Maxillary

Sinus Augmentation:
Continuing
Education
Fixed restorations in the compromised posterior maxilla Course -
A Peer-Reviewed Publication 4 CEUs

The Academy of Dental Therapeutics and

Stomatology is an ADA CERP Recognized Provider

Written By:
Stephen S. Wallace, DDS Associate Clinical Professor, New York University,
Department of Implant Dentistry
This CE course is written for Dentists, Periodontists, Implantologists and Oral Surgeons
The cost of this CE course is $55.00 for 4 CEUs
Cancellation/Refund Policy - Any participant who is not 100% satisfied with this course can request a full
refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.
This course was made possible by an unrestricted
educational grant from

Educational Objectives
This article will focus on the lateral
window sinus elevation procedure. Its
role as a preprosthetic surgical procedure
will be discussed and the surgical
technique presented. An evidence-
based decision process will be presented
so that appropriate decisions can be
made that will lead to the most positive
patient outcomes.
After reading this article the clinician will
be able to:
1. Identify appropriate graft materials for
sinus surgery.
2. Compare implant survival rates
pertaining to membrane placement.
3. Select implants based on surface
texture.
Introduction
Implant dentistry has dramatically changed
the way we approach our fully and partially
edentulous patients. A technique that was
introduced to specifically address the edentulous
mandible has evolved to encompass therapy to
the edentulous maxilla, the partially edentulous
patient and finally, to the patient missing a single
tooth.1
Bone loss following tooth extraction and/
or periodontal disease can complicate the
placement of root-form implants due to a lack of
sufficient height or width of residual bone. This
can be overcome with ridge augmentation
procedures that can restore the lost bone volume.
The posterior maxilla may present an additional
obstruction to implant placement due to
pneumatization (increasing size) of the maxillary
sinus. Some patients possess limited crestal bone
height in the posterior maxilla even when teeth are
present and it is not uncommon for the sinuses to
pneumatize further after the extraction of the
posterior teeth.
Pneumatization alone, even without any additional
loss of crestal bone due to periodontal disease,
may be sufficient to prevent the uncomplicated
placement of even short implants in the posterior
maxilla without prior sinus elevation surgery.
Figure 1 and Figure 2 give an example of the
change in bone height that can be achieved with
the lateral window sinus elevation technique.
The surgical technique of maxillary sinus floor
elevation was first published by Boyne in 1980.2 In
the 25 years since that introduction a host of
surgical procedures have been developed to correct
Figure 1. Posterior maxilla with
pneumatized sinus and minimal
crestal bone height. Crestal bone
height in molar region is 3-4 mm.
Figure 2. Maxillary sinus grafted with
Bio-Oss¤ xenograft prior to the
placement of implants. Crestal bone
height is now 15 mm.
the bone deficiency created by sinus pneumatization.
They are all forms of sinus elevation surgery and the
techniques include variations of Boyne s lateral
window antrostomy, the osteotome sinus floor
elevation, crestal core elevation and the localized
management of the sinus floor.3,4,5
Recent evidence-based literature reviews by Wallace,
et al and Del Fabbro, et al have reported remarkable
levels of success for all of these techniques.6,7 In light
of the improved prosthetic options that maxillary
posterior implant placement can make available to our
patients, it is important for both surgical and
restorative dentists to be aware of this therapeutic
approach and know how best to maximize patient
outcomes. This maximization will result from a
decision-making process whereby the proper choices
can lead to an increase in implant survival from the
average sinus lift survival rate of 91.8% to a survival
rate of 98.6%. This is an implant survival rate that is as
good as one can expect with implant placement in the
anterior mandible.
Surgical technique
The lateral window technique begins with a full
thickness mucoperiosteal flap to gain access to the
lateral bony wall of the sinus. An antrostomy, or
window, is made in the lateral wall with a diamond bur
using either a surgical or a high speed hand piece.
The bony window can then be rotated horizontally
along with sinus membrane elevation or it can be
completely removed. The Schneiderian (sinus)
membrane is reflected across the sinus floor and then
superiorly up the medial sinus wall. The elevated
membrane thus becomes the superior and distal
walls of a compartment in the lower 1/3 of the sinus
that will receive the bone graft. Once the graft
material is placed the lateral window should be
covered with a biologic barrier membrane prior to
suturing the flap back into position. The graft is
allowed to mature, with the formation of new bone
around the graft particles, prior to implant placement
simultaneously with grafting if sufficient crestal bone is Figure 10.
present to stabilize them. The implants are given Bio-Gide¤
sufficient time to integrate in the grafted sinus and resorbable
then restored with traditional implant prosthetic collagen
membrane in
components. The surgical procedure is demonstrated place over the
in Figures 3-10. graft

