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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Graft-Free Sinus Augmentation Procedure: a Literature Review</title><author><name sortKey="Pinchasov, Ginnady" sort="Pinchasov, Ginnady" uniqKey="Pinchasov G" first="Ginnady" last="Pinchasov">Ginnady Pinchasov</name><affiliation><nlm:aff id="aff1"><institution><sup>1</sup>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></nlm:aff></affiliation></author><author><name sortKey="Juodzbalys, Gintaras" sort="Juodzbalys, Gintaras" uniqKey="Juodzbalys G" first="Gintaras" last="Juodzbalys">Gintaras Juodzbalys</name><affiliation><nlm:aff id="aff1"><institution><sup>1</sup>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24800051</idno><idno type="pmc">4007367</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4007367</idno><idno type="RBID">PMC:4007367</idno><idno type="doi">10.5037/jomr.2014.5101</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000839</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000839</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Graft-Free Sinus Augmentation Procedure: a Literature Review</title><author><name sortKey="Pinchasov, Ginnady" sort="Pinchasov, Ginnady" uniqKey="Pinchasov G" first="Ginnady" last="Pinchasov">Ginnady Pinchasov</name><affiliation><nlm:aff id="aff1"><institution><sup>1</sup>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></nlm:aff></affiliation></author><author><name sortKey="Juodzbalys, Gintaras" sort="Juodzbalys, Gintaras" uniqKey="Juodzbalys G" first="Gintaras" last="Juodzbalys">Gintaras Juodzbalys</name><affiliation><nlm:aff id="aff1"><institution><sup>1</sup>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Oral & Maxillofacial Research</title><idno type="eISSN">2029-283X</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The restoration of edentulous posterior maxilla
with dental implants is challenging due to a deficient posterior
alveolar ridge. Over the last decade an advance in the graftless bone
augmentation procedures had occurred where the space left beneath the
Schneiderian membrane is filled with blood clot in order to produce bone
formation. The aim of present article is to review the scientific
literature with respect to bone formation in the sinus, after membrane
elevation procedure, without using any bone substitutes.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>A comprehensive review of the current literature was
conducted according to the PRISMA guidelines by accessing the NCBI PubMed
database. The articles were searched from 1993 to 2013. English language
articles with minimum one year patient follow-up and radiological and/or
histological diagnostics of newly formed bone were included. Articles were
excluded, if usage of bone graft or bone substitutes and/or usage of osteotome
has been made during sinus lift operation.</p></sec><sec sec-type="results"><title>Results</title><p>A total of 19
studies were included: 2 studies were related to the sinus membrane’s osteogenic
potential, 3 to the histological evidence of bone formation in monkeys and
humans, 12 to the radiologic evidence of bone gain, and 2 to the
space-maintaining management. 100% of the reviewed articles presented with
increased bone formation and high implant survival rates resulting from the
graft-free technique.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>It is clearly shown in the
review that the potential of the maxillary sinus to heal and to form new bone
without bone grafts or substitutes is of high nature.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Bell, Gw" uniqKey="Bell G">GW Bell</name></author><author><name sortKey="Joshi, Bb" uniqKey="Joshi B">BB Joshi</name></author><author><name sortKey="Macleod, Ri" uniqKey="Macleod R">RI Macleod</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tatum, H Jr" uniqKey="Tatum H">H Jr Tatum</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Boyne, Pj" uniqKey="Boyne P">PJ Boyne</name></author><author><name sortKey="James, Ra" uniqKey="James R">RA James</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Troedhan, A" uniqKey="Troedhan A">A Troedhan</name></author><author><name sortKey="Kurrek, A" uniqKey="Kurrek A">A Kurrek</name></author><author><name sortKey="Wainwright, M" uniqKey="Wainwright M">M Wainwright</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Moher, D" uniqKey="Moher D">D Moher</name></author><author><name sortKey="Liberati, A" uniqKey="Liberati A">A Liberati</name></author><author><name sortKey="Tetzlaff, J" uniqKey="Tetzlaff J">J Tetzlaff</name></author><author><name sortKey="Altman, Dg" uniqKey="Altman D">DG Altman</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Higgins, Jpt" uniqKey="Higgins J">JPT Higgins</name></author><author><name sortKey="Green, S" uniqKey="Green S">S Green</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Srouji, S" uniqKey="Srouji S">S Srouji</name></author><author><name sortKey="Kizhner, T" uniqKey="Kizhner T">T Kizhner</name></author><author><name sortKey="Ben David, D" uniqKey="Ben David D">D Ben David</name></author><author><name sortKey="Riminucci, M" uniqKey="Riminucci M">M Riminucci</name></author><author><name sortKey="Bianco, P" uniqKey="Bianco P">P Bianco</name></author><author><name sortKey="Livne, E" uniqKey="Livne E">E Livne</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Srouji, S" uniqKey="Srouji S">S Srouji</name></author><author><name sortKey="Ben David, D" uniqKey="Ben David D">D Ben-David</name></author><author><name sortKey="Lotan, R" uniqKey="Lotan R">R Lotan</name></author><author><name sortKey="Riminucci, M" uniqKey="Riminucci M">M Riminucci</name></author><author><name sortKey="Livne, E" uniqKey="Livne E">E Livne</name></author><author><name sortKey="Bianco, P" uniqKey="Bianco P">P