Cairo Dental Journal (25)

Number (1), 43:52

Janurary, 2009

Long term follow up for Closed Technique

of sinus lift with simultaneous implantation
with and without grafting Using Direct
Digital Radiography and CT scan
Hanan M.R Shokier1 and Naglaa Shawky2
1. Lecturer of Oral and Maxillofacial Surgery, Faculty of Oral and Dental Medicine, Azhar university
Girl Branch
2. Lecturer of Oral radiology and Diagnosis, Faculty of Oral and Dental Medicine, Azhar university
Girl Branch

..

Abstract
ehabilitation of Posterior maxillary using dental implant is considered a problem. This
is not only for poor bone quality but also due to decrease in adequate bone height

as a result of sinus pneumatization and or alveolar ridge resorption .Reconstruction

of posterior maxilla through inlay grafting of maxillary sinus can be done through open or closed
sinus lift .Closed technique is considered less invasive technique that allow upwardly displace sinus
floor lining with simultaneous implantation using osteotome .This study was done to evaluate the
success rate of closed sinus lift with simultaneous implantation at 60 months postoperatively using
both digital radiography and CT scan for grafted and ungrafted sides .Ten patients with bilaterally
missing upper six molar and atrophic alveolar ridge (only 5 to 7 mm height from crest of ridge to
sinus floor )were selected ,bilateral sinus lift in both sides were done for every case with simultaneous
implantation. one side with Frios algipore as alloplastic graft and the other without grafting .After 9
months ,fixed crowns were constructed and the cases were followed up for 60 months as a long term
follow up study both clinically and radiographically At the end of follow up period one implant out of
twenty was failed ,the other nineteen implants showed proper ossoeintegration.,the bone density and
height below elevated sinus lining increased in both grafted and ungrafted sides .The increase in the
grafted side was not significant.

..

INTRODUCTION

into antrum (Wagner 1991).

Posterior maxillary region is often a problematic area

Unfortunately the additional height of the ridge result

for insertion of dental implants. In addition to the post

in decreased inter-arch space, therefore augunentation

extraction atrophic changes that occur to the posterior

of bone into the maxillary sinus floor without downward

alveolar ridge, the pneumatization of maxillary sinus

movement of maxilla is the most advantageous (Blitzer

adds to the problem and may lead to implant perforation

et al 1985 )

(44)

Misch 1999 reported that open sinus graft procedure

has been considered the most predictable method to

grow bone height up to 20 mm compared with any other
intra oral grafting technique with graft success rate and
an implant survival rate greater than 98 %. In spite that
open technique of sinus lift has achieved high success
rate but also multiple complications have been reported.
It is an invasive difficult procedure with multiple
complications, as lining tear with graft lost inside the
sinus, injury to infra orbital neurovascular bundle with
severe hemorrhage, that can not be controlled by electrosurgery for fear of lining necrosis with graft loss, and
difficult access in case of multiple septa ,in which the
osteotomy must be done between these septa (Bergh
et al 2000).
Other surgical techniques have been developed to
overcome the drawbacks of open sinus lift technique.
Summer 1994 introduced a less invasive alternative
for sinus floor elevation with concurrent grafting and
immediate implantation. In this technique, he conserved
both the bone removed during implant preparation and
added additional graft material to upwardly displace the
floor of sinus through small localized area with no need
for membrane dissection or long term treatment. Closed
technique of sinus lift is indicated for patients who have
at least 5 to 6mm of bone remaining between the crest
of the ridge and floor of sinus, as the initial stability of
implant is from the pre existing bone under antral floor
(Summer 1994).

