserted into pristine bone in
the posterior maxilla. Emmerich et al.9 concluded
that implants placed in augmented bone through
* Research Center for the Study of Periodontal Disease, University of Ferrara,
Ferrara, Italy.
† Section of Dentistry, ‘‘Casa Sollievo della Sofferenza’’ Hospital, San
Giovanni Rotondo, Italy. doi: 10.1902/jop.2009.090275

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J Periodontol • January 2010 Trombelli, Minenna, Franceschetti, Minenna, Farina

a transcrestal sinus floor elevation showed a survival MATERIALS AND METHODS

rate of 90.9% after 24 months of loading. Consis- Study Population
tently, Tan et al.6 showed an estimated implant sur- Eleven consecutively treated patients (six men and
vival of 92.8% (95% confidence interval: 87.4% to five women; age range: 33 to 65 years; mean age:
96.0%) at a 3-year follow-up. 48.8 – 9.8 years) seeking implant-supported pros-
Surgical techniques for sinus floor elevations using thetic rehabilitation of the edentulous posterior max-
the transcrestal approach are mainly based on the illa were included in the study. All cases were selected
fracture or perforation of the sinus floor by means of and treated at the Research Center for the Study of
osteotomes11-13 or burs.2,10,14-19 However, both os- Periodontal Disease, University of Ferrara, or the Sec-
teotome and bur-driven procedures present advan- tion of Dentistry, ‘‘Casa Sollievo della Sofferenza’’
tages and limitations. The use of osteotomes may Hospital, from May 2007 to January 2009. All the
increase the density of the soft maxillary bone while clinical procedures were performed in full accor-
tenting the Schneiderian membrane by the hydraulic dance with the Declaration of Helsinki and the Good
pressure of the bone graft pulled into the sinus. More- Clinical Practice Guidelines (GCPs). Each patient pro-
over, if implant site preparation is implemented by the vided written informed consent before participation.
use of a trephine drill,10,14,19 the trephined core of au- In all cases, the residual bone at ‡1 site where im-
togenous bone may usefully contribute to the vertical plants should be placed was judged insufficient ac-
bone augmentation when used to elevate the sinus cording to the prosthetic treatment plan. Table 1
floor. However, when a thick layer of alveolar bone re- shows the residual bone height at sites where the sinus
mains coronal to the sinus floor, the osteotome tech- floor elevation procedure was performed.
nique may require extensive malleting trauma during Before the sinus lift procedure, all oral diseases, in-
the sinus floor elevation, which may eventually cause cluding periodontal disease, were thoroughly treated.
post-surgery sequelae such as benign paroxysmal Inclusion criteria to select a patient for the sinus lift
positional vertigo (BPPV).20-22 In addition, the action procedure were as follows:25,26 indications for im-
of osteotomes can hardly be controlled during the plant-supported prosthetic rehabilitation based on
application of malleting pressure, thus resulting in accurate diagnosis and treatment planning; systemic
an unwanted penetration of the instruments and/or and local conditions that were compatible with im-
the graft in the sinus cavity with a potential membrane plant placement and sinus floor elevation procedures;
perforation. The use of burs with different working the absence of signs and symptoms of sinus diseases,
lengths provides a controlled perforation of the sinus as confirmed by clinical examination and radio-
floor, restraining the action of the cutting edge to graphic assessment immediately prior to the maxil-
the native bone and limiting the risk for perforation lary sinus floor augmentation; residual bone height
of the sinus membrane. Unfortunately, the currently (i.e., the distance from the bone crest to the sinus
available drilling devices tend not to preserve the floor) ‡4 mm; verbal or written informed consent pro-
residual native bone during implant-site preparation vided; and patient willing to comply with the study
and sinus floor perforation; therefore, the bur-driven protocol.
procedure usually calls for the additional use of a The sinus lift procedure was not performed when
graft for sinus augmentation. systemic and local conditions which contraindicated
Recently, we proposed a minimally invasive a sinus floor elevation were present.25,26
technique‡ that is characterized by transcrestal ac-
cess to the sinus cavity by means of specially de- Surgical Technique
signed drills and osteotomes.23,24 The procedure According to the prosthetic treatment planning, the
represents a modification of the technique proposed location for implant placement was established, and
by Fugazzotto.10 However, the major novelty resides the residual bone height at such locations was first
in the fact that all manual and rotating instruments are measured on periapical radiographs as the distance
used with adjustable stop devices that restrict the from the bone crest to the sinus floor and confirmed
working action of burs and osteotomes to the vertical by a computerized tomography scan as needed. This
amount of residual bone, thereby preventing the acci- measure represented the radiographic working length
dental penetration of instruments into the sinus cav- (rWL). Surgical stents based on a diagnostic wax-up
ity. These stop devices have a variable length (from were only used when indicated by the prosthetic treat-
4 to 11 mm) and may be adapted to all manual and ment plan.
rotating instruments. All patients were administered an antibiotic pre-
The purpose of the present case series was to pres- medication (amoxicillin, 2 g, 1 hour before the surgi-
ent data on the clinical outcomes and postoperative cal procedure). A local injection of anesthesia was
morbidity of sinus floor elevation procedures per-
formed using this new minimally invasive technique. ‡ Smart Lift, Meta CGM, Reggio Emilia, Italy.