Figure 3.
Full thickness flap
elevated and lateral
window outlined
The goals of the sinus elevation procedure are
the creation of vital bone in the posterior
maxilla, the osseointegration of the implants
placed in that bone and the survival of those
implants under occlusal load.

Figure 4. How successful we are in this endeavor will be

Window outlined affected by the decisions we make about graft
with #8 diamond material selection, membrane placement and
bur implant surface selection

Within the last year, two evidence-based

reviews have been published on the sinus
elevation technique (Wallace & Froum, Del
Fabbro, Testori, et al).6,7
Figure 5.
Outline Evidence-based reviews are structured,
completed with unbiased compilations of the best evidence
sinus membrane available. The data from similar studies is then
visible combined to enlarge the database in order to
achieve greater statistical power.

This combined data is then subjected to

meta-analysis so that the variables that affect
the outcome of this procedure can be isolated
Figure 6. and their affects quantified.
Membrane
elevation initiated Evidence-Based Decision Making
with Hu-Friedy
Kramer #3
curette Graft Materials
Autogenous bone
Autogenous bone was the first graft material to be
Figure 7. widely utilized as a sinus grafting material. Many early
Membrane studies involved the harvesting of a block graft from
elevation the iliac crest and then stabilizing this graft with
completed up implants placed through the remaining crestal bone
the medial wall and into the graft. Autogenous bone grafts from the
of the sinus hip, knee and various intraoral sites have also been
utilized in particulate form. The utilization of grafts of
100% autogenous bone has a number of
disadvantages. Harvesting of this bone generally
involves hospitalization (extraoral) or requires a
Figure 8. second surgical site (intraoral), thus increasing the
Bio-Oss¤ (an length of time of the surgery, the surgical risk and the
organic bovine morbidity of the procedure. Secondarily, clinicians
xenograft) being have reported a more-than-average graft resorption
placed in anterior when using iliac bone.8
compartment
with a syringe A computerized tomographic study by Uchida, utilizing
Sim/Plant diagnostic software, calculated that 5.47 cc
of graft material would be required to graft a sinus for
the placement of multiple 15 mm implants.9 The 11 cc
Figure 9. of graft material required for a bilateral case would
Bio-Oss¤ generally exceed that which could be harvested
(a xenograft) has intraorally. For the above-mentioned reasons it has
been placed to a become practical to utilize bone replacement grafts
height of 15 mm alone, or in combination with autogenous bone, as a
sinus grafting material.
Demineralized freeze-dried bone
Demineralized freeze-dried bone (DFDBA) has
also been utilized as a sinus graft material.
While used successfully by some clinicians, the
results published following the Academy of
Osseointegration Sinus Consensus Conference
showed both poor bone quality and a poor
implant survival rate (85%). Furthermore, this
demineralized graft is susceptible to slumping ,
or settling, with a concomitant loss of graft height.
It has a volumetric resorption rate second only to
that of autogenous bone.8
Xenografts
Xenografts have been very well documented as a
sinus grafting material. They have been used alone
or as part of a composite graft combined with
autogenous bone, venous blood or platelet-rich
plasma. In the Wallace review, the survival rate for
implants placed in xenografts was similar to that of
implants placed in particulate autogenous bone
grafts.6
The Del Fabbro review was even more specific
in the documentation of the utilization of
xenografts. Survival rates for implants placed in
100% xenograft, composite grafts, and 100%
autogenous bone grafts were 96%, 94.9% and
87.7% respectively as seen in Table 1.
Table 1. Implant Survival Rates
with Various Grafting Materials
Type of graft # placed # failed survival rate %
100%
autogenous 3398 418 87.7%
composite graft 2011 103 94.9%
100% bone
replacement 1120 45 96.0%
Studies by Hallman, Hising and Valentini all have
shown a higher implant survival rate when using
100% Bio-Oss® as a bone replacement graft
than when either 100% autogenous bone or
composite grafts of Bio-Oss® and autogenous
bone are utilized.10,11,12
Efficacy of Xenografts
The efficacy of xenografts is likely due to a
combination of factors:
1. Osteoconductivity.
2. Slow resorbability.
3. The residual graft material does not interfere