Rosen et al 1999 Maksoud 2001 and awike 2003

reported that the most important negative factor in

closed technique of sinus lift is that it is less predictable

when there is 4mm or less of pre-existing alveolar bone

height beneath-the sinus. Another complication is the

perforation of membrane, loss of graft material inside the

sinus with antrum infection, dislodging the implant or

paralleling pin into the maxillary sinus and development

of mucocele inside the bone graft mass with obliteration

of sinus (Regve et al., 1995)

Different graft materials have been used to augment

the sinus floor to increase the bone available for implant

installation. It is either Autogenous graft, Allogenic

grafts, Xenografts and Allo-plastic grafts:

Frios Algipore is a alloplastic materials that is

obtained from calcium encrusted sea algae. It consists of

100% inorganic, biocompatible calcium phosphate over

95% of the composition is in the form of apatite and is

highly analogus to bone apatite.(Kasperk.,et al,1988) The

main advantage of Frios algipore is that, it is structurally,
chemically and physiologically analogus to natural bone

with continous resorption that allow replacement of

it with bone of the host.(Bieniek,et al 1989 ),Also the

high porosity of Frios Algipore result in excellent blood

absorption and coagulation behavior, that activate new

bone formation ( Hotz et al 1990 ),hence this study was

planned to make long term follow up for closed technique

of sinus lift with simultaneous implantation with and

Rosen et al., 1999 explained that, the tips of

these osteotomes have a concave nose and sharp edge
which can be used to shave bone from the side wall of
osteotomy site. In addition to its tapered form that allow
the instrument to penetrate easily also it can compress
bone creating a denser area for implant placement with
no heat generation,

without grafting .

Closed technique of sinus lift was divided by Summer

1994 into 2 techniques, osteotome sinus floor elevation
(OSFE) and bone added osteotome sinus floor elevation
(BAOSFE) in which Graft material is used on the top of
osteotome to elevate the sinus floor and act as a hydraulic

40 years old.

plug to push up the sinus boundary (Misch, 1999).

..

Materials and Methods

Ten partially edentulous patients of both sexes were

selected from out-patient clinic, Oral Surgery Department,

Faculty of Oral and Dental Medicine, Cairo University,

their ages ranged from 20 to 50 with an average age of

The selection was according to the following criteria

All patients were apparently in good general health,

with missing upper first or second molars bilaterally,

with pneumatization of their maxillary sinuses and there

(45)

is at least six-millimeters of remaining alveolar height

between the floor of maxillary sinus and the crest of
alveolar ridge at the site of osteotomy as indicated from
the diagnostic panoramic radiographs.

Each patient received 2 implants one on each side

of maxillary dental arch at the edentulous site of missing

first or second maxillary molar.

The osteotomy sites of each selected patient were

divided into two groups.

The implant was installed after closed sinus lifting

without using any grafting material. (Gel-foam was used).

The same as in group 1, but (Frios algipore) was used

as a graft material to elevate sinus lining before implant

insertion (without using gel-foam).

Surgical procedures for implant installation

Per-apical and panorama was done preoperative for

every case to determine bone length below sinus floor

A. surgical template was constructed to localize the

First surgical phase (fixture installation)

A pyramidal muco-periosteal flap was performed in
the prepared surgical site area using No.15 surgical blade.
The surgical stent was introduced in the patients mouth,
to mark the fixture site using round surgical bur. Then
drilling was started using a 1.6 mm diameter pilot drill
and continued to size 2.8 mm
Then the osteotome of 3-mm diameter was used to
complete the enlargement of the osteotomy site. The
osteotomy so produced was completed 2 mm shorter of
the antral floor.
The osteotomy of the other side was prepared by the
same technique. Both osteotomy sites were enlarged until
its diameter were equal to the size of the intended implant,
hence, the osteotomy site was enlarged to size 3-mm for
implant diameter size of 3.7-mm and to diameter of 4-mm
when implant diameter size was 4.5-mm.
In the osteotomy of the first implant site the osteotome
was advanced into the osteotomy site with light malleting
using gelfoam over the concave tip of the osteotome
(Group I). While in the second osteotomy site, Frios
Algipore graft material was carried on the concave tip
of the osteotome to be inserted into the osteotomy site
before any attempt was made to raise the sinus floor
(Group II) ( Fig. 1) .

standard position of implant placement:

B. Implant selection :

SEMADOS Root form internally hexed pure titanium

grade 4 implants with aluminum-oxide blasted surface1

were selected.The diameters of implants were selected

either 3.75 or 4.5-mm according to ridge width while the
implants length was selected 3 to 4 mm longer than the
host site.

All selected patients were instructed to take a dose of

betalactame clavulanate amoxicillin2 625 mg every eight

hour preoperatively for one day before surgery.