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Minimally Invasive Technique for Sinus Floor Elevation Volume 81 • Number 1

Table 1.
Descriptive Statistics of the Study Population According to Localization of the
Edentulous Site, Height and Width of Residual Bone, Graft Material Used in
Conjunction With the Sinus Lift Procedure, and Implant Dimensions

Implant
Residual Bone Dimensions

Edentulous rWL sWL Width Length Width

Patient Site (mm) (mm) (mm) Graft Material (mm) (mm)

1 First molar 3.0 5.0 10.0 Granules of synthetic hydroxyapatite 10.0† 5.0
with equine collagen*

2 Second 9.0 9.0 10.0 Autogenous cortical bone particulate 13.0‡ 4.0
premolar
3 First molar 7.0 7.0 9.0 Granules of synthetic hydroxyapatite 9.5‡ 4.0
with equine collagen*
4 First molar 8.0 6.0 14.0 Autogenous cortical bone particulate 11.0§ 4.0
§
5 Second 4.0 4.0 5.5 Granules of synthetic hydroxyapatite 9.0 4.0
premolar with equine collagen*
6 Second 7.0 7.0 8.0 Granules of synthetic hydroxyapatite 11.0‡ 4.0
premolar with equine collagen*

First molar 5.0 5.0 8.0 Granules of synthetic hydroxyapatite 9.5‡ 4.0
with equine collagen*
7 First molar 7.0 7.0 9.0 Autogenous cortical bone particulate 11.0§ 4.0
†
8 Second 4.0 4.0 5.0 Granules of MG-enriched 8.5 3.75
premolar hydroxyapatitei
9 First premolar 7.0 7.0 6.0 Granules of bovine-derived porous 10.0# 4.0
bone mineral¶

Second 4.0 4.0 6.0 Granules of bovine-derived porous 10.0# 4.0

premolar bone mineral¶
10 First molar 6.0 6.0 5.0 Granules of bovine-derived porous 10.0† 4.0
bone mineral¶
11 Second 8.0 8.0 6.0 Granules of bovine-derived porous 11.0# 4.0
premolar bone mineral¶

First molar 7.0 7.0 6.0 Granules of bovine-derived porous 11.0# 4.0
bone mineral¶
Mean 6.1 6.1 7.7 10.3 4.1
SD 1.8 1.6 2.6 0.9 0.3
MG = magnesium.
* Biostite, GABA Vebas, Rome, Italy.
† OSSEOTITE, BIOMET 3i, Palm Beach Gardens, FL.
‡ SPI Element, Thommen Medical, Grenchen, Switzerland.
§ Osseospeed, Astra Tech Dental, Molndal, Sweden.
i SINTlife, Finceramica, Faenza, Italy.
¶ Bio-Oss, Geistlich Biomaterials, Thiene, Italy.
# Nobel Replace Straight, Nobel Biocare, Gothenburg, Switzerland.