with osseointegration.
The most important factor that can be
attributed to xenografts is their osteoconductivity.
Osteoconductivity may be defined as the direct
apposition of vital bone on the xenograft surface.
This is very well demonstrated in Figure 11. This
newly formed vital bone (red) is ultimately
responsible for the osseointegration of the implant
in the grafted site.
Figure 11. Osteoconduction. Bone deposition directly
on the Bio-Oss¤ graft particles at 6 months. Stevenel s
blue and picric acid fuchsin (Bio-Oss - yellow, osteoid —
green, new bone — red) Original magnification x 20.
A second feature of the xenograft material is
that it is slowly resorbable when placed in the
maxillary sinus. This quality both prevents
slumping (loss of graft height) and adds
approximately 25% to the overall mineral content
of the matured graft. An average taken from 8
published histological studies showed 25% vital
bone formation, 25% residual xenograft and 50%
marrow in the matured sinus graft. The resulting
50% total mineralized tissue (new bone + residual
graft) makes the future implant receptor site
equivalent in density to that of type 2 (dense) bone.
The third feature is the repeated histological finding
that implants placed in sinuses grafted with
Bio-Oss® are never seen in direct contact with the
graft material. This is evidence that the residual graft
material, while providing support and density, does
not interfere with osseointegration.13,14
Issues of safety are of paramount concern to us as
dentists when placing graft material in the human
body. A great amount of undue concern has been
placed on xenogenic material due to the outbreak
of bovine spongiform encephalopathy (BSE) in
Europe. Regulations and testing of xenografts are
quite extensive. The raw material for U.S. products
is sourced from the long bones of U.S. cattle only.
The material is processed by heat and chemicals to
insure that it is sterile and prion-free. For
Bio-Oss® the proof of deorganification is obtained
through BioRad assay, SDS-PAGE testing and
SDS-PAGE + Western blotting.15,16 To date, there
has never been a reported case of disease
transmission attributed to particulate xenografts.
Membranes
Membrane placement is the second major
variable evaluated in the sinus reviews. The
Wallace review has shown that the utilization of a
barrier membrane over the lateral window has a
positive affect on implant survival.6 The three
controlled trials listed in Table 2 all showed higher
implant survival rates when a membrane was
used.17,18,19 Further, twenty additional studies
showed implant survival with a membrane to be
93.6% compared to 88.7% without a membrane.
Table 2. Membrane vs. No Membrane
(intra-study comparison in controlled trials)
Study with membrane without
membrane
Tarnow, et al17 28 implants - 100% 27 implants - 92.6%
Tawil, et al18 29 implants - 93.1% 32 implants - 78.1%
Froum, et al19 133 implants - 99.2% 82 implants - 96.3%
The advent of guided bone regeneration
techniques in the early 1990 s improved our
ability to repair compromised implant receptor
sites. Sinus grafting may be considered as a form
of guided bone regeneration within a cavity.
Guided bone regeneration utilizes membranes to
isolate the area of regeneration and exclude
non-osteogenic connective tissue from the graft
site. When a membrane is placed over a grafted
bone defect, completely sealing the defect
from the outside environment, the following
characteristics are observed in the regenerated
tissue beneath the membrane:
1. Corticalization of the graft surface.
2. Contiguity of the graft particles.
3. Increased vascularity of the maturing graft.
Histological studies of sinus grafts by Tarnow, et
al and Froum, et al both show these changes as
well as a dramatic increase in vital bone content
when a membrane is utilized compared to cases
where it is not used (25% and 11.8% respectively
in the Tarnow study).17,19 Figure 12 shows a
completely regenerated lateral window area eight
months after sinus grafting with Bio-Oss® and
placing a Bio-Gide® membrane over the window.
Figure 12.
Clinical appearance of lateral window area 8 months
after sinus grafting. Lateral wall is completely restored.
As in guided bone regeneration, the first membranes
widely utilized in sinus grafting were non-resorbable
e-PTFE (Gore-Tex®) membranes. To be effective,
these membranes had to be fixated by tacking them
to the bone surface. Removal of the membrane
required the flap reflection at the time of implant
placement surgery to be as extensive as it was for
