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Treatment Options for the
Posterior Edentulous Jaw:
Surgical Options for Implant
Therapy in the Posterior
Maxilla of Partially Edentulous
Patients
Daniel Buser, Alberto Monje, Waldemar Polido
6 Forum Implantologicum
Prof. Dr. Daniel Buser
is Professor and Chair-
man of the Department
of Oral Surgery and Sto-
matology at the School
of Dental Medicine,
University of Bern. He
did research at Harvard,
USA from 1989 to 1991, with sabbaticals at the Baylor
College of Dentistry, USA (1995), the University
of Melbourne, Australia (2007/2008) and Harvard
School of Dental Medicine, Boston, USA (2016). His
main scientific interests include tissue integration of
dental implants, guided bone regeneration including
autografts and bone substitutes. He has authored/
co-authored more than 350 publications. Daniel
Buser was ITI President from 2009 to 2013 and has
received several awards, among them the the André
Schroeder Research Prize (1995) and the Brånemark
Osseointegration Award (2013). With over 30 years
of surgical experience, he continues to treat more
than 150 implant patients per year.
Dr. Alberto Monje
started his research
career as a clinical post-
doc at The University
of Michigan in 2011.
He then obtained the
certificate and Masters
in Periodontology
from the University of Michigan, Department of
Periodontics and Oral Medicine in 2016. He has
also received awards and grants for his research and
clinical achievements from scientific societies such
as the American Academy of Periodontology, the
International Team for Implantology and the Osteol-
ogy Foundation. He is currently the ITI Scholar in
the Department of Oral Surgery at the University
of Bern, Switzerland, headed by Prof. Daniel Buser,
where his research focus is on the long-term
outcomes of surgical options for the rehabilitation
of the posterior atrophic ridges.