performed with 2% mepivacaine with 1:100,000 epi- ter the full-thickness flap elevation, a first drill (locator
nephrine. The preparation of the implant site was per- drill) was used to perforate the cortical bone to a depth
formed by manual and rotating instruments according £3.5 mm at the site where the implant was to be
to a precise sequence of use (Figs. 1A through 1H). Af- placed. A second drill (probe drill) with a diameter

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J Periodontol • January 2010 Trombelli, Minenna, Franceschetti, Minenna, Farina

3.2 or 4.0) that corresponded to

the Ø of the trephine preparation
(Fig. 2G). If the alveolar bone core
was found to be inside the tre-
phine, the bone core was gently
removed from the trephine and re-
placed in the alveolar bone prepa-
ration. The osteotome was used
under gentle malleting forces to
implode the trephined bone core
over the sinus floor.
In relation to the extent of ver-
tical bone augmentation to be
achieved, a cortical bone par-
ticulate or a bone substitute was
Figure 1.
Set of instruments and sequence of use. A) Locator drill. B) Probe drill. C) Probe osteotome.
further grafted and condensed
D) Radiographic pin. E) Guide. F) Trephine bur. G) and H) Calibrated osteotome. into the sinus by the osteotome
(Table 2). The graft was con-
densed with the osteotome used
of 1.2 mm (Ø 1.2 mm) and cutting only at the top edge at the sWL, thus preventing any unwanted penetra-
was used to define the position and orientation of the tion of the instruments into the sinus cavity. In all
implant. To minimize the risk of a sinus floor perfora- cases, implants were positioned with healing abut-
tion, the bur was used with an adjustable stop device ment at the same surgical session. Flaps were closed
that was always set at least 1 mm shorter than the rWL by means of 6-0 sutures.
(Figs. 2A and 2B). The probe osteotome (Ø 1.2 mm) Patients were prescribed non-steroidal anti-inflam-
was carefully inserted into the site prepared by the matory drug therapy (nimesulide, 100-mg tablets, as
probe drill and gently forced in an apical direction needed) and a chlorhexidine mouthrinse¶ (10 ml three
through the cancellous bone until the cortical bone times a day for 3 weeks). Sutures were removed 7
resistance of the sinus floor was met. Therefore, the days after surgery.
probe osteotome provided the surgical working length
Clinical Recordings
(sWL), which represented the true anatomic distance
At the time of the sinus lift procedure, the following
from the bone crest to the sinus floor in the exact lo-
data were recorded: rWL; sWL, as assessed by the
cation where the implant was to be placed (Fig. 2C;
probe osteotome; bone width, measured with a digital
Table 1). Thus, the working action of all manual
caliper as the bucco-lingual Ø of the alveolar crest at
and rotating instruments used in subsequent surgical
the sites of implant insertion (after the use of the probe
steps was set at the sWL by using the proper adjust-
drill); duration of the sinus floor elevation procedure
able stop device. When needed, a radiographic pin
(in minutes, from cortical perforation to implant
(Ø 1.2 mm) was used to check the orientation and
placement); grafting procedure (i.e., bone core with
depth of the prepared site by means of a periapical
or without use of additional bone graft or bone substi-
x-ray. The radiographic pin handle had Ø 4.0 mm,
tutes); incidence of membrane perforation, as evalu-
thus permitting the evaluation of the spatial relation-
ated by the Valsalva maneuver, or other intrasurgery
ship between the prepared site and the bucco-lingual
complications; and primary stability of the implant
and mesio-distal dimensions of the alveolar ridge.
(evaluated at a 30-N torque).
This helped to determine the Ø of the implant to be
Immediately after surgery, patients were asked to
placed. Then, a guide drill of Ø 3.2 mm (for an implant
assess the following: pain experienced during the si-
Ø 3.75 O 4.5 mm) or 4.0 mm (for an implant Ø 4.8 O
nus lift procedure, recorded by a 100-mm visual ana-
5.0 mm) was used. This drill followed the Ø 1.2-mm
log scale (VAS) (ranging from no pain to intolerable
site preparation and created a crestal countersink 2
pain); discomfort/trauma experienced during the si-
mm deep (Fig. 2D), where the trephine bur§ was in-
nus lift procedure, recorded by a 100-mm VAS (rang-
serted (Fig. 2E). Such a countersink enabled the tre-
ing from no discomfort to maximum discomfort);
phine bur to center its working action according to the
and presence of complications related to the sinus lift
desired orientation. The trephine bur (Ø 3.2 or 4.0),
procedure.
set at the sWL, produced a bone core up to the sinus
floor (Fig. 2F). After the removal of the trephine bur,
§ Smart Lift Drill, Meta.
the bone core was condensed and malleted to fracture i Smart Lift Elevator, Meta.
the sinus floor by means of a calibrated osteotomei (Ø ¶ Dentosan 0.12%, Johnson & Johnson, Neuchatel, Switzerland.