Bianco</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Palma, Vc" uniqKey="Palma V">VC Palma</name></author><author><name sortKey="Magro Filho, O" uniqKey="Magro Filho O">O Magro-Filho</name></author><author><name sortKey="De Oliveria, Ja" uniqKey="De Oliveria J">JA de Oliveria</name></author><author><name sortKey="Lundgren, S" uniqKey="Lundgren S">S Lundgren</name></author><author><name sortKey="Salata, La" uniqKey="Salata L">LA Salata</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Boyne, Pj" uniqKey="Boyne P">PJ Boyne</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sohn, Ds" uniqKey="Sohn D">DS Sohn</name></author><author><name sortKey="Moon, Jw" uniqKey="Moon J">JW Moon</name></author><author><name sortKey="Moon, Kn" uniqKey="Moon K">KN Moon</name></author><author><name sortKey="Cho, Sc" uniqKey="Cho S">SC Cho</name></author><author><name sortKey="Kang, Ps" uniqKey="Kang P">PS Kang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lundgren, S" uniqKey="Lundgren S">S Lundgren</name></author><author><name sortKey="Andersson, S" uniqKey="Andersson S">S Andersson</name></author><author><name sortKey="Gualini, F" uniqKey="Gualini F">F Gualini</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lundgren, S" uniqKey="Lundgren S">S Lundgren</name></author><author><name sortKey="Andersson, S" uniqKey="Andersson S">S Andersson</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sohn, Ds" uniqKey="Sohn D">DS Sohn</name></author><author><name sortKey="Lee, Js" uniqKey="Lee J">JS Lee</name></author><author><name sortKey="Ahn, Mr" uniqKey="Ahn M">MR Ahn</name></author><author><name sortKey="Shin, Hi" uniqKey="Shin H">HI Shin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chen, Tw" uniqKey="Chen T">TW Chen</name></author><author><name sortKey="Chang, Hs" uniqKey="Chang H">HS Chang</name></author><author><name sortKey="Leung, Kw" uniqKey="Leung K">KW Leung</name></author><author><name sortKey="Lai, Yl" uniqKey="Lai Y">YL Lai</name></author><author><name sortKey="Kao, Sy" uniqKey="Kao S">SY Kao</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hatano, N" uniqKey="Hatano N">N Hatano</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author><author><name sortKey="Lundgren, S" uniqKey="Lundgren S">S Lundgren</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Moon, Jw" uniqKey="Moon J">JW Moon</name></author><author><name sortKey="Sohn, Ds" uniqKey="Sohn D">DS Sohn</name></author><author><name sortKey="Heo, Ju" uniqKey="Heo J">JU Heo</name></author><author><name sortKey="Shin, Hi" uniqKey="Shin H">HI Shin</name></author><author><name sortKey="Jung, Jk" uniqKey="Jung J">JK Jung</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thor, A" uniqKey="Thor A">A Thor</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author><author><name sortKey="Hirsch, Jm" uniqKey="Hirsch J">JM Hirsch</name></author><author><name sortKey="Rasmusson, L" uniqKey="Rasmusson L">L Rasmusson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Balleri, P" uniqKey="Balleri P">P Balleri</name></author><author><name sortKey="Veltri, M" uniqKey="Veltri M">M Veltri</name></author><author><name sortKey="Nuti, N" uniqKey="Nuti N">N Nuti</name></author><author><name sortKey="Ferrari, M" uniqKey="Ferrari M">M Ferrari</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Lin, Ic" uniqKey="Lin I">IC Lin</name></author><author><name sortKey="Gonzalez, Am" uniqKey="Gonzalez A">AM Gonzalez</name></author><author><name sortKey="Chang, Hj" uniqKey="Chang H">HJ Chang</name></author><author><name sortKey="Kao, Sy" uniqKey="Kao S">SY Kao</name></author><author><name sortKey="Chen, Tw" uniqKey="Chen T">TW Chen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Cricchio, G" uniqKey="Cricchio G">G Cricchio</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author><author><name sortKey="Lundgren, S" uniqKey="Lundgren S">S Lundgren</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ellegaard, B" uniqKey="Ellegaard B">B Ellegaard</name></author><author><name sortKey="K Lsen Petersen, J" uniqKey="K Lsen Petersen J">J Kølsen-Petersen</name></author><author><name sortKey="Baelum, V" uniqKey="Baelum V">V Baelum</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ellegaard, B" uniqKey="Ellegaard B">B Ellegaard</name></author><author><name sortKey="Baelum, V" uniqKey="Baelum V">V Baelum</name></author><author><name sortKey="K Lsen Petersen, J" uniqKey="K Lsen Petersen J">J Kølsen-Petersen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Johansson, L" uniqKey="Johansson L">LÅ Johansson</name></author><author><name sortKey="Isaksson, S" uniqKey="Isaksson S">S Isaksson</name></author><author><name sortKey="Adolfsson, E" uniqKey="Adolfsson E">E Adolfsson</name></author><author><name sortKey="Lindh, C" uniqKey="Lindh C">C Lindh</name></author><author><name sortKey="Sennerby, L" uniqKey="Sennerby L">L Sennerby</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kaneko, T" uniqKey="Kaneko T">T Kaneko</name></author><author><name sortKey="Masuda, I" uniqKey="Masuda I">I Masuda</name></author><author><name sortKey="Horie, N" uniqKey="Horie N">N Horie</name></author><author><name sortKey="Shimoyama, T" uniqKey="Shimoyama T">T Shimoyama</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="iso-abbrev">J Oral Maxillofac Res</journal-id><journal-id journal-id-type="publisher-id">JORM</journal-id><journal-title-group><journal-title>Journal of Oral & Maxillofacial Research</journal-title></journal-title-group><issn pub-type="epub">2029-283X</issn><publisher><publisher-name>Stilus Optimus</publisher-name><publisher-loc>Kaunas, Lithuania</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24800051</article-id><article-id pub-id-type="pmc">4007367</article-id><article-id pub-id-type="publisher-id">v5n1e1ht</article-id><article-id pub-id-type="doi">10.5037/jomr.2014.5101</article-id><article-categories><subj-group subj-group-type="heading"><subject>Literature Review</subject></subj-group></article-categories><title-group><article-title>Graft-Free Sinus Augmentation Procedure: a Literature Review</article-title></title-group><contrib-group><contrib id="contrib1" contrib-type="author" corresp="yes"><name><surname>Pinchasov</surname><given-names>Ginnady</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib><contrib id="contrib2" contrib-type="author"><name><surname>Juodzbalys</surname><given-names>Gintaras</given-names></name><xref ref-type="aff" rid="aff1">1</xref></contrib></contrib-group><aff id="aff1" rid="aff1"><sup>1</sup><institution><sup>1</sup>Department of Oral and Maxillofacial Surgery, Kaunas University of Medicine</institution><country>Lithuania.</country></aff><author-notes><corresp>Ginnady Pinchasov,
