Double Transcrestal Sinus Lift Procedure with Collagen as Bone Void Filler Alone in Atrophic Maxilla: 5 Years Retrospective Radiological Study

Case Series

Austin Med Sci. 2022; 7(2): 1066.

Double Transcrestal Sinus Lift Procedure with Collagen as Bone Void Filler Alone in Atrophic Maxilla: 5 Years Retrospective Radiological Study

Crespi R¹, Toti P², Covani U², Crespi G², Brevi BC³ and Menchini-Fabris GB¹*

¹School of Dentistry, Saint Camillus International University of Health and Medical Sciences, Italy

²Tuscan Dental Institute, Versilia Hospital, Italy

³Department of Maxillo-Facial Surgery, Hospital and University of Pisa, Italy

*Corresponding author: Menchini-Fabris GB, San Rossore Dental Unit, San Rossore Hospital, Vialedelle Cascine 152 San Rossore, 56122 Pisa, Italy

Received: June 30, 2022; Accepted: July 21, 2022; Published: July 28, 2022


Objectives: The present study aimed to investigate the effectiveness of transcrestal double-elevation of the maxillary sinus (TSFE) with an implant placement during the second-stage surgery in the maxillary areas with a residual alveolar bone less than 3mm.

Materials and Methods: Patients with long-standing edentulous areas underwent double TSFE surgery involving a first transcrestal maxillary sinus floor augmentation with a collagen sponge to fill the intrabony cavity and a second osteotome-mediated sinus floor elevation by using an electromagnetic device and immediate implant placement. The radiographic changes in bone heightwere measured and compared during the different time intervals by nonparametric statistics with p < 0.01.

Results: Twenty-eight patients were retrospectively selected for the study. A total of 42 implants were positioned in 28 augmented sinuses. After the first TSFE surgery, no minor swelling of gingival mucosa, no mucositis, or flap dehiscence with suppuration was found. After three months a second TSFE with simultaneous implant placement was performed; four patients experienced minor nasal bleeding. Significant increases in the bone height had been respectively reported for the first (from 2.3±0.2 to 9.5 ± 0.3 mm) and second surgeries with p-values less than 0.0001 and an overall bone height measured 5 years after the first surgery of 12.2±0.3 mm.

Conclusion: The present study suggested to clinicians the possibility of osteotome double sinus lifting and grafting with highly absorbable collagen material, generally used as a haemostatic agent alone in case of residual bone height less than 3 mm.

Keywords: Double transalveolar sinus floor elevations; Collagen sponge; Highlyresorbable substitute material; Dental implants


RBH: Residual Bone Height; CBCT:Cone Beam Computerized Tomography; CT:Computerized Tomography; AH:Alveolar Height; ΔAH:Alveolar Height Change; TSFE:Transalveolar Sinus Floor Elevation.


Maxillary sinus pneumatization was a physiologic process that most commonly could occur in older adults after long-standing edentulism after the removal of more distal teeth [1]. It was highly likely that the cause of the “fourth expansion” of the maxillary sinus, as it’s usually called by the anatomists, could be explained as resulting from a disuse/atrophy phenomenon after tooth loss. Reduction of functional could create an imbalance between apposition and resorption of alveolar bone beneath the sinus so causing a shift in the remodeling process towards a combination of volume enlargement of the sinus as well as loss of the alveolar bone [2]. A very particular case was when the maxillary sinus was fully hyperpneumatized at the expense of the edentulous alveolar ridge [3]. To rehabilitate an edentulous patient with an implant-supported prosthesis in the posterior dentition, maxillary sinus surgery was often recommended if the Residual Bone Height (RBH) ranged from 1 mm to 6 mm in thickness [4].

It was recently supposed by some researchers that the substantial increase in the volume of bone beneath the sinus floor could be achieved without any use of bone-substituting materials [5,6].