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Minimally Invasive Technique for Sinus Floor Elevation Volume 81 • Number 1

Outcome variables were re-

corded on the radiographs using
a digital ruler. To evaluate the
change in height of the grafted si-
nus floor for each implant, the var-
iables were: 1) implant length (IL),
defined as the distance from the
apex to the head of the implant;
and 2) bone level (BL), defined
as the distance from the top of
the radio-opaque grafted area to
the head of the implant. Both
measurements were taken at the
middle longitudinal axis of the im-
plant. To express the relationship
between sinus-graft height and
IL, the BL ratio was calculated as
BL/IL. A value ‡1.0 indicated that
the grafted sinus floor covered the
implant apex. A value <1.0 indi-
cated that the implant apex was
not completely covered by the
grafted sinus floor. Therefore, the
relationship between the grafted
sinus floor and implant was classi-
fied into three groups: group 1, in
which the grafted sinus floor was
Figure 2. above the implant apex; group 2,
Surgical steps of the technique for transcrestal sinus floor elevation. A) At this edentulous first molar in which the implant apex was at
site, the residual bone height, as measured on periapical radiograph, amounted to 7 mm (rWL). the same level of the grafted sinus
B) The probe drill was used at the rWL with the 7-mm adjustable stop device. C) The rWL was floor; and group 3, in which the
confirmed through tactile perception of the sinus floor using the probe osteotome. Therefore, the
grafted sinus floor was below the
sWL was set at 7 mm for the next steps. D) The guide drill created a crestal countersink to enable
the trephine bur to center its working action according to the desired direction. E) The trephine bur implant apex.27
Ø 3.2 trephined a bone core up to the sinus floor. F) The bone core was left in situ. G) The bone All measurements were under-
core was condensed to fracture the sinus floor by means of the osteotome. H) Periapical radiograph taken by a single investigator (GF)
taken immediately after surgery. I) Six-month periapical radiograph. who was not involved in the sur-
gical procedure. Radiographs of
the same patient were masked as
At 7 days post-surgery, the following recordings to the observation interval.
were performed: dosage of nimesulide assumed dur-
Statistical Analyses
ing the post-surgery period; current level of pain, re-
The patient was regarded as the statistical unit. Data
corded by a 100-mm VAS (ranging from no pain to
are expressed as means – SD. Changes in the BL/IL
intolerable pain); and presence of post-surgery com-
from baseline to 6 months were evaluated using the
plications related to the sinus lift procedure.
Student t test for paired observations. The level of
statistical significance was defined at 5%.
Radiographic and Morphometric Evaluations
Radiographic evaluations were based on periapical
radiographs. The assessment of the rWL at the sites RESULTS
of implant placement was made on an x-ray taken im- The rWL and bone width are described in Table 1.
mediately before the sinus augmentation procedure. The mean duration of the sinus lift procedure was
A first post-surgery radiograph (baseline) was taken 23.4 – 8.8 minutes. No membrane perforation or any
within 2 weeks from the sinus lift procedure to evalu- other surgical complications were recorded during
ate the implant positioning and the amount of sinus or immediately after the procedure when the Valsalva
grafting around the apical portion of the implant maneuver was performed. A total of 14 implants were
(Fig. 2H). Subsequently, periapical radiographs were placed, with eight patients contributing one implant
taken 6 months post-surgery (Fig. 2I). and three patients contributing two implants. Implant