<addr-line>Siaures 103-21, LT-49238, Kaunas</addr-line><country>Lithuania</country>Phone: +370 64333569<email>gabriel.genady@gmail.com</email></corresp></author-notes><pub-date pub-type="collection"><season>Jan-Mar</season><year>2014</year></pub-date><pub-date pub-type="epub"><day>1</day><month>4</month><year>2014</year></pub-date><volume>5</volume><issue>1</issue><elocation-id>e1</elocation-id><history><date date-type="received"><day>11</day><month>2</month><year>2014</year></date><date date-type="accepted"><day>3</day><month>8</month><year>2014</year></date></history><permissions><copyright-statement>Copyright © Pinchasov G, Juodzbalys G. Published in the JOURNAL OF ORAL &
MAXILLOFACIAL RESEARCH (http://www.ejomr.org),
1 April 2014.</copyright-statement><copyright-year>2014</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p><pmc-comment>CREATIVE COMMONS</pmc-comment>This is an open-access
article, first published in the JOURNAL OF ORAL & MAXILLOFACIAL RESEARCH,
distributed under the terms of the Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported
License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/">http://creativecommons.org/licenses/by-nc-nd/3.0/</ext-link>), which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work and is properly cited.
The copyright, license information and link to the original publication on (<ext-link ext-link-type="uri" xlink:href="http://www.ejomr.org">http://www.ejomr.org</ext-link>)
must be included.</license-p></license></permissions><self-uri xlink:type="simple" xlink:href="http://www.ejomr.org/JOMR/archives/2014/1/e1/v5n1e1ht.htm"></self-uri><abstract><title>ABSTRACT</title><sec sec-type="objectives"><title>Objectives</title><p>The restoration of edentulous posterior maxilla
with dental implants is challenging due to a deficient posterior
alveolar ridge. Over the last decade an advance in the graftless bone
augmentation procedures had occurred where the space left beneath the
Schneiderian membrane is filled with blood clot in order to produce bone
formation. The aim of present article is to review the scientific
literature with respect to bone formation in the sinus, after membrane
elevation procedure, without using any bone substitutes.</p></sec><sec sec-type="material and methods"><title>Material and Methods</title><p>A comprehensive review of the current literature was
conducted according to the PRISMA guidelines by accessing the NCBI PubMed
database. The articles were searched from 1993 to 2013. English language
articles with minimum one year patient follow-up and radiological and/or
histological diagnostics of newly formed bone were included. Articles were
excluded, if usage of bone graft or bone substitutes and/or usage of osteotome
has been made during sinus lift operation.</p></sec><sec sec-type="results"><title>Results</title><p>A total of 19
studies were included: 2 studies were related to the sinus membrane’s osteogenic
potential, 3 to the histological evidence of bone formation in monkeys and
humans, 12 to the radiologic evidence of bone gain, and 2 to the
space-maintaining management. 100% of the reviewed articles presented with
increased bone formation and high implant survival rates resulting from the
graft-free technique.</p></sec><sec sec-type="conclusions"><title>Conclusions</title><p>It is clearly shown in the
review that the potential of the maxillary sinus to heal and to form new bone
without bone grafts or substitutes is of high nature.</p></sec></abstract><kwd-group><kwd>bone formation</kwd><kwd>dental implants</kwd><kwd>maxillary sinus
floor augmentation</kwd><kwd>Schneiderian membrane.</kwd></kwd-group></article-meta></front><body><sec sec-type="intro"><title>INTRODUCTION</title><p>The pyramid-shaped maxillary sinus (or
antrum of Highmore) is the largest of the paranasal sinuses, and drains
into the middle meatus of the nose. The sinus is lined with
mucoperiosteum, with cilia that beat toward the ostia. This membrane is
also referred to as the “Schneiderian Membrane”, which is histologically
a bilaminar membrane with ciliated columnar epithelial cells on the
internal (or cavernous) side and periosteum on the osseous side. The
size of the sinuses varies in different skulls, and even on the two
sides of the same skull [<xref rid="B1" ref-type="bibr">1</xref>]. As a result of long term edentulism a
decrease in the bone level of the alveolar process occurs due to
postextractional bone resorption and sinus pneumatisation [<xref rid="B2" ref-type="bibr">2</xref>]. The aim
of sinus lift procedure is to compensate this bone loss by creating
increased bone volume in the maxillary sinus and thus enabling
installation of dental implants. Initially, the most popular bone
grafting materials are autogenous bone grafts and other bone substitutes
[<xref rid="B3" ref-type="bibr">3</xref>]. The disadvantages of such methods are high costs for grafting
material, time consuming and high morbidity, because harvesting of bone
grafts is needed. The results of a paper published by Troedhan et al.