the lateral window surgery.
If bioabsorbable barrier membranes could be
utilized over the lateral window, and achieve the
same results, this latter surgery could be less
extensive and therefore less traumatic.
A recent study has compared the results utilizing
either absorbable (Bio-Gide®) or non-absorbable
barrier membranes (e-PTFE, Gore-Tex®) over the
lateral window. The results show both a similar
vital bone formation (17.6% and 16.9%
respectively) and a similar implant survival rate
(97.6% and 97.8% respectively) for the two types
of membranes.20
Implants
A third variable that affects implant survival in
sinus grafts is the surface texture of the implants
that are placed in the graft. Both the Wallace
(Table 3) and Del Fabbro (Table 4) reviews show a
dramatic difference in implant survival when
comparing rough to machined implants.6,7
Table 3. Survival Rates for Rough vs.
Machined Implants
surface std error mean least sq. mean
machined 1.98 82.4 84.0
rough 2.82 95.2 91.6
Table 4. Distribution of Implants and
Overall Survival Rate According to Implant
Surface Texture.
# # # % tot. of implant survival
subgroup studies patients implants implants failures rate %
turned 19 726 2827 40.44% 406 85.64%
rough 18 882 2939 42.05% 115 96.09%
not classified 5 445 1224 17.51% 67
total 2053 6990 100.00% 588
The large differences observed in implant survival
are most likely a result of the known differences in
implant bone contact achieved by the rough and
smooth surfaces. Studies utilizing special
implants that have both surfaces on the same
implant show a large difference in implant bone
contact between the surfaces. By having both
surfaces on the same implant, these studies rule
out the variable of comparing implants that were
placed in different sites.
The study by Lazzara showed bone implant
contact for Osseotite® and machined surfaces
to be 79.7% and 46.5% respectively in good
quality bone but only 51.7% and 8.1%
respectively in poor quality bone.21 Trisi, in a
similar study, has shown that the bone-implant
contact with machined implants is usually less
than you would expect given the bone quality
of the receptor site.22 On the contrary, the
Osseotite® surface always had better than
expected bone contact. Davies has shown that
the textured Osseotite® surface is better able to
stabilize the blood clot on the surface, allowing
for bone formation directly on the surface
(contact osteogenesis).23
The inability of the machined surface to stabilize
the blood clot leads to retraction of the clot and
bone formation away from the implant surface
(distance osteogenesis).
A recent study at the New York University
Department of Implant Dentistry has shown that
machine-surfaced implants are much more likely
to fail than implants with textured surfaces when
placed in sinus grafted cases with reduced
residual crestal bone height.24 This is yet another
clinical deficiency resulting from the poor bone
implant contact that is established with a
machined surface.
Conclusions
One result of the Wallace evidence-based
review was the publication of the following
statement by the American Academy of
Periodontology: 6
There is evidence to indicate that the
lateral window technique for the sinus bone
augmentation procedure is successful at
regenerating sufficient bone for implant
placement. The implant survival rate is greater
than 90% which is similar to implants placed in
native bone. The evidence-based reviews
further identified some of the important
variables that affect the outcome of this
procedure. These variables are listed as
follows:
1. Particulate bone grafts result in a higher
survival rate than block grafts.
2. Bone replacement grafts result in a higher
implant survival rate than autogenous bone
or composite grafts
3. Rough surface implants result in a higher
survival rate than machine-surfaced
implants.
4. Membrane placement over the lateral
window results in a higher implant survival
rate than if a membrane is not used.
Additional studies were presented in the
present paper showing that the xenograft
Bio-Oss® achieves its predictable success
through a combination of its osteoconductivity,
its characteristic slow resorbability and
its lack of interference with the process
of osseointegration. Evidence was also
presented to show that, with regard to
bone formation and implant survival,
comparable positive affects are achieved
with the bioabsorbable Bio-Gide® and the
nonabsorbabe Gore-Tex® e-PTFE barrier
mebranes.
A clinician can utilize an evidence-based