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J Periodontol • January 2010 Trombelli, Minenna, Franceschetti, Minenna, Farina

Table 2.
Descriptive Statistics of the Study Population According to IL, BL, and the Relationship
Between Sinus-Graft Height and IL (BL ratio) as Assessed Immediately Before Surgery
and at 6 Months Post-Surgery

IL (mm) BL (mm) BL Ratio

Immediately Immediately Immediately

Patient Site After Surgery 6 Months After Surgery 6 Months After Surgery 6 Months

1 First molar 10.7 10.3 12.8 14.0 1.2 1.3

2 Second premolar 13.0 13.0 15.7 15.5 1.2 1.2

3 First molar 12.5 9.5 15.8 9.9 1.3 1.0
4 First molar 9.0 9.0 11.0 11.0 1.2 1.2
5 Second premolar 9.4 10.2 11.9 11.6 1.3 1.1

6 Second premolar 11.0 11.0 12.9 13.1 1.2 1.2

First molar 9.5 8.5 11.4 11.0 1.2 1.3
7 First molar 12.1 11.5 17.9 16.5 1.5 1.4

8 Second premolar 12.1 9.4 14.5 12.6 1.2 1.3

9 First premolar 10.0 10.0 10.5 10.9 1.1 1.1
Second premolar 10.0 10.0 12.2 11.7 1.2 1.2

10 First molar 11.0 11.0 12.4 12.4 1.1 1.1

11 Second premolar 11.0 11.0 12.3 12.4 1.1 1.1
First molar 11.0 11.0 12.3 12.4 1.1 1.1

Mean 10.9 10.4 13.1 12.5 1.2* 1.2*

SD 1.2 1.2 2.1 1.8 0.1 0.1
* Intragroup statistical comparison (Student t test for paired observations): not significant (P >0.05).

dimensions (length and width) are summarized in Ta- post-surgery, seven patients stated that they assumed
ble 1. Immediately after implant placement, all im- nimesulide (mean dosage: 2.9 – 2.1 tablets; range: one
plants showed primary stability. Transmucosal and to six tablets) during the first 7 postoperative days. The
submerged healing was used in 10 and four implants, 7-day VAS score for pain was 2.1 – 4.9 (range: 0 to 14).
respectively. No patients or implants were lost during the
In all cases, the trephined bone core created by the 6-month observational follow-up. In all cases, an im-
trephine bur was used for the sinus floor elevation. In plant-supported prosthesis was inserted at 4 to 6
three cases, the alveolar bone core was found inside months after implant placement.
the trephine bur, removed, and repositioned in the Radiographic measurements are reported in Table
alveolar bone preparation. Additionally, a graft of 2. The mean BL ratio varied from 1.2 – 0.1 (range: 1.1
autogenous bone particles, harvested with either to 1.5) at baseline to 1.2 – 0.1 (range: 1.0 to 1.4) 6
a bone scraper device# or a trephine bur, was used months after surgery (P >0.05). At baseline, all im-
in three sites, a hydroxyapatite-collagen biomate- plants were in group 1; a shift to group 2 was observed
rial** was used in five sites, a deproteinized bovine for one implant at 6 months (Table 2).
bone allograft†† was used in five sites, and a magne-
sium-enriched hydroxyapatite-based material‡‡ was
used in one site (Table 1).
Immediately after surgery, the VAS scores for pain # Safescraper, Meta.
** Biostite, GABA Vebas, Rome, Italy.
and discomfort were 9.4 – 13.4 (range: 0 to 37) and †† Bio-Oss, Geistlich Biomaterials, Thiene, Italy.
17.0 – 22.2 (range: 0 to 67), respectively. At 7 days ‡‡ SINTlife, Finceramica.