[<xref rid="B4" ref-type="bibr">4</xref>] discuss that the key role of the sinus membrane, as the main carrier
of bone reformation after sinus lift procedures, as multiple
experimental studies suggested. Thus the importance of minimal invasive
and rupture free sinuslift procedures is underlined and does not depend
on the type of grafting material used. The potential of new bone
formation without bone graft in the maxillary sinus was presented in a
variety of studies including radiological and histological evidence, and
recent studies indicate high success rates of such method [<xref rid="B6" ref-type="bibr">6-10</xref>].
Because of the disadvantages of existing methods that was described
above and because of the recent studies regarding the potential of new
bone formation without bone graft, there is an importance in reviewing
the existing information in the literature. The aim of this paper is to
review the scientific data regarding to the natural bone formation in
the sinus, after membrane elevation procedure, without using any bone
substitutes.</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><p><bold>Types of publication</bold></p><p>The review included studies on humans and
animals published in the English language. Letters, editorials, PhD
theses and abstracts were excluded.</p><p><bold>Types of studies</bold></p><p>The review included any published
observational studies (cross-sectional surveys, cohort and case-control
studies), clinical trials of treatment and case series. Single case
reports were excluded.</p><p><bold>Population</bold></p><p>Studies of adult patients with performed
graft-free sinus augmentation were selected.</p><p><bold>Graft-free sinus augmentation definition</bold></p><p>Graft-free sinus augmentation is a sinus
lift procedure using the lateral window approach by Boyne [<xref rid="B3" ref-type="bibr">3</xref>], while no
bone graft or other substitute is being used for the bone gain beside
blood clot.</p><p><bold>Outcome measures</bold></p><p>Studies with radiological and/or
histological diagnostics of newly formed bone in the sinus were
included.</p><p><bold>Literature search strategy</bold></p><p>According to the PRISMA guidelines [<xref rid="B5" ref-type="bibr">5</xref>] an
electronic search was conducted using MEDLINE (PubMed) to locate
articles concerning graft-free sinus lifts. The search terms used were:
„sinus lift“, „sinus membrane elevation“, „sinus augmentation“, „sinus
lift without bone graft“ and „implant placement without bone graft“. Due
to the low number of relevant articles and to insure the sensitivity of
the systemic review the articles were searched from 1993 to 2013.
Bibliographies of the selected articles were also manually searched.
<xref ref-type="fig" rid="fig1">Figure 1</xref> illustrates the work-flow of the comprehensive literature
review. Titles derived from this broad search were independently
screened by two authors based on the inclusion criteria. Disagreements
were resolved by discussion. Full reports were obtained for all the
studies that were deemed eligible for inclusion in this paper.</p><fig id="fig1" orientation="portrait" position="float"><label>Figure 1</label><caption><p>PRISMA
flow diagram.</p></caption><graphic xlink:href="jomr-05-e1-g001"></graphic></fig><p><bold>Inclusion and exclusion criteria</bold></p><p>Inclusion criteria for the selection were:</p><list list-type="bullet" id="L1"><list-item><p>English language;</p></list-item><list-item><p>Minimum one year patient follow-up;</p></list-item><list-item><p>Radiological and/or histological
diagnostics of newly formed bone.</p></list-item></list><p>Exclusion criteria for the selection were:</p><list list-type="bullet" id="L2"><list-item><p>Usage of bone graft or bone substitutes
has been made;</p></list-item><list-item><p>Usage of osteotome has been made.</p></list-item></list><p><bold>Article review and data extraction</bold></p><p>The search delivered 2205 search results
from which 86 abstracts were reviewed (<xref ref-type="fig" rid="fig1">Figure 1</xref>). A total of 75 articles
were ultimately reviewed in full. Preliminary exclusion was made by the
title and its relevancy, later by abstract and articles availability
online. Finally, articles that did not meet the inclusion and exclusion
criteria, where filtered as followed: usage of bone graft or bone
substitutes has been made (8), usage of osteotome has been made (32) and
no minimum one year follow-up was found (13). The data was included on
328 patients.</p><p><bold>Quality assessment</bold></p><p>The Cochrane collaboration bias summary for
potential bias was used to assess the quality of studies and identify
papers with intrinsic flaws in method and design [<xref rid="B6" ref-type="bibr">6</xref>].</p></sec><sec sec-type="results"><title>RESULTS</title><p>A total of 19 studies were included in this
review. 2 studies were related to sinus membrane’s osteogenic potential,