decision-making process to dramatically
improve implant survival rates in the grafted
maxillary sinus. In the Wallace evidence-based
review the average implant survival for the
lateral window procedure was 91.8%. By
making the two decisions to utilize rough
surfaced implants and particulate bone grafts
the implant survival rate became 94.5%. By
making a third decision to place a membrane
over the lateral window, the implant survival
rate became 98.6%.
The ability to place implants in the
compromised posterior maxilla with a very
high predictability will allow us, as clinicians,
to more predictably treat our patients with
more favorable treatment plans. Certainly,
patient function and comfort will be improved
if we choose to place fixed restorations
instead of removable dentures in our partially
and completely edentulous patients.
pg. 12
Author Profile
Stephen S. Wallace, DDS
Dr. Wallace is an Associate Professor at the New York
University Department of Implant Dentistry. He is a
Diplomat of the International College of Oral
Implantologists and a Fellow of the Academy of
Osseointegration. He maintains a private practice in
periodontics in Waterbury, CT. Dr Wallace is a national
and international speaker on topics relating to implant
dentistry. He has published numerous articles on sinus
elevation surgery and the effects of biologic width
around implants. He is an editor of a maxillary sinus
surgery text (Italian) and has authored chapters in sinus
texts in the USA. Dr. Wallace has recently published an
evidence-based review on sinus elevation surgery.
If you have any questions or comments for
the author(s) of this CE course please e-mail
authorquestions@ineedce.com.
Please reference course title & author.
Disclaimer
This course has been made possible through an
unrestricted educational grant by Osteohealth.
Dr. Wallace has been paid an honorarium by
Osteohealth to author this course.
References
1. Branemark 10 or 20 year data article
2. Boyne PJ, James RA. Grafting of the maxillary sinus floor with
autogenous marrow and bone. J Oral Surg 1980;38:613- 616.
3. Summers RB. The osteotome technique: Part 3 — Less invasive
methods of elevating the sinus floor. Compend Contin Educ Dent
1994;15(6):698-708.
4. Toffler M. Site development in the posterior maxilla using
osteocompression and apical alveolar displacement.
Compend Contin Educ Dent 2001;22:775-790.
5. Bruschi GB, Scipioni A, Calesini G, Bruschi E. Localized
management of the sinus floor with simultaneous implant
placement: A clinical report. Int J Oral Maxillofac Implants
1998;13:219-226.
6. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on
the survival of endosseous dental implants. A systematic review.
Ann Periodontol 2003;8:328-343.
7. Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic
review of survival rates for implants placed in the grafted
maxillary sinus. Int J Periodontics Restorative Dent
2004;24:565-578.
8. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the
sinus consensus of 1996. J Oral Maxillofac Implants
1998;13(supplement).
9. Uchida Y, Goto M, Katsuki T, Soejima Y. Measurement of
maxillary sinus volume using computerized tomographic images.
Int J Oral Maxillofac Implants 1998;13:811-818.
10. Hallman M, Sennerby L, Lundgren S. A clinical and histologic
evaluation of implant integration in the posterior maxilla after sinus
floor augmentation with autogenous bone, bovine
hydroxyapatite, or a 20:80 mixture. Int J Oral Maxillofac Implants
2002;17:635-643.
11. Hising P, Bolin A, Branting C. Reconstruction of severely
resorbed alveolar crests with dental implants using a bovine
mineral for augmentation. Int J Oral Maxillofac Implants
2001;16:90-97.
12. Valentini P, Abensur D. Maxillary sinus floor elevation for implant
placement with demineralized freeze-dried bone and bovine
bone (Bio-Oss): A clinical study of 20 patients. Int J Periodont
 Rest Dent 1997;17:233-241.
13. Scarano A, Pecora G, Piatelli M, Piatelli A. Osseointegration in a Course Questions
sinus augmented with bovine porous bone mineral: Histological
results in an implant retrieved 4 years after case insertion. A 1. Inadequate crestal bone height for implant
case report. J Periodontol 2004;75:1161-1166. placement may result from
a. periodontal bone loss.
14. Valentini P, Abensur D, Densari D, Graziani JN, H mmerle CHF. b. pueumatization of the sinus.
Histological evaluation of Bio-Oss¤ in a 2-stage sinus floor c. both of the above.
elevation and implantation procedure. A human case report.
Clin Oral Implants Res 1998;9:59-64. d. none of the above.

