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 Table of Contents  
Year : 2022  |  Volume : 22  |  Issue : 3  |  Page : 215-224

Survival rate of dental implant placed using various maxillary sinus floor elevation techniques: A systematic review and meta-analysis

Department of Prosthodontics, Ahmedabad Dental College and Hospital, Ahmedabad, Gujarat, India

Date of Submission06-Jun-2022
Date of Acceptance06-Jun-2022
Date of Web Publication18-Jul-2022

Correspondence Address:
Rajal Shah
Department of Prosthodontics, Ahmedabad Dental College and Hospital, Bhadaj-Ranchodpura Road, Off., Sardar Patel Ring Road, Near Science City, Ahmedabad - 382 115, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jips.jips_283_22

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Aim: The aim of this systematic review is to evaluate the survival rate of dental implant placed using different maxillary sinus floor elevation techniques.
Setting and Design: PRISMA guidelines were used for this systematic review and meta-analysis.
Materials and Methods: Relevant articles were searched from Medline, PubMed, Google Scholar, ScienceDirect, and Cochrane trials. Articles published in English language were selected. Hand search was further conducted. For risk of bias, two tools were used, i.e., Cochrane tool for randomized controlled trials (RCTs) and new castle Ottawa quality assessment tool for non-RCTs.
Statistical Analysis: For statistical meta-analysis RevMan 5.4 software was used.
Results: Seventeen studies were finalized. All studies were included in the meta-analysis to check the implant survival rate. There is no statistical difference between direct and indirect techniques, and forest plot was derived for direct approach (P = 0.688, 95% confidence interval [CI] 0.9691) and for indirect approach (P = 0.686 and 95% CI 0.970).
Conclusion: There is no statistically significant difference in the survival rate of implant placed using direct or indirect sinus lift approach procedures. Hence, the technique is selected as per the indications given for each direct and indirect procedure.

Keywords: Bone grafting, crestal sinus lift and lateral window approach, dental implants, maxillary sinus, sinus floor elevation technique

How to cite this article:
Shah D, Chauhan C, Shah R. Survival rate of dental implant placed using various maxillary sinus floor elevation techniques: A systematic review and meta-analysis. J Indian Prosthodont Soc 2022;22:215-24

How to cite this URL:
Shah D, Chauhan C, Shah R. Survival rate of dental implant placed using various maxillary sinus floor elevation techniques: A systematic review and meta-analysis. J Indian Prosthodont Soc [serial online] 2022 [cited 2022 Dec 7];22:215-24. Available from: https://www.j-ips.org/text.asp?2022/22/3/215/351278

  Introduction Top

The rehabilitation of missing or lost teeth by means of implant reconstruction is a predictable treatment option. Implant placement in the posterior maxilla is the most challenging. Poor bone quality and quantity are limiting factors, for which different methods have been proposed.[1],[2],[3]

The maxillary sinus is a pyramidal-shaped cavity in the maxilla with a volume of 12–15 ml. Its anterior border extends into the pre-molar roots or distal surface of canine roots, and the posterior border reaches the maxillary tuberosity.[4] Due to its structure and location, the maxillary sinus sometimes challenges the proper placement of the implant.[5]

Techniques used for vertical bone augmentation are direct, indirect and combination of both the techniques.[6]

Autogenous bone is the most commonly used grafting material and is considered gold standard.[7],[8] SFE from a lateral window approach is most commonly used technique, which was first proposed by Tatum in 1977 and first published by Boyne and James in 1980.[1]

In comparison to SFE with a lateral window approach, the osteotome procedures are less invasive to elevate the membrane, reduces the operation time, and minimum postoperative discomfort,[10] was introduced by Summers in 1994.[7],[9]

Selection of the techniques depends on the anatomy of sinus floor and lateral wall of sinus and the residual bone height (RBH). For bone height <5 mm, lateral window approach is performed and for height ≥5 mm crestal approach is performed. Hence, RBH is the deciding factor between the two methods.[11] The use of piezoelectric technique, preserves soft tissue and maintains precision and a clear surgical site without blood during bone cutting.[12] Antral membrane balloon elevation technique is a modification of bone-added osteotome sinus floor elevation technique. In this technique, antral membrane balloon elevation is carried out through the osteotomy site.[13],[14],[15]

Hence, various maxillary sinus lift techniques with different modifications are studied based on the availability of type and amount of bone. The aim of this systematic review is to evaluate the survival rate of implants placed with different maxillary sinus lift procedures through a meta-analysis.

  Materials and Methods Top

To carry out this review PRISMA guidelines and population, intervention, comparison, outcome, and study design (PICOS) structure were used to develop the search strategy.

Population, intervention, comparison, outcome, and study design framework

According to PICOS strategy, P represents patients having maxillary edentulous space in the posterior region requiring sinus floor elevation for implant placement, I represents maxillary sinus floor elevation for dental implant placement, C represents different sinus floor elevation techniques, O represents survival rate of dental implants and S represents combination of in vivo studies including randomized controlled trial (RCT), prospective, retrospective, and clinical studies.