Fig. (1) Using of osteotome in closed sinus lift

1. Titanium Srew implant. Semados implant system. BEGO.Germany.

2. Augumentine 625 mg consists of Amoxicillin 500 mg and k Clavulanate 125 mg, Beecham pharmaceuticals medical
union,company, Egypt, under license from a smith kline Beecham co., England

(48)

Bone height below sinus lining along mesial part

of fixtures

The mean value of bone height was 7.56 mm along

the mesial part of fixture below sinus lining one day after

closed sinus lift and become 9.76 mm at 18 months and

The mean value of bone height was 6.57 mm along
the mesial part of fixture below sinus lining one day after
closed sinus lift and become 8.01 mm at 18 months and
increased to 13 mm at 60 months postoperatively in the
side of closed sinus lift with simultaneous implantation
without grafting (Fig 3)

increased to 11.5 postoperatively)in the side of closed

sinus lift with simultaneous implantation with grafting.

The change in bone height over time interval along

mesial sides was statistically significant: p value,<0.001
.The difference in the mean value of bone height between

grafted and ungrafted side along mesial sides of fixture

was statistically non-significant (p=0.186) (Fig 4) .

Fig. (3) One, eighteen, sixty months Post sinus lift in the ungrafted side using DDR showing increased in bone

height and density along apical part of fixture

Fig. (4) One,eighteen, and sixty months Post sinus lift in the grafted side using DDR showing increased in bone

height and density along apical part of fixture.

(50)

proper engagement and initial stabilization of implant in

cases of closed sinus lift technique with simultaneous
implantation.(Orset et al., 1998 and Cavicchia, 2001).
Regarding implant selection, the shortest implant
used in this study was 10 in mm length, as this length is
considered the least value of 3.75-mm Diameter-implant
that could tolerate masticatory forces without failure
(Speikremann et al., 1995).
Preoperative antibiotic was given one day before
surgeryand extend for 5 days postoperatively . Peterson
LJ 1990 and Olson., 1984 found that the incidence of
infection in sinus graft procedure is about 10% to 15%
but can be reduced to 1% with using excellent technique
and prophylactic antibiotic .
Incision line was made buccal to crest of the ridge
to enhance vision during surgery and ensure complete
coverage of implant after suturing, therefore, minimizing
the risk of implant contamination during healing period
and preventing epithelial cells down-growth. Also
infection control was considered during surgical stages
under strict aseptic condition to enhance success of
osseointegration (Cranin et al., 1993 and Speikerman
et al., 1995).
Closed technique was preferred to open technique in
sinus lift as it is a less invasive technique that enables
placement of implants of 10 millimeter or longer
simultaneously with reduction in operative time ,better
postoperative comfort and preservation of the sinus cavity
integrity compared with conventional sinus graft(open
technique)
(Dvarpanah et al.,2001)
Depending on osteotomes mainly during implant bed
preparation was suitable with the poor bone quality of
maxilla as osteotomes compressed the bone horizontally
and vertically creates a denser area for implant placement
with no dehiscence or heat generation, in addition to
great tactile sensitivity with the use of osteotome. (
Awike, 2003)
Frios Algipore was selected as a grafting material
as it matches the biological properties and the natural
architecture of natural bone and the close similarity of
its (H-A) to that of enamel makes it able to bind certain

bone matrix growth factors when its granules were

implanted sub-periosteally. Moreover the phycogenic
material showed bone formation on its granules and easily
vascularised by penetration of its pores with capillaries
(Kasperk 1988)
In the non grafted site collagen sponge was used above
the concave tip of osteotome during fracture of the sinus
floor to protect the lining against accidental tear, also it
acts as a barrier between the sinus and the implant that
provides some useful space for blood clot stabilization
This is in addition to the consistency of collagen sponge
that is not easily to displace into the sinus and if accidental
protrusion of the material occurs, such material is easily
resorbed (Cavicchia 2001).
Radiographic evaluation was carried out using
Digora computerized system which allows storing and
manipulation of the radiographic information through the
image processing. This system eliminates conventional
radiographic limitations due to processing, loss of some
radiographic details, and ensures accurate recording of
bone density around apical part of fixture below sinus
lining (Lazzerini et al., 1996).
Using of Long cone paralleling technique with Rinn
XCP periapical film holder and individually constructed
acrylic resin template allows obtaining a series of
accurate and repeatable radiographs and fixing the target
to the film distance every follow up period. Also using
long cone directed only the parallel rays to the imaging
plate, thus preventing divergence of X-rays and image
magnification (Plotnick et al., 1971).
Using linear density measurements rather than area
measurements in evaluating bone density were of great
benefit in preventing the overlapping of root or implant
part over the measured area, which might affect the
results .Also a mean of the three linear measurements at
each recorded side rather than single measurement could
also help to minimize the error.
During follow up periods ,the mean value of bone
density around apical part of fixture below sinus lining
was increased in both grafted and un-grafted side at 1, 3,
9 months postoperatively and decreased at 18 months
postoperatively for both sides and then increased