Dr. Waldemar D. Polido
is an oral and maxil-
lofacial surgeon with
DDS, MS and PhD
degrees from PUCRS
in Porto Alegre, Brazil,
and a residency in OMFS
at the University of
Texas, Southwestern Medical Center at Dallas, USA.
A Fellow and Speaker of the ITI, Dr. Polido was Chair
of the ITI Section Brazil from 2007 to 2009 and is
the current Education Delegate for the Section until
2018. He is also a member of the ITI Education
Committee. Dr. Polido lectures extensively in Brazil
and internationally on his main interests: advanced
and complex implant surgery and orthognathic
surgery. In March 2017 he joined the Indiana
University School of Dentistry in Indianapolis, USA,
as a Clinical Professor, Director of the Predoctoral
Program in Oral and Maxillofacial Surgery and
Co-Director of the Center for Implant, Esthetic
and Innovative Dentistry.
INTRODUCTION
Loss of teeth in the posterior maxilla is a
frequent scenario encountered in dentistry.
Brugger et al. (2015), analyzing a 3-year
patient pool in a surgical specialty clinic,
reported that the posterior maxilla accounted
for 36 % of the total number of sites treated
with dental implants (Brugger et al. 2015).
This area has always been considered a
challenging region with its unique anatomy
of teeth and alveolar bone as well as its
proximity and relationship to the maxillary
sinus. Early findings in implant dentistry
demonstrated significantly lower survival
rates in the posterior maxilla, which were
correlated with different causes such as
poor bone density, complex anatomy and
loading protocols with shorter healing
periods (Adell et al. 1981, Jaffin & Berman
1991). We must not forget that those were
the days where titanium implants with
a machined surface were most often used.
In addition, longer implants (≥ 15 mm)
with bicortical stabilization were recom-
mended (Bahat 1993). Hence, the use of
large autogenous bone grafts, mostly from
TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW
ABSTRACT
The rehabilitation of the posterior maxilla
with an implant-supported prosthesis
is often a demanding treatment for the
implant surgeon. The local anatomy can
be difficult due to a reduced ridge height
in potential implant sites. The present
clinically oriented paper discusses the
three most often utilized surgical options:
(i) the utilization of short implants, (ii)
sinus floor elevation (SFE) with the lateral
window technique, and (iii) SFE with the
transalveolar osteotome technique. A
thorough clinical and radiographic examin-
ation is required to choose the appropriate
surgical approach, which should offer a
successful outcome with high predict-
ability and a low risk of complications. In
addition, treatment should offer minimal
invasiveness and morbidity, when possible.
Low morbidity is offered by short 6-mm
implants, which are utilized when multiple
implants are feasible with splinted implant
crowns.
an extraoral donor site, was often recom-
mended (Tolman 1995).
The primary objectives of implant therapy
continue to be successful treatment out-
comes with high predictability concerning
long-term function and esthetics and low
risk of complications (Buser and Chen 2008).
The ultimate goal is long-term success of
30+ years, which means that an inserted and
restored implant should have the best pre-
requisites for successful long-term stability.
The secondary objectives of therapy include
minimal invasiveness and low morbidity,
including the least number of surgical pro-
cedures and shorter healing periods. In the
past 15 to 20 years of fine tuning in implant
dentistry, aspects related to the second-
ary objectives have substantially improved
to make implant therapy more attractive
for patients and more patient friendly but
without jeopardizing the primary objectives
of therapy (Buser et al. 2017).
Successful outcomes in implant therapy are
influenced by four factors as first outlined
by Buser and Chen (Buser and Chen 2008).
A single tooth replacement with 6-mm
implants in molar sites is only used in ex-
ceptional situations. In all other situations,
SFE is required. Both surgical techniques
are well documented, but the transalveo-
lar osteotome technique is utilized
less frequently, since it requires a ridge
height of 5–8 mm and a flat morphology
of the sinus floor. Whenever possible,
a simultaneous implant placement is per-
formed to avoid a second surgery. For that,
sufficient primary stability is important,
which can be optimized with tissue level
implants. In addition, grafting with a com-
posite graft is preferred, which includes
locally harvested autogenous bone chips
mixed with a low-substitution bone filler.
The various treatment options are dis-
cussed and documented with case reports.
Keywords: Posterior maxilla, sinus floor
elevation, short implants, transalveolar
technique, lateral window technique,
composite graft
This concept, documented with four inter-
connected circles, can also be applied to the
treatment of the posterior maxilla (Fig. 1).
The first and most important circle reflects
the implant surgeon, or rather his/her clin-
ical team, since the treatment quality by the
surgical and restorative dentist –sometimes
provided by the same person – is probably
the most crucial factor. Additional members
of the clinical team are also the dental
technician and – if available – the dental
hygienist for the supporting maintenance
care program. The talent and expertise
of the implant surgeon are decisive for the
treatment outcome, as he/she examines
the patient to establish his/her risk profile,
decides on the most appropriate treat-
ment option, selects the necessary bio-
materials, and finally performs the surgical
treatment. The crucial importance of this
first circle is also documented by the fact
that it is larger than the three other circles.
The second circle represents the patient
with his/her risk factors, indicators and
determinants, which include medical, dental
and anatomical risk factors together with
Volume 13 / Issue 1 / 2017 7
TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW

smoking. All these factors must be consid- Dental risk Anatomic risk
factors factors
ered in the selection of the most appropri-
ate treatment option. In the posterior Medical risk Smoking
factors
maxilla, the local anatomy is probably the Education Short implants
most relevant factor for the selection of the
Patient
Skills Transalveolar
treatment approach. technique

Implant Surgical Lateral window

The third circle represents the biomater- technique
ials, which include the selected implant
Surgeon Approach
Grafting vs.
and its material, surface, shape, diameter non-grafting
and length, and the implant abutment. In Bio- Simultaneous vs. staged
Experience approach
addition, bone grafts, bone substitutes, and materials
barrier membranes are important elements Implant type Xenografts
for sinus floor elevation (SFE) procedures. Allografts
Barrier
Lastly, the fourth circle to consider is the Membrane Autografts
treatment approach itself for a given clinical
situation. In the posterior maxilla with a Fig. 1: The four factors influencing outcomes for the rehabilitation of the posterior maxilla. The circle with the
reduced ridge height and pneumatized sinus implant surgeon is larger, documenting the crucial importance of the experience and treatment quality provided
by the implant surgeon
cavity, various treatment options are avail-
able to achieve the anticipated treatment
outcome.