3 studies were related to histological evidence of bone formation in
monkeys and humans, 12 studies were related to the outcome, implant
stability and radiologic evidence of bone gain after using the
graft-free augmentation, 2 studies were related to space-maintaining
management (<xref ref-type="table" rid="T1">Table 1</xref>).</p><table-wrap id="T1" orientation="portrait" position="float"><label>Table 1</label><caption><p>Description of studies included in the review</p></caption><table frame="hsides" rules="groups" width="580"><thead><tr><th rowspan="1" colspan="1">Study</th><th rowspan="1" colspan="1">Year of publication</th><th rowspan="1" colspan="1">Species</th><th rowspan="1" colspan="1">Diagnostic evidence</th></tr></thead><tbody><tr><td colspan="4" align="center" rowspan="1"><bold>Scheidrian membrane's osteogenic potential (
<italic>in vitro</italic>and
<italic>in vivo</italic>)</bold></td></tr><tr><td rowspan="1" colspan="1">Srouji et al. [7]</td><td align="center" rowspan="1" colspan="1">2009</td><td align="center" rowspan="1" colspan="1">mice</td><td align="center" rowspan="1" colspan="1">histologic</td></tr><tr><td rowspan="1" colspan="1">Srouji et al. [8]</td><td align="center" rowspan="1" colspan="1">2010</td><td align="center" rowspan="1" colspan="1">mice</td><td align="center" rowspan="1" colspan="1">histologic</td></tr><tr><td colspan="4" align="center" rowspan="1"><hr></hr></td></tr><tr><td colspan="4" align="center" rowspan="1"><bold>Studies regarding implant placement after graft-free sinus lift</bold></td></tr><tr><td rowspan="1" colspan="1">Palma et al. [9]</td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">Capuchin primates</td><td align="center" rowspan="1" colspan="1">histologic</td></tr><tr><td rowspan="1" colspan="1">Boyne et al. [10]</td><td align="center" rowspan="1" colspan="1">1993</td><td align="center" rowspan="1" colspan="1">monkeys</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Sohn et al. [11]</td><td align="center" rowspan="1" colspan="1">2010</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic + histologic</td></tr><tr><td rowspan="1" colspan="1">Lundgren et al. [12]</td><td align="center" rowspan="1" colspan="1">2003</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Lundgren et al. [13]</td><td align="center" rowspan="1" colspan="1">2004</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Sohn et al. [14]</td><td align="center" rowspan="1" colspan="1">2010</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Chen et al. [15]</td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Hatano et al. [16]</td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Moon et al. [17]</td><td align="center" rowspan="1" colspan="1">2011</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic + histologic</td></tr><tr><td rowspan="1" colspan="1">Thor et al. [18]</td><td align="center" rowspan="1" colspan="1">2007</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Balleri et al. [19]</td><td align="center" rowspan="1" colspan="1">2010</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Lin et al. [20]</td><td align="center" rowspan="1" colspan="1">2011</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Cricchio et al. [21]</td><td align="center" rowspan="1" colspan="1">2011</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Ellegaard et al. [22]</td><td align="center" rowspan="1" colspan="1">1997</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Ellegaard et al. [23]</td><td align="center" rowspan="1" colspan="1">2006</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td colspan="4" align="center" rowspan="1"><hr></hr></td></tr><tr><td colspan="4" align="center" rowspan="1"><bold>Space-maintaining management with graft-free sinus lift</bold></td></tr><tr><td rowspan="1" colspan="1">Johansson et al. [24]</td><td align="center" rowspan="1" colspan="1">2012</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr><tr><td rowspan="1" colspan="1">Kaneko et al. [25]</td><td align="center" rowspan="1" colspan="1">2012</td><td align="center" rowspan="1" colspan="1">humans</td><td align="center" rowspan="1" colspan="1">radiographic</td></tr></tbody></table></table-wrap><p><bold>Scheidrian membrane’s osteogenic
potential</bold></p><p>Studies, reviewed in this paper presented
well a creation of new bone formation in the maxillary sinus by mucosal
membrane lifting without the use of any graft material. Nevertheless,
the mechanism of this specific bone gain is yet unknown. However, Srouji
et al. [<xref rid="B7" ref-type="bibr">7</xref>], using both <italic>in vitro</italic> and <italic>in
vivo</italic> assays, attempted to
explore the bone formation beneath the sinus membrane on the maxillary
sinus floor. The aim was to test the osteogenic potential of human
maxillary sinus Schneiderian membrane (hMSSM). Samples of hMSSM were
cultured and studied in histological manner. Flow cytometry analysis was
conducted on cultures by adopting mesenchymal progenitor cell markers.