(48)

Bone height below sinus lining along mesial part

of fixtures

The mean value of bone height was 7.56 mm along

the mesial part of fixture below sinus lining one day after

closed sinus lift and become 9.76 mm at 18 months and

The mean value of bone height was 6.57 mm along
the mesial part of fixture below sinus lining one day after
closed sinus lift and become 8.01 mm at 18 months and
increased to 13 mm at 60 months postoperatively in the
side of closed sinus lift with simultaneous implantation
without grafting (Fig 3)

increased to 11.5 postoperatively)in the side of closed

sinus lift with simultaneous implantation with grafting.

The change in bone height over time interval along

mesial sides was statistically significant: p value,<0.001
.The difference in the mean value of bone height between

grafted and ungrafted side along mesial sides of fixture

was statistically non-significant (p=0.186) (Fig 4) .

Fig. (3) One, eighteen, sixty months Post sinus lift in the ungrafted side using DDR showing increased in bone

height and density along apical part of fixture

Fig. (4) One,eighteen, and sixty months Post sinus lift in the grafted side using DDR showing increased in bone

height and density along apical part of fixture.

(52)

6- Burger Veldhuijzen JP:Inffluence of mechanical factors on

19- Orset G. Komarnyckyj,DDS Robert M.London,DDS 1998

bone formation ,resorption and growth in vitro .In Hall K,editor

Osteotome single stage Dental implant placement with and

:Bone growth,Melbourne1993,CRC press .,(from misch 327)

7- Buckly MJ:osteoblasts increase their rate of division and align in
response to cyclic,mechanical tension in vitro,Bone Miner 4:225236,1988 quated from contempory implant dentistry,second
edition,mosby co.,st louis,Chicago,London,Toronto 1999
8- Cavicchi F.; Brafi F. and Giuliano P. : Localized augmentation
of the maxillary sinus floor through coronal approach for the
placement of implants. Int. J. Periodontics Restorative Dent.,
21: 475-485, 2001
9- Cranin A., Klein M and Simons A.: Atlas of implantology.
Mosby Publishers Inc. New York. 1999.
10 Davar Panah M.; Martinez H.; Francois Tecucianu J.; Hage
G.; Lazzara R.: The modified osteotome technique. Int. J.
Periodontics Restorative Dent., 21: 599-607, 2001.
11- Hassler CR, Rylicky EF,Cummings KD et al; Quantification of
bone stress during remodling,J Biomech 13:185-190,1980 .
12- Isaksson S.: Evaluation of three bone grafting techniques
for severly resorbed maxillae in conjunction with immediate
endosseous implants the international Journal of Oral &
Maxillofac. Implants, 9: 679-688. 1994
13- Kasperk C,Ewers R, Simon B,Kasperk K,Bone replacement
material from Algae ,Dtsch Zahnazllz 43,116-119.1988 .
14- Kent J.N. and block M.S.: Simultaneous maxillary sinus
floor bone grafting and placement of hydroxyl apatite coated
implants. J. Oral Maxillofac. Surg., 47 : 238, 1989.
15- Lazzerinni, F., Minorati, D., Nessi, R. and Gagliani, M.:
Measurement parameters in dental radiology. A comparison
between traditional and digital technique. J. Radiol., Med., 91:
364, 1996.
16- Misch C.: Contemporary implant dentistry. Second edition.
Mosby co., St. Louis, Chicago, London, Toronto; 1999.
17- Maksoud M.: Complication after maxillary sinus augmentation:
a case report implant dentistry; 10 (3) : 168 170, 2001.
18- Olson M,OConnor M,Schwartz ML:Surgcal wounds infection