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Minimally Invasive Technique for Sinus Floor Elevation Volume 81 • Number 1

DISCUSSION followed the direction provided by the probe drill. This

The present case series illustrates a minimally inva- operative sequence ensured a proper implant position
sive procedure of a sinus floor elevation using a trans- and angulation during the procedure. Other tech-
crestal approach for implant insertion. The mean niques were reported where burs of variable length
residual bone height, as assessed during surgery, that were provided with a shoulder stop were used
was 6.1 mm (range: 4 to 9 mm), whereas the mean to perforate the sinus floor.14 Unfortunately, in such
length of the implants inserted in augmented sites a procedure, the selection of the working length of
was 10.3 mm (range: 8.5 to 13 mm). Six months after the rotating instruments is only based on the radio-
surgery, a newly formed mineralized tissue was found graphic examination, leading to a potential under- or
at or beyond the level of the implant apex in all cases. overestimation of the amount of residual bone height.
No complications were observed either during the In our study cohort, the mean residual bone height,
surgical procedure (e.g., membrane perforation) or as assessed during surgery, amounted to 6.1 mm,
after the completion of surgery (e.g., BPPV). and the mean length of the implants placed in aug-
The rationale for this technique was essentially de- mented sites was 10.3 mm. Six months after surgery,
rived from a previously described procedure where periapical radiographs showed that the grafted sinus
the combined use of a trephine bur and osteotomes floor was above the implant apex in 13 implants and
was suggested.10 Previous reports using such tech- at the level of the implant apex in one implant, indi-
niques showed a cumulative success rate of 98.0% cating the presence of newly formed mineralized tis-
after 13 to 48 months of follow-up.10 The technique sue around the entire portion of the implants exposed
proposed by Fugazzotto10 implied the use of a tre- in the sinus cavity. The vertical augmentation of the
phine drill penetrating up to 1 mm from the sinus floor. implant site was provided by the condensed tre-
Then, an osteotome was used to implode (by the use phined bone core that was displaced into the sinus.
of a mallet) the trephined bone core to a depth of 1 mm This intrusion osteotomy procedure elevated the si-
less than the initial trephine cut. The hydraulic pres- nus membrane, thus creating a space for blood clot
sure exerted by the autogenous bone core determined formation. It is conceivable that the contribution of
the bone core to the intrasinus bone formation may
the fracture of the sinus floor with vertical augmenta-
relate to the amount of residual bone at the implant
tion of the implant site. Although proven effective, this
site (i.e., the more native bone pushed into the sinus,
technique seems highly technique sensitive, particu-
the more newly formed bone). When a limited amount
larly with respect to the control of the working action
of residual bone is present with respect to the amount
of the trephine bur and osteotome. It is conceivable
of bone needed for proper implant placement, bone
that direct damage of the sinus membrane due to in-
formation may be implemented by the additional use
strument penetration over the sinus floor can occur
of a graft. In our study, a graft of autogenous cortical
during the drilling action of the trephine bur and from bone particulate or hydroxyapatite-based material
the mallet pressure on the osteotomes. was used in conjunction with the trephined bone core
In our procedure, all instruments in the surgical set to elevate the sinus floor. Grafting material was added
were characterized by laser marks at 4, 5, 6, 7, 8, 9, incrementally and condensed into the sinus by the
10, and 11 mm to allow for the accurate control of osteotome. During the grafting procedure, only the
the working length. Moreover, the working action of graft biomaterial exerted the hydraulic pressure to tent
the rotating and manual instruments was restricted the sinus membrane, whereas any direct penetration
to the residual (native) bone. The working length of the osteotome into the sinus cavity was prevented
was first established radiographically and confirmed by the adjustable stop device. A previous study28
by the combined use of the probe drill and probe os- seemed to suggest an enhanced osteoinductive/
teotome. The probe drill is provided with a top cutting conductive potential with the additional use of bone
edge that can easily proceed into the cancellous bone substitutes. Pjetursson et al.28 compared the transcres-
reaching the proximity of the sinus floor. Then, the tal sinus floor elevation by means of osteotomes with
sWL was defined by tactile perception of the cortical and without the additional use of deproteinized bovine
bone of the sinus floor derived from the gentle use bone matrix. Gains in radiographic bone height of 4.1
of the probe osteotome. Once the sWL was estab- and 1.7 mm were observed in grafted and non-grafted
lished, the use of adjustable stop devices dictated sites, respectively. The evaluation of the adjunctive
the extent of the working action of the manual and ro- effect of grafting materials to the sinus lift procedure
tating instruments, thus minimizing the risk for mem- was beyond the purpose of the present case report.
brane perforation and post-surgery infections. Whether and to what extent the minimally invasive
The preparation of the implant site was performed sinus lift approach may benefit by the additional use
by manual and rotating instruments according to of different bone substitutes needs to be further
a precise sequence of use (Figs. 1A through 1H) and assessed.