Using relevant <italic>in vitro</italic> assays
the potential to osteogenic differentiation by the hMSSM cells was
analyzed. It was seen that the cells are capable of inducing and
reviling different osteogenic markers such as osteonectin, osteopontin,
osteocalcin, alkaline phosphatase, bone morphogenic protein-2, as well
as to induce their extracellular matrix mineralization. Further, the
osteogenic potential of hMSSM-derived cells was confirmed <italic>in
vivo</italic> experiments, where
cultured cells and a ceramic mix consisted from HA/β-TCP were connected
into a fibrin clot and implanted under the skin of thymic mice. After 8
weeks of healing formation of histology-proven bone at ectopic sites
subsequent to transplantation of hMSSM-derived cells where present. It
was deducted that genuine osteogenic potential is connected with the
hMSSM and may be of great contribution to the development of successful
sinus augmentation techniques. In 2010, Srouji et al. [<xref rid="B8" ref-type="bibr">8</xref>] tests whether
such osteogenic activity relies on inherent osteogenic capacity, that
existing in the sinus membrane using simulation <italic>in
vivo</italic> clinical condition
of sinus lifting in an animal model. Human Schneiderian membrane was
folded around a fibrin clot that was later transplanted subcutaneously
into mice. New bone formation was observed, as well as in the previous
experiment, illustrating the innate osteogenic potential within the
maxillary Schneiderian sinus membrane and its importance of
understanding and potentially improving bone regeneration in sinus
lifting procedures in the future.</p><p><bold>Histological evidence of bone formation</bold></p><p>The first histological evidence to verify
new bone formation was demonstrated in 2006 by Palma et al. [<xref rid="B9" ref-type="bibr">9</xref>] on four
tufted capuchin primates that experienced maxillary sinus membrane
elevation surgery using a replaceable bone window technique. According
to Palma et al. [<xref rid="B9" ref-type="bibr">9</xref>] study, no differences on new bone formation, implant
stability and bone-implant contacts was demonstrated between two groups
with and without adjunctive autogenous bone graft, furthermore stronger
bone tissue response is seen in Oxidized implants than the control
turned surface. An alike clinical studies with monkeys was already
described in 1993 by Boyne [<xref rid="B10" ref-type="bibr">10</xref>] where maxillary sinus floor augmentation
on five monkeys was preformed, by simply elevating the maxillary sinus
membrane without the use of bone grafting. Implants were placed
bilaterally in the sinus perforating into it 5 mm. Protruding implant in
the right antrum was placed with bone graft and in the contra-lateral
implant no bone grafts where used. Radiologic evidence of new bone was
seen around the implant in which no bone graft was administered, though
unlike Palma’s et al. [<xref rid="B9" ref-type="bibr">9</xref>] study no histological evidence was yet to be
shown. Only 2 years afterwards a first histological evidence of new bone
formation in the maxillary sinus with membrane elevation only was
obtained on humans by Sohn et al. [<xref rid="B11" ref-type="bibr">11</xref>] where 21 implants were placed,
with an average residual bone height of 5 mm after 6 months they where
evaluated. All implants remained stable during the study period in
clinical evaluations. Bone formation and new sinus floors were found in
both radiographic and histological evaluations.</p><p><bold>Graft-free sinus procedure using lateral
window approach</bold></p><p>Lundgren et al. [<xref rid="B12" ref-type="bibr">12</xref>] presented a case study
in 2003 on a patient that needed a removal of mucosal cyst of the
maxillary sinus and augmentation of the maxillary sinus in order to pace
an implant later on. An intra-sinus mucosal cyst was removed through a
prepared bony window in the lateral antral wall. The ruptured mucosa was
sutured and the bone window was replaced. A space created by bony walls
and sinus membrane had been formed. After 3 months of healing, clear
radiographic signs of bone formation were observed. The space between
the replaced bony window and the lifted sinus membrane was filled with
newly formed bone. This was an unexpected healing pattern witch lead him
to conclude that the creation of a space between the bone surfaces and
the sinus mucosa in the combination of the surgical trauma result in
spontaneous bone formation in the maxillary sinus. Since the
predictability of the technique presented above is yet unknown in 2004
Lundgren et al. [<xref rid="B13" ref-type="bibr">13</xref>] conducted a study in order to investigate the
possibility to perform sinus membrane elevation and facilitate implant
placement without any additional bone grafting material and whether it
is a valid technique. The study group consisted out of 10 patients in
whom a total of 12 maxillary sinus floor augmentations were performed
and 19 implants were installed. The bony window was dissected, elevated
superiorly, and sutured to the sinus wall to create and maintain a
compartment for blood clot formation. The implants were installed then
the bony window was replaced, and the flap was sutured into position.