15. Benke D, Olah A, M hler. Protein-chemical analysis of Bio-Oss 2. Sinus elevation surgery has been used for how
bone substitute and evidence on its carbonate content. many years?
Biomaterials 2001;22:1005-1012. a. 1
16. Wenz B, Oesch B, Horst M. Analysis of the risk of transmitting
b. 5
bovine spongiform encephalopathy through bone grafts derived c. 15
from bovine bone. Biomaterials 2001;22:1599-1606. d. 25
17. Tarnow DP, Wallace SS, Froum SJ. Histologic and clinical 3. Variations in sinus elevation surgery include:
comparison of bilateral sinus floor elevations with and without a. lateral window antrostomy.
barrier membrane placement in 12 patients: Part 3 of an b. osteotome sinus elevation.
ongoing prospective study. Int J Periodontics Restorative Dent c. crestal core elevation.
2000;20:116-125.
d. all of the above.
18. Tawil G, Mawla M. Sinus floor elevation using a bovine bone
mineral (Bio-Oss) with or without the concomitant use of a 4. Implant survival in the grafted maxillary
bilayered collagen barrier (Bio-Gide): A clinical report of sinus is:
immediate and delayed implant placement. Int J Oral Maxillofac a. generally poor.
Implants 2001;16:713-721. b. generally favorable.
19. Froum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho S-C. c. as high as implant placement in
Sinus floor elevation using anorganic bovine bone matrix non-grafted bone.
(OsteoGraf/N) with and without Autogenous bone: A clinical, d. much lower than that seen in non-grafted
histologic, radiographic, and histomorphometric analysis — bone.
Part 2 of an ongoing prospective study. Int J Periodont Rest
Dent 1998;18:529-543. 5. Surgical technique for the lateral window
20. Wallace SS, Froum SJ, Tarnow DP, Cho S-C. Sinus procedure
augmentation using anorganic bovine bone (Bio-Oss¤) with a. utilizes flapless surgery.
bioabsorbable and non-absorbable membranes. Int J b. involves split thickness flap techniques.
Periodontics Restorative Dent 2005;25: accepted for c. involves full thickness flap entry.
publication. d. involves bone surgery only.
21. Lazzara RJ, Testori T, Trisi P, Porter S, Weinstein RL. A human
histologic analysis of Osseotite and machined surfaces using
6. Exposing the sinus membrane is accomplished
implants with 2 opposing surfaces. Int J Periodontics a. with bone chisels.
Restorative Dent 1999;19:117-129. b. with osteotomes.
c. with burs.
22. Trisi P, Lazzara RJ, Rao W, Rebaudi A. Bone — implant contact d. with all of the above.
and bone quality: Evaluation of expected and actual bone
contact on machined and Osseotite implants. Int J Periodontics 7. Once outlined, the bony window in the
Restorative Dent 2003;23:535-546.
lateral wall
23. Dziedzic DM, Davies JE, et al. Proceedings of the 5th a. is hinged superiorly.
Biomaterials conference.University of Toronto Press 1996:124. b. is removed.
c. both a and b above.
24. Wallace SS, Elian N, Kim MG, Kim BS, Zaky J, Cho SC, Froum d. neither a or b above.
SJ, Tarnow DP. The relationship between residual crestal bone
height and the implant survival rate in the augmented maxillary
sinus. Submitted for publication Jan 2005. 8. The goals of sinus elevation are
a. the creation of bone in the maxillary sinus.
b. integration of implants in the grafted
Registered Trademarks sinus.
c. having the placed implants function under
load.
Bio-Oss® and Bio-Gide® are registered trademarks of Ed. d. all of the above.
Geistlich S ehne Ag Fuer Chemiche Industrie, licensed by
Osteohealth Company. 9. The best information that we have for
achieving predictable results with the sinus
Osseotite® is a registered trademark of Implant elevation procedure are
Innovations, Inc. a. expert opinions.
b. evidence-based reviews.
c. commercial advertising brochures.
Gore-Tex® is a registered trademark of W.L. Gore & d. hands-on courses.
Associates, Inc.
10. Evidence-based reviews are good sources of
information because they
a. are unbiased.
b. consider the best available evidence.
c. gain statistical power by combining like data.
d. all of the above.