In accordance with the scope of the Forum the posterior maxilla in partially edentulous recommendations for when to use which
Implantologicum, the purpose of this patients. It reflects the authors’ personal treatment option to have the best chance
clinical paper is to discuss the surgical long and thoroughly documented experience of a successful treatment outcome in this
options available for implant therapy in in the field. In addition, it provides clinical challenging clinical scenario.

Fig. 2a: Buccal view of the first quadrant with an Fig. 2b: The panoramic view of the CBCT shows Fig. 2c: The occlusal CBCT view shows the sinus
extended edentulous space. Tooth #14 is hopeless a reduced ridge height in area 15 and 16. pneumatization, a sufficient crest width in all potential
and needs to be removed. The patient is asking The Schneiderian membrane is slightly thickened. implant sites, and a radiolucent interradicular lesion
for a fixed dental prosthesis There is no bone septum visible at tooth #17

Fig. 2d: The oro-facial CBCT at tooth #14 shows Fig. 2e: The oro-facial CBCT in area #15 shows Fig. 2f: The oro-facial CBCT in area #16 shows suf-
sufficient crest width of >6 mm for a future implant sufficient crest width, but a ridge height of less than ficient crest width, but a ridge height of only 2.5 mm,
placement 4 mm requiring a staged SFE procedure