without sinus elevation:A Clinical report .Int J Oral,Maxillofac

Implants. 13 :799-804.1998
20- Peterson LJ:Antibiotic prophylaxis against wound infections in
Oral Maxillofac Surg 48:617-620 1990.
21- Peterson, Thomas A,Marciani: Oral and Maxillofascial Surgery,
Philadephia,WBsaunders 1997
22- Piecuch JF., Goldberg AJ.,Shastry CV.,Chrzanowski RB.:
Compressive strength of implanted porous replamine form
H.A. J Biomed Mater Res 18; 39-45.1984
23- Rosen P.S.; Summers R.; Mellado J.; Salkkin L.; Shanaman
R.; Marks M.; Fugazzotto P.: The bone added osteotome sinus
floor elevation technique: Multicenter retrospective report of
consecutively treated patients. Int. J. Oral Maxillofac. Implant,
14: 853-858, 1999
24- Regve E.; Smith R.A.; Perott D.H. and Pogrel M.A.: Maxillary
sinus complications r elated to endosseous implants: Int. J. Oral
& Maxillofac. Implants. 10: 451, 461, 1995.
25- Spiekermann H., Donath K. Hassell T., Jovanovic S. and Richter
J.: Color Atlas of Dental Medicine. Theme Medical Publishers,
Inc., New York 1995.
26- Summers R.B.: The osteotome technique : part 3 less invasive
methods of elevating the sinus floor compend contin Edue
dent., Vol. XV, No 6.1994
27- Tatum H.: Maxillary sinus implant reconstruction. Dent. Clin
North Am., 30 : 207-229, 1986.
28- Ten Cate R. et al.: Oral Histology. Development, Structure, and
Function. Mosby Publishers Inc. New York. 1999.
29-Wagner J.R.: A 3 1/2 year clinical evaluation of resorbable
hydroxyl apatite osteogen (HA Resorb) used for sinus lift
augmentations in conjunction with the insertion of endosseous
implants. J. Oral Implantol., 17 : 152, 1991.
30- White E, Shors EC.: Neo-material aspects of Interpore-200

:a 5 year prospective syudy of 10,i93 Wounds at the Minneapolis

porous hydroxyl apatite, Dent Clin North Am 1986:30; 49-

VA Medical Center ,Ann Surg 199:253,1984

67.1986

(50)

proper engagement and initial stabilization of implant in

cases of closed sinus lift technique with simultaneous
implantation.(Orset et al., 1998 and Cavicchia, 2001).
Regarding implant selection, the shortest implant
used in this study was 10 in mm length, as this length is
considered the least value of 3.75-mm Diameter-implant
that could tolerate masticatory forces without failure
(Speikremann et al., 1995).
Preoperative antibiotic was given one day before
surgeryand extend for 5 days postoperatively . Peterson
LJ 1990 and Olson., 1984 found that the incidence of
infection in sinus graft procedure is about 10% to 15%
but can be reduced to 1% with using excellent technique
and prophylactic antibiotic .
Incision line was made buccal to crest of the ridge
to enhance vision during surgery and ensure complete
coverage of implant after suturing, therefore, minimizing
the risk of implant contamination during healing period
and preventing epithelial cells down-growth. Also
infection control was considered during surgical stages
under strict aseptic condition to enhance success of
osseointegration (Cranin et al., 1993 and Speikerman
et al., 1995).
Closed technique was preferred to open technique in
sinus lift as it is a less invasive technique that enables
placement of implants of 10 millimeter or longer
simultaneously with reduction in operative time ,better
postoperative comfort and preservation of the sinus cavity
integrity compared with conventional sinus graft(open
technique)
(Dvarpanah et al.,2001)
Depending on osteotomes mainly during implant bed
preparation was suitable with the poor bone quality of
maxilla as osteotomes compressed the bone horizontally
and vertically creates a denser area for implant placement
with no dehiscence or heat generation, in addition to
great tactile sensitivity with the use of osteotome. (
Awike, 2003)
Frios Algipore was selected as a grafting material
as it matches the biological properties and the natural
architecture of natural bone and the close similarity of
its (H-A) to that of enamel makes it able to bind certain