Search strategy

An electronic literature search focusing on the purposes was performed using PubMed, Medline, Embase, and Cochrane from 1997 to 2020. The search methodology applied was combination of MeSH terms and keywords such as maxillary sinus, bone grafting, dental implants, sinus floor elevation technique, crestal sinus lift, lateral window approach, and survival rates. The searches were limited to articles written in English with an associated abstract. The studies found after hand search was also included.

Inclusion criteria

  1. Prospective and retrospective studies
  2. Cohort studies and randomized control trial
  3. Studies on human
  4. ≥6 months to ≤5 years of follow-up period
  5. Studies with all different sinus floor elevation techniques.

Exclusion criteria

  1. Case reports
  2. Non-clinical studies
  3. Animal studies
  4. Inadequate data
  5. Systematic reviews and meta-analyses already undertaken.

Screening for selection

The titles and abstracts were examined by two investigators. The complete text of relevant research articles was given to each investigator to review independently. The third investigator resolved the disagreement and conflict regarding the inclusion of the articles.

Risk of bias

For randomized control trials, Cochrane risk of bias tool was used and for non-randomized trials new castle Ottawa scale was used [Table 1], [Table 2] and [Graph 1].
Table 1: Risk of bias based on new castle Ottawa Quality Assessment Scale for cohort study

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Table 2: Determining the Quality of Studies Based on Newcastle-Ottawa Scale

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Statistical analysis

The statistical analysis was carried out for included studies according to the data, on survival rate of implant placement using various sinus lift procedures through meta-analysis. For this, all the data according to inclusion criteria were taken into consideration. Mean value, P value, and heterogeneity values were obtained and the forest plots were obtained for both direct and indirect sinus lift techniques, RevMan 5.4 software was used.

  Results Top

Study selection

The search identified 895 titles on maxillary sinus lift techniques, out of which 835 were excluded on the basis of titles. Out the 60 titles selected, only 37 articles were selected on the bases of abstract. After full-text analysis, 19 articles were selected and further two more articles were excluded as per inclusion–exclusion criteria and inappropriate data. Thus, 17 articles were selected for the present systematic review [Figure 1].
Figure 1: Flow-chart of the search strategy

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Study characteristics

The 17 articles selected were published between 1998 and 2020. The research comprised nine clinical studies, five prospective, two retrospective studies, and one RCT study in the present study, a total of 337 implants were placed using direct approach and 922 implants were placed using indirect approach [Table 3].
Table 3: Summary of all maxillary sinus floor elevation techniques in included studies

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Follow-up period ≥6 months was considered after implant placement and meta-analysis was obtained for both direct and indirect approach [Table 4], [Table 5], [Table 6] and [Figure 2], [Figure 3], [Figure 4]. A forest plot was fabricated [Figure 2], [Figure 3], [Figure 4].
Table 4: Direct sinus lift technique

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Table 5: Indirect sinus lift technique using osteotome

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Table 6: Indirect sinus lift techniques (overall)

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Figure 2: Forest plot for direct technique

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Figure 3: Forest plot for indirect technique using osteotome

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Figure 4: Forest plot all indirect techniques

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[Figure 2], forest plot for studies using direct approach[16],[17],[21],[29],[30],[32] depicted P = 0.688, 95% confidence interval [CI] 0.969.

[Figure 3] and [Figure 4], forest plot for studies using indirect approach[16],[18],[19],[20],[22],[23],[24],[25],[26],[27],[28],[31],[32] depicted P = 0.686 and 95% CI 0.970.

Graph result

The survival rate of each technique was calculated and given [Table 7], [Table 8] and [Figure 5], [Figure 6].
Table 7: Survival rate of direct approach procedures (%)

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Table 8: Survival rate of indirect approach procedures (%)

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Figure 5: Survival rate of direct approach procedures (%)

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Figure 6: Survival rate of indirect approach procedures (%)

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Overall survival rate for direct approach is 95.98% and for indirect approach is 95.79%.

There was no major mean difference in the survival rate of direct approach and indirect approach.

  Discussion Top

Systematic reviews are considered as best evidence from the scientific literature. Different techniques have been used for maxillary sinus lift procedures for implant placement in the posterior maxilla region based on the availability of RBH. Thus, this systematic review was carried out to evaluate the available data on various maxillary sinus floor elevation. Analyzing survival outcomes of implant placed through various direct and indirect sinus lift techniques was one of the primary objectives of this systematic review. Nine clinical studies, six prospective, and two retrospective studies were identified and included in this systematic review. In this review, in vivo studies were included because they are well accepted for supplying basic scientific knowledge and for their clinical relevance.