11. Three important variables discussed in the

evidence-based reviews are
a. type of graft material, use of a membrane,
sterile surgical technique.
b. method of flap entry, handling of the bone
window, use of membrane.
c. type of graft material, use of a membrane,
type of implant surface.
d. handling of the bone window, sterile
surgical technique, use of membrane.

pg. 13
12. The first graft material to be utilized
extensively in sinus grafting was
a. autogenous bone.
b. demineralized freeze-dried bone.
c. composite grafts.
d. xenografts.
13. Disadvantages when using autogenous bone
may include
a. need for hospitalization.
b. need for a second surgical site.
c. re-pneumatization of the sinus following
grafting.
d. all of the above.
14. Harvesting autogenous bone
a. increases surgical time.
b. increases morbidity.
c. increases surgical risk.
d. all of the above.
15. Demineralized freeze-dried bone as a graft
material
a. cannot be utilized successfully due to lack
of mineral.
b. maintains its volume after grafting.
c. appears to have a lower success rate
than other graft materials.
d. must be used as a composite graft.
16. Xenografts for sinus grafting have been used
a. alone.
b. mixed with blood.
c. as composite grafts with autogenous
bone.
d. all of the above.
17. Xenografts like Bio-Oss® are successful
because they
a. are osteoconductive.
b. are slowly resorbable.
c. do not interfere with osseointegration.
d. all of the above.
18. The most important factor in the success of
Bio-Oss® as a graft material is its
a. slow resorbability.
b. osteoconduction.
c. non-interference with osseointegration.
d. ready availability.
19. Bio-Oss® bone replacement graft material
a. is provided sterile.
b. is prion-free.
c. has a 100% safety record as a graft
material.
d. all of the above.
20. A bone replacement graft may be considered
osteoconductive if
a. vital bone forms directly on its surface.
b. it is slowly resorbed.
c. it has a high mineral content.
d. it is safe and readily available.
21. Studies on implant survival with various
grafting materials show highest implant survival
rates when which of the following is utilized
a. 100% autogenous bone.
b. composite grafts that include autogenous
bone.
c. 100% bone replacement grafts.
d. all of the above.
22. One of the following results is not seen when
a membrane is placed over the lateral window
a. corticalization of the graft surface.
b. fixation of the graft to the membrane
surface.
c. contiguity of the graft particles.
d. increased vascularity of the maturing
graft.
pg. 14
23. When compared to bioabsorbable barrier
membranes, non-absorbable (e-PTFE) barrier
membranes placed over the window
a. give better results.
b. are easier to place.
c. are easier to remove.
d. none of the above.
24. In a study comparing the bioabsorbable
Bio-Gide® membrane to the non-absorbable
e-PTFE membrane, use of the Bio-Gide®
membrane resulted in
a. the same bone quality.
b. the same implant survival rate.
c. less invasive implant placement surgery.
d. all of the above.
25. Use of a membrane over the lateral window
results in the following:
a. increase in vital bone percentage in the
matured graft.
b. increase in implant survival on implants
placed in the grafted sinus.
c. both a and b above.
d. neither a or b above.
26. With regard to implant surface
micromorphology, both the Wallace and Del
Fabbro reviews have shown6,7
a. higher implant survival with textured than
machined surfaces.
b. higher implant survival with machined
than textured surfaces.
c. similar implant survival with both surfaces.
d. no comparisons could be made due to
insufficient data.
27. The difference in implant survival between
the rough and machined surfaced implants were
said be due to which of the following
a. better primary stability with the rough
surface.
b. better clot retention on the rough
surfaced implants.
c. better implant to bone interface on the
rough surfaced implants.
d. b and c above.
28. The better implant to bone interface on the
rough surface is due to
a. greater primary stability achieved with the
rough surfaced implants.
b. contact osteogenesis.
c. distance osteogenesis.
d. the use of implants with 2 surfaces.
29. According to a recent NYU study, the
increased failure rates when implants are placed
into minimal crestal bone may be due to
a. a general lack of primary stability.
b. the micro-motion resulting from
inadequate primary stability.