bone matrix growth factors when its granules were

implanted sub-periosteally. Moreover the phycogenic
material showed bone formation on its granules and easily
vascularised by penetration of its pores with capillaries
(Kasperk 1988)
In the non grafted site collagen sponge was used above
the concave tip of osteotome during fracture of the sinus
floor to protect the lining against accidental tear, also it
acts as a barrier between the sinus and the implant that
provides some useful space for blood clot stabilization
This is in addition to the consistency of collagen sponge
that is not easily to displace into the sinus and if accidental
protrusion of the material occurs, such material is easily
resorbed (Cavicchia 2001).
Radiographic evaluation was carried out using
Digora computerized system which allows storing and
manipulation of the radiographic information through the
image processing. This system eliminates conventional
radiographic limitations due to processing, loss of some
radiographic details, and ensures accurate recording of
bone density around apical part of fixture below sinus
lining (Lazzerini et al., 1996).
Using of Long cone paralleling technique with Rinn
XCP periapical film holder and individually constructed
acrylic resin template allows obtaining a series of
accurate and repeatable radiographs and fixing the target
to the film distance every follow up period. Also using
long cone directed only the parallel rays to the imaging
plate, thus preventing divergence of X-rays and image
magnification (Plotnick et al., 1971).
Using linear density measurements rather than area
measurements in evaluating bone density were of great
benefit in preventing the overlapping of root or implant
part over the measured area, which might affect the
results .Also a mean of the three linear measurements at
each recorded side rather than single measurement could
also help to minimize the error.
During follow up periods ,the mean value of bone
density around apical part of fixture below sinus lining
was increased in both grafted and un-grafted side at 1, 3,
9 months postoperatively and decreased at 18 months
postoperatively for both sides and then increased

(51)

gradually during follow up period for

postoperatively in both sides .

60 months

The gradual increase in bone density below sinus

lining in both gafted and un-grafted sides may attributed
to the osteogenic activity of the peri-osteal layer of
sinus lining in response to stimuli caused by closed
sinus lift with simultaneous implantation. This is in
accordance with, Kent 1989, Burger and Veldhuijzen
1993 and Tencate 1998 who explained that intrusion
of grafts, physiologic stimuli, mild strain or even teeth
to the maxillary alveolar ridge below sinus-lining cause
reactive-bone formation below the sinus floor, where the
osteoblasts of the peri-osteal layer of sinus lining exhibit
a more differentiation state with an increase in alkaline
phosphatase and matrix protein production. In addition,
Misch 1999 mentioned that surgical placement of dental
implants elicit an ostoegenic response that is largely
driven by local cytokines and growth factors.
While, the significant increase in bone density in the
grafted side might be due to the effect of Frios Algipore
as grafting material below sinus lining. White et al, 1986
described this grafting material as it is granule form
mimcs the macrostructure of natural bone with continuous
uniform channels and interconnected pores that allow for
optimal permeability that encourages tissue in growth,
vascularization ,and deposition of new bone .He added
that the bone healing around this type of bone graft
characterized by fibrovascular invasion at first followed
by osteoblastic invasion, organization and completed by
lamellar bone apposition on the graft surface .
At 18 months postoperatively the bone density below
sinus lining around apical part of fixture decreased for
both group but with more significant decrease in the
ungrafted side .This was explained by different opinions.
Hassler et al., 1980 found that when stresses on bone
cells (osteoblast) exceed 6.9 x10 N/mm cell destruction
occur with decrease in their number.
Buckley et al 1988., explained the decrease in bone
density as a result of break down in cellular attatchment
with cells migration in an attempt to minimize the strain
to which they subjected. Also Burger and Veldhuizen
1993 attributed the decrease in bone density to the