Sinus lift techniques are most commonly used and highly predictable surgical procedure to overcome bone height deficiencies in the posterior maxilla (Wallace et al. 2007).[15] RBH for all lateral antrostomy procedure was <5 mm and >5 mm for crestal approach [Table 3]. Complications that occurred during sinus floor elevation are: bleeding from sinus membrane or from lateral bony window (Solar et al. 1999), laceration of the buccal flap, injury to infra-orbital nerve, and accidental membrane perforation (Pikos 2006). Modifications with direct as well as indirect techniques used reduced the complications during the procedures. Bone grafting done using bio-Oss and autogenous bone increased the implant survival rate. Furthermore, pre- and post-surgical antibiotic administration helped in infection-free field for surgery and also reduced discomfort to the patient postsurgery.

It is difficult to compare the large number of studies on maxillary sinus lift techniques due to differences in type of implants used, the patient's follow-up and quantity of residual bone present, techniques used, and evaluation methods.[33]

In the present study, a total of 337 implants were placed using direct approach from six included studies. Modifications such as piezosurgery and antral membrane balloon elevation were used in three studies by direct approach. Two studies were carried out using piezosurgery that provided advantage of atraumatic sinus elevation and clear surgical site. Although studies that used Piezosurgery preparation for lateral window approach showed sinus perforation rate of 3.6%.[34]

One study with subantral membrane elevation via balloon was included along with direct approach, which is considered less technique sensitive, proposed by Soltan and Smiler.[35] Few studies[35],[36] have documented antral balloon elevation method. Kfir et al.[22] achieved success in 91.6% for initial 12 patients and 100% success in second series of 12 patients, without complications. In antral balloon elevation method along with direct approach, initial procedural success was 100% and implant survival rate 96.8% after 6 months of follow-up.[29] Major advantages of antral balloon protocol are low incidence of infection and bleeding and low risk of perforation of sinus membrane, even in anatomically complex conditions.[37]

A lateral window approach is considered to be performed with a residual bone <5 mm. One-step and two-step lateral antrostomies are performed where one step was performed with RBH 4–6 mm in which simultaneous implant placement was done along with elevation. Moreover, majorly two-step is performed where bone graft material is placed and waited and implant placement is done after 6–8 months.[16] More bone gain was obtained nearly 10–12.7 mm through lateral window approach compared to osteotome technique (Zitzmann et al., 1998).[16]

Out of 337 implants placed, 18 implants failure resulted using direct approach with overall survival rate of 96.9%.

A total of 13 studies are included of maxillary sinus floor elevation using osteotome technique, in which total of 922 implants are placed. The osteotome technique was most frequently performed a study to elevate antral membrane. The advantage of this technique, as contrasted with lateral approach, are that it is less invasive and that it has shorter healing and waiting period. The increase of 3.5 mm of bone was noticed which is slightly below the values reported by summers.[12]

When 4 to 5 mm of alveolar bone is available below the sinus floor, the use of osteotomes is considered less traumatic than repeated malleating to the patients. The author has utilized a formula of 2 × 2 as the maximum size of the implant to be placed following trephine and osteotome core implosion. If 5 mm residual bone is present, maximum of 8 mm implant length will be contemplated. If a longer implant is desirable osteotome with modified trephine technique is imploded.[38]

Out of 13 studies included with indirect approach, nine studies performed osteotome technique in indirect approach with the overall survival rate of 97.1% of osteotome technique. Two studies were performed with indirect approach using Piezosurgery with survival rate 94.6% and 98.5%. Moreover, two studies were performed with antral membrane balloon elevation method with survival rate of 95% and 100%.

Bio-oss graft material showed good clinical results, reported by Hallman and Nordin[39],[40] who used it in connection with a conventional sinus lift and Brägger et al.[41] who used it with osteotome sinus floor elevation.

Even there are very limited studies with hydraulic sinus floor elevation that fulfilled the inclusion criteria of the study conducted. Hydraulic forces avoided the rupture of the sinus membrane using osteotome techniques. One study by Li et al. in 2013[26] showed 100% survival rate of implant using hydraulic pressure technique.

Hence, a total of 35 implants failed out of 922 implants placed using indirect techniques with the overall survival rate of 97%.

In this review, implants used were surface treated with Ti plasma-sprayed (TPS) and SLA (sandblasting, large grit, and acid etch). According to Bornstein et al., in their study, SLA implants showed 100% survival rate and TPS implants showed 89% survival rate.[21]

Biological and mechanical complications might cause failure in implant therapy.[42]

The results of the study showed, furthermore extensive future studies are needed especially a randomized control trial as such studies are lacked in the present research study along with newer modifications involving sinus floor elevation using hydraulic pressure and antral membrane balloon elevation methods.

  Conclusion Top

Hence, summarizing and highlighting the findings of this systematic review, the following conclusions are drawn:

  • Overall survival rate of implants placed by direct approach is 96.9%
  • Overall survival rate of implants placed using indirect approach is 97%.

Due to the limited number of well-performed RCT studies published to date, this systematic review concludes that there is no statistically significant difference in the survival rate of implant placed using direct and indirect approach procedures. Hence, the technique is selected as per the indications given for each direct and indirect technique.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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