Moreover, it seemed that simple elevation of the Schneiderian membrane could stimulate new bone formation, which was found to be very close to the limit of surgical margins [7]. Some studies describing results of simple elevation of the sinus membrane without any grafting material suggested that the membrane had good osteoinductive properties [8,9].

The present study aimed to investigate the effectiveness of transcrestal double-elevation technique of the maxillary sinus with an implant placement during the second-stage surgery in the maxillary areas with a residual alveolar bone less than 3 mm. The radiographic changes in height had to be measured and compared during the different time intervals.

Materials and Methods

Patient Selection

Subjects were arbitrarily selected from a single cohort of patients who underwent dental implant-supported prosthetic rehabilitation for the present study with a retrospective design with no control subjects or randomization. All patients were treated by a single experienced surgeon (UC) and rehabilitated by a single prosthodontist (CR) from October 2010 to November 2018 at the Tuscan Stomatologic Institute and followed up at the Complex Operating Unit of Maxillo-Facial Surgery of the University of Pisa.

Retrospective analyses of routinely collected data resulted from a revision process based on patients’ case sheets that were performed after all the subjects selected for this case-cohort study signed an explicit consent for the retrospective analysis.

All procedures performed in studies involving human participants followed the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Inclusion Criteria

Patients were included in the selection if they met the following criteria:

• adulthood (greater than or equal to 18 years); • mono or bilateral large edentulous area before rehabilitation in the posterior maxilla; • presence of residual bone height between 1 mm and 2 mm measured from the alveolar crest to floor of maxillary sinus; • treatment with double transcrestal sinus floor elevations technique; • delayed dental implant placement and prosthetic rehabilitation; • full set of preoperative (before first surgery) and postoperative 3D imaging at 3 months (before implant placement) and 5 years survey.

Exclusion Criteria

Patients were excluded if any of the following criteria were present:

• metal corruption of the CBCT scans;• treatment with irradiation and/or bone resection as part of a cancer treatment plan;• administration of bisphosphonates (intravenous and/or oral);• report of smoking habit (more than 10 cigarettes/days);• report of alcohol or drug abuse.

Surgical Procedure

The need for vertical bone augmentation was established by Computerized Tomographic (CT) scanning. All patients were administered local anesthesia (Lidocaine 2% with epinephrine 1:80,000, Xylocaine®, AstraZeneca SpA, Milan, Italy). Surgical guidelines recommended premedication with non-steroidal antiinflammatory drugs (mainly naproxen, 1.5g, Naprosyn, RecordatiSpA, Milan, Italy) and antimicrobial agents (mainly ciprofloxacin§§) 1 hour before surgery. Antibacterial and anti-inflammatory drugs administration was continued at most for one week after surgery. A partial-thickness flap was made by a crestal incision and elevated in the alveolar crestal area needing vertical expansion [10].

Occlusal and rectangular-shaped access to the maxillary sinus was created with bone tips mounted on a piezoelectric device (SONICflex™, Kavo, Germany). Then the edges of the trapdoor were gently fractured from the rest of the bone of the alveolar process with osteotomes mounted on an electromagnetic device (Magnetic Mallet®, Osseotouch, Turbigo, Italy The sinus membrane was carefully detached using a manual curette (De Marco N° 2, Hu-Friedy, Chicago, IL, USA), mobilized, and pushed inside the sinus with the autogenous bone fragment pushed [11]. When the amount of new space was deemed sufficient to meet the need of the clinician a collagen sheet (Condress®, Abiogen Pharma, Pisa, Italy) was placed to fill the gap and to maintain an apically displaced trapdoor. A primary wound closure by sutures was performed and removed after 7 days (Figure 1). The second same technique-the same surgeon approach was repeated after 3 months combined with an immediate implant placement procedure (Figure 2). The sinus floor was newly pushed up, and, after placement, the dental implant itself provided a tenting effect. After implant (Perfect, Avenir, Santarcangelo di Romagna, Italy) placement the flaps were positioned to their original level and secured with sutures. A scheme of the surgical steps was depicted in (Figure 3).