decrease in the differentiation of osteoblasts and decrease

in their production of alkaline phosphatase and bone
matrix proteins as a result of strain..
The decrease in bone density below sinus lining in
the grafted side at eighteen months postoperatively
might occur as a
in spite of using grafting material
result of graft resorption or degradation .Holmes 1979
examined the histological feature of the regenerated
bone after grafting with Frios Algipore and said that the
newly formed bone was of immature woven bone up to
two months, by six months it had matured into lamellar
bone and after 12 months bio degradation of 29% of it
occur. While Piecuch et al., 1984 explained the decrease
in density of regenerated bone with loading as a result
of low compressive strength of Frios Algipore and the
ability of augmentation material to shatter under peak
load into fragments.
The increase in bone density at 60 months
postoperatively for both grafted and ungrafted sides may
be due to the maturation of newly formed bone below
lining that occurred with functioning ,also the resorption
of alloplastic (frios algipore ) and its replacement with
autogenous bone in the grafted side . (Misch 1999 )
described alloplastic graft as space filler that is completely
resorbed before replacement with autogenous bone.so the
difference in bone density between grafted and ungrafted
was not significant .

..

Refrences

1- Awike K.M.: The use of osteotomes with internal sinus floor

elevation. Dental News, volume X, 1, 2003.

2- Bergh V ,D ; Bruggenkateten C.M.; Disch F.J.M. and Tuinzing

D.B.: Anatomical aspects of sinus floor elevations. Clin. Oral

Impl , 11 : 256. Munksgaard 2000.

3- Bergh van den JPA; Bruggenkate ten C.M.; Disch F.J.M.;

Tuinzing D.B.: Anatomical aspect of sinus floor elevation. Clin.

Oral Impl. Res., 11: 256-265, 2000.

4- Bieniek,K.W,Kupper H,Spiekermann H:Animal experiments

to study periodontal Implantation of compact macroporous

granulates,Zwr 11,985-960 ,1989 .

5- Blitzer A.; Lawson W.; Friedman W.H.: Surgery of the paranasal

sinuses, Philadelphia, WB Saunders 1985 .

(52)

6- Burger Veldhuijzen JP:Inffluence of mechanical factors on

19- Orset G. Komarnyckyj,DDS Robert M.London,DDS 1998

bone formation ,resorption and growth in vitro .In Hall K,editor

Osteotome single stage Dental implant placement with and

:Bone growth,Melbourne1993,CRC press .,(from misch 327)

7- Buckly MJ:osteoblasts increase their rate of division and align in
response to cyclic,mechanical tension in vitro,Bone Miner 4:225236,1988 quated from contempory implant dentistry,second
edition,mosby co.,st louis,Chicago,London,Toronto 1999
8- Cavicchi F.; Brafi F. and Giuliano P. : Localized augmentation
of the maxillary sinus floor through coronal approach for the
placement of implants. Int. J. Periodontics Restorative Dent.,
21: 475-485, 2001
9- Cranin A., Klein M and Simons A.: Atlas of implantology.
Mosby Publishers Inc. New York. 1999.
10 Davar Panah M.; Martinez H.; Francois Tecucianu J.; Hage
G.; Lazzara R.: The modified osteotome technique. Int. J.
Periodontics Restorative Dent., 21: 599-607, 2001.
11- Hassler CR, Rylicky EF,Cummings KD et al; Quantification of
bone stress during remodling,J Biomech 13:185-190,1980 .
12- Isaksson S.: Evaluation of three bone grafting techniques
for severly resorbed maxillae in conjunction with immediate
endosseous implants the international Journal of Oral &
Maxillofac. Implants, 9: 679-688. 1994
13- Kasperk C,Ewers R, Simon B,Kasperk K,Bone replacement
material from Algae ,Dtsch Zahnazllz 43,116-119.1988 .
14- Kent J.N. and block M.S.: Simultaneous maxillary sinus
floor bone grafting and placement of hydroxyl apatite coated
implants. J. Oral Maxillofac. Surg., 47 : 238, 1989.
15- Lazzerinni, F., Minorati, D., Nessi, R. and Gagliani, M.:
Measurement parameters in dental radiology. A comparison
between traditional and digital technique. J. Radiol., Med., 91:
364, 1996.
16- Misch C.: Contemporary implant dentistry. Second edition.
Mosby co., St. Louis, Chicago, London, Toronto; 1999.
17- Maksoud M.: Complication after maxillary sinus augmentation:
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