During the study period all implants showed stability and clear signs of
bone formation, this clearly demonstrated great potential of bone
formation and regeneration capability in the maxillary sinus without the
use of additional bone grafts. Lundgren et al. [<xref rid="B13" ref-type="bibr">13</xref>] concluded that in
general it is achieved by the principle of guided tissue regeneration,
but the precise mechanisms of this healing pattern are yet unknown. As a
result of previous studies that showed bone formation capability without
bone grafts, in 2010 Sohn et al. [<xref rid="B14" ref-type="bibr">14</xref>] presented a study that
demonstrating new bone formation in the maxillary sinus using absorbable
gelatin only. The study consisted of seven patients treated with sinus
augmentation with restorable gelatin sponge membrane and simultaneous
implant placement. The lateral bony window was formed and the sinus
membrane was elevated to make space. 18 implants were placed and the
absorbable gelatin sponge was inserted in the new compartment under the
elevated sinus membrane. After an average of 6 months given for the
implants to integrate, new bone formation in the maxillary sinus was
seen on radiographs. It was mentioned that due to failed
osseointegration 2 implants were removed. The study showed clearly that
implant placement with gelatin sponge can be a predictable procedure for
sinus augmentation without using bone graft. In 2007, a study was
published by Chen et al. [<xref rid="B15" ref-type="bibr">15</xref>] where maxillary sinus augmentation without
bone graft using only blood was preformed in 33 patients. The average
age of the patients was 55 years old. 47 implants were followed for more
than 2 years after prosthesis delivery. The sinus mucosal membrane was
elevated with the bony window still attached to the membrane (trap-door,
open-window method). The implants were placed immediately with sinus
lifting procedure. Patients where evaluated after 2 years displaying
100% of fixture survival. Increases in bone height ranged from 3 mm to 9
mm with an average of 4.5 mm bone gain thus it was concluded that the
survival rate was good. In 2007, a case series was presented by Hatano
et al. [<xref rid="B16" ref-type="bibr">16</xref>] of 6 patients that undergone a maxillary sinus floor
augmentation using peripheral venous blood alone. After the elevation of
a mucoperiosteal flap the lateral wall of sinus cavity was exposed. The
piezoelectric saw with thin blade connected to piezoelectric device was
used with copious saline irrigation to create the lateral window of the
maxillary sinus. The bony window was detached carefully to expose the
sinus membrane. The sinus membrane was carefully elevated from the sinus
floor walls with a manual elevator. 14 implants where installed
penetrating into the sinus cavity. The sinus cavity was then filled with
patient’s own peripheral venous blood. The bone window was replaced with
medical tissue glue for closure of the potential gap in the bony window
of the osteotomy thus preventing blood leakage from the created
compartment in the maxillary sinus. After 6 months, the implants were
evaluated. One of the 14 implants failed but successful new bone
formation was found in all sinuses as seen from radiographs. In 2011,
Moon et al. [<xref rid="B17" ref-type="bibr">17</xref>] published a similar study to the one presented above by
Hatano et al. [<xref rid="B16" ref-type="bibr">16</xref>] Moon’s et al. [<xref rid="B17" ref-type="bibr">17</xref>] study results presenting with
similar conclusions thus giving further justification and strengthens
Hatano’s et al. [<xref rid="B16" ref-type="bibr">16</xref>] study results. In the study, fourteen patients were
consecutively treated and in total 17 sinus lifts had been made. In
Hatano’s et al. [<xref rid="B16" ref-type="bibr">16</xref>] study lateral window approach was used. The lateral
bony window was created using a piezoelectric saw, and the sinus
membrane was elevated to make space. The sinus cavity was filled with
venous blood and resorbable blast media-surfaced dental implants were
placed simultaneously. After 6.8 months, the sinus augmentations were
evaluated and new bone formation in the maxillary sinus was seen by both
radiographic and histological evaluation. Overal, implant survival rate
was 93.5% and according to the histomorphometric data vital bone
formation was 38.7%. Of the 31 implants placed, 2 failed. It was
mentioned in the study that all failures occurred when implants were
placed into the extraction socket. It was established that a maxillary
sinus floor augmentation using peripheral venous blood and simultaneous
placement of dental implants is a reliable procedure and this is in
coincidence with Hatano et al. [<xref rid="B16" ref-type="bibr">16</xref>]. In 2007, Thor [<xref rid="B18" ref-type="bibr">18</xref>] presented a
study, where 20 patients were treated with implant therapy. 44 Astra
Tech implants, in total, were placed in the maxillary sinus (27 sinuses
were lifted). Implants were followed every year in the period of time
between November 2001 to June 2004 and all the implant installations
carried without graft material. The sinus membrane elevation preformed
in a matter where a bony window was removed from the maxillary anterior
sinus wall. Implants were placed in the residual bone right after
elevation of the mucosal membrane. During the surgery, perforations of
the mucosal membrane was recorded together with the bone height.
Abutments were connected after 6 months of healing. Evaluation after an
average time of 27.5 months resulted in 97.7% of implants survival rate
and 6.51 mm was the average gain of bone at the maxillary sinus.
Although bone formation was successful few complications had occurred,
in 41% of operated sinuses observed perforations of the maxillary sinus
mucosal membrane and one implant was lost. Marked bone gain was observed
around long implants as well as in the case when the residual bone below
the sinus was low. In 2010, Balleri et al. [<xref rid="B19" ref-type="bibr">19</xref>] presented a study, where
fifteen patients were recruited for sinus augmentation in combination
with implant placement without biomaterials. A mean residual bone height
of the patients was 6.2 mm. A replaceable bone window was opened and the
membrane was dissected from the sinus walls. 28 of Astra Tech implants
were installed in the residual crest (the implants were keeping the
membrane in the elevated position). After 1 year, the implants, where
evaluated and the average bone gain was 5.5 mm. All of the implants
survived at the end of the follow-up. It was established that the bone
gain was less than the average bone gain in membrane elevation which is
8.2 mm. Bone regeneration was less at the distal aspect of the most
posterior-placed implant. The height of membrane lift was not correlated
with the amount of regenerated bone. In other words, the length of the
implants was not related to the amount of gained bone unlike in Thor’s