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J Periodontol • January 2010 Trombelli, Minenna, Franceschetti, Minenna, Farina

In our study, no membrane perforation was re- CONCLUSIONS

corded during or immediately after the sinus lift pro- The investigated technique represents a minimally in-
cedure when the Valsalva maneuver was performed. vasive surgical option for sinus floor elevation. The
Recently, a systematic review6 reported incidences technique is based on a standardized, user-friendly
of membrane perforation ranging from 0% to 21.4% sequence of manual and rotating instruments used
and postoperative infection from 0% to 2.5% after with a controlled working action aimed at preventing
transcrestal sinus elevation by means of different surgical complications. However, further controlled
surgical procedures. In most of the clinical studies clinical trials are needed to evaluate the effectiveness
reported in the literature,6 including the present re- and safety of this technique compared to other sinus
port, the incidence of such complications may have floor elevation procedures.
been underestimated due to the limited accuracy of
the Valsalva maneuver in the recognition of mem-
brane perforations. In an experimental evaluation29 ACKNOWLEDGMENTS
of maxillary sinus membrane response after eleva- The authors thank Meta CGM, Reggio Emilia, Italy,
tion with the osteotome technique in human ca- for producing and providing the surgical set. This
davers, membrane perforation was observed in six study was supported by the Research Center for the
of 25 implants (24%), with the risk increasing ac- Study of Periodontal Diseases, University of Ferrara,
cording to the increase in the extent of sinus floor and partly by the fund ‘‘Regenerative Medicine for
elevation needing to be obtained. An endoscopic Osteo-Articular Diseases’’ from the Regional Health
study30 revealed that the sinus floor may be ele- Service of Emilia-Romagna, Italy. The authors report
vated up to 5 mm without perforating the sinus no conflicts of interest related to this case series.
membrane. However, another endoscopic study31
demonstrated the risk of membrane perforation
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11. Coatoam GW. Indirect sinus augmentation procedures 24. Trombelli L, Minenna P, Franceschetti G, Farina R,
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expansion technique with osteotomes: A study of 4 Correspondence: Prof. Leonardo Trombelli, Research
cases. Int J Oral Maxillofac Implants 2008;23:129- Center for the Study of Periodontal Disease, University of
132. Ferrara, Corso Giovecca 203, 44100 Ferrara, Italy. Fax
23. Trombelli L, Minenna P, Franceschetti G, Farina R, 39-0532-202329; e-mail: [Link]@[Link].
Minenna L. Smart-Lift technique for the elevation of
the maxillary sinus floor with a transcrestal approach. Submitted May 15, 2009; accepted for publication August
Implantologia 2008;6:9-18. 24, 2009.

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