c. the poor implant to bone contact
achieved with the machined surface.
d. all of the above.
30. The high implant survival rates that can be
achieved with maxillary sinus grafting allow
clinicians to
a. predictably treat patients with a
compromised posterior maxilla.
b. utilize fixed as opposed to removable
appliances.
c. successfully place implants in the
compromised posterior maxilla.
d. all of the above.
 ANSWER SHEET
Maxillary Sinus Augmentation:
This course is intended for dentists, dental hygienists, and dental assistants.
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11. Would you participate in a program similar to this one in the future
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_______________________________________________________ 15. A B C D E 30. A B C D E
AUTHOR(S) SPONSOR/PROVIDER necessarily reflect those of the ADTS. Completing a single
Stephen S. Wallace, DDS The Academy of Dental Therapeutics and Stomatology, Inc. continuing education course does not provide enough
(ADTS) is the only sponsor/provider. This course was made information to make the participant an expert in the field
AUTHOR(S) DISCLAIMER possible through an unrestricted educational grant from related to the course topic. It is a combination of many
Dr. Wallace has been paid an honorarium by Osteohealth Osteohealth. No manufacturer or third party has had any educational courses and clinical experience that allows the
to author this course. input into the development of course content. All content has participant to develop skills and expertise.
been derived from references listed and the opinions of
EDUCATIONAL OBJECTIVES clinicians. Please direct all questions pertaining to the ADTS PARTICIPANT FEEDBACK
This article will focus on the lateral window sinus elevation or the administration of this course to the Program Director, Please e-mail all questions to aeagle@ineedce.com, or fax
procedure. Its role as a preprosthetic surgical procedure will P. O. Box 116, Chesterland, OH 44026 or aeagle@ineedce.com. (216)398-7922.
be discussed and the surgical technique presented. An
evidence-based decision process will be presented so that COURSE CREDITS/COST RECORD KEEPING
appropriate decisions can be made that will lead to the most All participants scoring at least 70% (answering 21 or more The ADTS maintains records of your successful completion
positive patient outcomes. questions correctly) on the examination will receive of any exam. Please contact our offices for a copy of your
verification of 4 CEUs. The formal continuing education continuing education credits report. This report, which will list
After reading this article the clinician will be able to: program of this sponsor is accepted by the AGD for all credits earned to date, will be generated and mailed to you
Fellowship/Mastership credit. For current term of acceptance within five business days of receipt of your request; a report
1. Identify appropriate graft materials for sinus surgery. please contact the ADTS. “DANB Approval” indicates that a fee of $25 will be billed to you.
continuing education course appears to meet certain
2. Compare implant survival rates pertaining to membrane specifications as described in the DANB Recertification CANCELLATION / REFUND POLICY
placement. Guidelines. DANB does not, however, endorse or Any participant who is not 100% satisfied with this course
recommend any particular continuing education course and can request a full refund by contacting the Academy of
3. Select implants based on surface texture. is not responsible for the quality of any course content. Dental Therapeutics and Stomatology in writing.
Participants are urged to contact their state dental boards for
INSTRUCTIONS continuing education requirements. The cost of this course is COURSE EVALUATION
All questions should have only one answer. Grading of this $55.00. We encourage participant feedback pertaining to all courses.
examination is done manually. Participants will receive Please be sure to complete the attached survey included
verification of passing by mail within two weeks after taking EDUCATIONAL DISCLAIMER with the answer sheet.
an examination. The opinions of efficacy or perceived value of any products
or companies mentioned in this course and expressed © 2005 The Academy of Dental Therapeutics and Stomatology
herein are those of the author(s) of the courses and do not

pg. 15