[<xref rid="B18" ref-type="bibr">18</xref>] study from 2007, where greater bone formation was observed around
the long implants. Not only all of the 28 implants were stable during
the first year of loading and that no additional costs for biomaterials
were necessary, but also problems concerning bone harvesting as
morbidity were avoided. In 2011, Lin et al. [<xref rid="B20" ref-type="bibr">20</xref>] presented a 5-year
follow-up of 80 implants in 44 patients. The implants weere placed
immediately after the lateral trap-door window procedure to accomplish
maxillary sinus elevation without bone grafting. Surgeries were carried
out with either local or general anesthesia and prophylactic antibiotics
were given. Full-thickness flaps were carefully elevated following a
midcrestal incision. Extreme care was taken to radically elevate the
sinus membrane from the trap-door window. The floor, lateral wall, and
posterior wall of the sinus membrane were detached and pushed upward and
medially to allow the placement of dental implants into the bone
chamber. After five years, the survival rate was 100%. Before the
treatment, 3 mm of residual bone height was required for inclusion and
on average residual bone height was 5.1 mm. New bone formation in the
sinus was confirmed and the average gained bone height after five years
was 7.4 mm. Cricchio et al. [<xref rid="B21" ref-type="bibr">21</xref>] presented a study were a total of 84
patients underwent 96 membrane elevation procedures and simultaneous
placement of 239 implants without adding any graft material. Changes of
bone height in relation to the implants were measured using intraoral
radiographs taken at insertion. The implant follow-up period ranged
between 1 - 6 years after implants loading. All of the implants
demonstrated stability after 6 months of healing and a high implant
survival rate of 98.7% was seen through the follow-up. An average of 5.3
± 2.1 mm of intra-sinus new bone formation was observed on the
radiographs. Resonance Frequency Analyses (RFM), adequate primary
stability and small changes over time. The advantages of the graftless
technique as well as in other studies was presented stating that it
eliminates the costs of grafting materials and reduces the risks for
morbidity related to harvesting of bone grafts. Ellegaard et al. [<xref rid="B22" ref-type="bibr">22</xref>]
presented a study in 1997, where 24 periodontally compromised patients
were treated with implant therapy of which 38 included sinus lift
procedure. The patients, who where chosen for the study needed at least
2 implants each. In total, 80 implants were installed in the posterior
maxilla. Fenestration was prepared in the lateral sinus wall after that
the sinus membrane was lifted and the implants were inserted creating a
compartment filled with blood between themselves and the sinus membrane.
The implants where loaded after 5 to 6 months. During an annual
follow-up, 35 out of 38 implants were successfully integrated. On a
follow-up radiographs it was seen that new bone formation accrued around
the part of the implants, which is protruding up into the sinus cavity.
A follow-up of the study above was presented in 2006 by Ellegaard et al
[<xref rid="B23" ref-type="bibr">23</xref>]. Were tested, all patients that was treated with implant therapy
between 1990 and 2002 out of 262 implants was placed in the maxillary
sinus. The results of the study had sown that similar success rate is
present in implants in periodontal compromised patients as well as in
ordinary implants.</p><p><bold>Development of methods improving
space-maintaining management</bold></p><p>Recently, two studies where published, one
by Johansson et al. [<xref rid="B24" ref-type="bibr">24</xref>] and another by Kaneko et al. [<xref rid="B25" ref-type="bibr">25</xref>]. Both studies
already approve that sinus lifting without graft materials allows new
bone formation in the sinus and in their research they use this as a
fact, though both of the studies state that the amount of bone formation
varies. The papers aim into improving the amount of new bone by enabling
new methods for space-maintaining management. Hollow hydroxyapatite
space-maintaining device was used in Johansson’s et al. [<xref rid="B24" ref-type="bibr">24</xref>] study and
titanium bone fixation device was presented in Kaneko’s et al. [<xref rid="B25" ref-type="bibr">25</xref>]
paper. Both studies concluded that predictable bone formation is
attained by space-maintaining devices.</p></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>From the data that extracted from the
current literature we see clear radiological evidences to bone formation
in the sinus after using lateral window technique for the lift while
using blood clot alone for the bone formation [<xref rid="B15" ref-type="bibr">15-16</xref>]. The key role to
this bone formation lies in Schneiderian membrane and the bone gain does
not depend much on the type of grafting material used [<xref rid="B1" ref-type="bibr">1</xref>]. The leading
reason to the bone regeneration is the innate osteogenic potential of
the Schneiderian membrane and the basic principle behind bone formation
is by guided tissue regeneration. While not all of the factors for this
verity are clear, as well as the exact bone formation mechanism, it is
possible that efficient space-maintaining management predicts an
increase in bone gaining [<xref rid="B24" ref-type="bibr">24-25</xref>]. In Thor et al. [<xref rid="B18" ref-type="bibr">18</xref>] study it’s been
observed that the amount of bone gain around long implants was greater,
this strengthens that the height of membrane lift is correlated with the
amount of regenerated bone. Though, controversy Balleri et al. [<xref rid="B19" ref-type="bibr">19</xref>]
study showed no such correlation. It can be beneficial if we could
identify how much bone formation we should expect since it is less
invasive and cost effective procedure. We suggest that in order to
achieve better results perhaps more research must be conducted
investigating the predictability of bone formation with focus on
individual patient’s potential for this method.</p></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>It is clearly shown in the review that the
potential of the maxillary sinus to heal and to form new bone without
bone grafts or substitutes is of high nature. The technique presented
proved to be reliable for bone augmentation of the maxillary sinus
floor. As the exact mechanisms of action on how the bone formation in
the sinus occurs, it is not fully cleared. More clinical studies need to
be carried out to clarify the bone formation mechanism and
predictability in the maxillary sinus after sinus lift without using any
bone graft materials.</p></sec></body><back><ack><sec sec-type="acknowledgments and disclosure statements"><title>ACKNOWLEDGMENTS AND DISCLOSURE STATEMENTS</title><p>The authors report no conflicts of interest
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