8 Forum Implantologicum

ANATOMIC RISK FACTORS
IN THE POSTERIOR MAXILLA
For surgical treatment planning in the
posterior maxilla, a detailed pre-surgical
examination of the remaining teeth, the
alveolar ridge dimensions and the maxillary
sinus play an important role in the decision-
making process to find the most suitable
treatment approach. For this, the utiliza-
tion of a 3-dimensional (3D) radiographic
analysis utilizing a cone beam computer-
ized tomography (CBCT) is recommended
nowadays (Jensen & Katsuyama 2011;
Bornstein et al. 2015). The detailed clinical
and radiographic examination must include
several aspects, which are listed in Table 1.
A typical case report is shown in Fig 2.
In the posterior maxilla, the main anatomi-
cal challenge is the ridge height due to
the proximity of the maxillary sinus cavity.
Nunes et al. reported in a CBCT study
that the crest width is most often sufficient
for the placement of a standard diameter
implant (4 mm) (Nunes et al. 2013).
The main problem was the lack of sufficient
subantral bone height. The ridge height
significantly decreased towards the first
and second molar sites. In first molar sites,
88.2% showed a ridge height of <8 mm
and 55% of <5 mm.
In addition, the anatomy of the sinus floor
must be analyzed before choosing the
surgical approach. If the sinus floor has a
flat configuration in the mesio-distal and
oro-facial direction, a transalveolar SFE pro-
cedure with the use of osteotomes can be
considered, which is a less invasive surgical
technique. However, if the sinus floor has
an oblique configuration in at least one of
the two directions, the use of the transalveo-
lar osteotome technique increases the risk
of tearing the lining mucosa during surgery.
As such, the lateral window technique
is the treatment of choice under these
anatomical conditions.
In some cases, the posterior maxilla can
have a combined vertical and horizontal
deficiency with an increased inter-arch
space, which might require the need for
a more complex 3D bone reconstruction
(Chiapasco et al. 2009).
TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW
• the neighboring teeth that are still
present in the quadrant,
• the width and height of the alveolar
ridge at potential implant sites,
• the bone density,
• the extension of the maxillary sinus,
• the status of the Schneiderian
membrane,
• the presence, location and height of
bone septa
• the presence of foreign bodies in the
maxillary sinus, and
• the presence of sinus pathology like
mucous retention cysts or acute/
chronic sinusitis (Baciut et al. 2013,
Bornstein et al. 2015)
Table 1: The clinical and radiographic examination
should include these aspects
Once this clinical and radiological examina-
tion has been carried out, the most reason-
able surgical option can be selected, which
offers the best chance for a successful
outcome with high predictability and low
risk of complications.
SURGICAL OPTIONS IN SITES
WITH REDUCED RIDGE HEIGHT
IN THE POSTERIOR MAXILLA
The clinician has three options from
a surgical point of view:
1. Utilization of short dental implants for
a standard implant placement without
bone grafting
2. The lateral window technique for SFE
(simultaneous and staged approach)
3. The transalveolar osteotome technique
for SFE (simultaneous approach)
In the following, all three treatment options
will be discussed, including the selection
of appropriate biomaterials such as the
Authors (year) Follow-up Implant
(months) length (mm)
Rossi et al. (2016) 60 6 No
Felice et al. (2014) 60 6.6
Table 2: Long-term studies on the effectiveness of short dental implants in posterior sites
implant type, bone grafts and bone substi-
tutes, barrier membranes and the healing
periods.
1. The utilization of short dental implants
The use of short implants has been regarded
as an effective alternative to approach
the posterior atrophic maxilla with minimal
invasiveness (Monje et al. 2013). A recent
prospective 1-year study on patient-reported
outcomes has highlighted the high satisfac-
tion obtained with the use of short im-
plants compared to SFE, as it decreases
morbidity, treatment time and cost (Thoma
et al. 2015). The utilization of short (6 mm)
Straumann implants with the TPS surface
goes back to the late 1980s, and favorable
clinical results were first reported in the
late 1990s (ten Bruggenkate et al. 1998).
In the past 10 years, short (6 mm) implants
have attracted a lot of interest (Srinivasan
et al. 2014). It is noteworthy, however,
that it must be differentiated between single
standing implants and multiple adjacent
implants, which can be splinted. In the case
of multiple implants, short (6 mm) implants
have been routinely utilized in the posterior
maxilla with good clinical outcomes, but
they are routinely splinted (Figs 3a–b).
For single standing implants, routine appli-
cation of such implants is not recommended
in molar sites. This conservative approach
is supported by two recent prospective
5-year studies with short, 6-mm implants
(Table 2). One study with single standing
implants in the posterior mandible
(Rossi et al. 2016) showed a failure rate of
13.3% at 5 years, which is unacceptable
from our point of view. Another study with
splinted implants showed slightly better
outcomes, but still with a 6.3% failure
rate at 5 years (Felice et al. 2014). In rare
cases, such as for elderly patients with
a clearly reduced bite force, excep-
tions are made for short single standing
implants (Fig. 4).
Splinted Patients Implants Survival
implants (n) (n) rate
30 30 86.7 %
Yes 30 60 93.7 %
Volume 13 / Issue 1 / 2017 9
TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW

Fig. 3a: Distal extension situation in the right maxilla treated with two short 6-mm Fig. 3b: In the left maxilla, a short 6-mm implant is splinted to a
implants in a patient with no parafunctional habits. The short implants helped longer implant to bypass a SFE procedure. Both TL implants have
to avoid a SFE procedure. All three TL implants have been in function for 4 years been in function for 4 years and have stable bone crest levels
and show excellent bone crest levels

Fig. 4a: Panoramic CBCT view of a single posterior
tooth gap in area 16 in an 87-year-old patient.
The adjacent hollow-cylinder implant has been in place
for more than 20 years. The ridge height is borderline
with more bone volume in the mesial area
Fig. 4b: Considering the age and reduced masticatory Fig. 4c: Successful treatment outcome with an implant-
function of the elderly patient, a short 6-mm was supported single crown, 2 years post-loading
utilized, slightly tilted to avoid a perforation of the
sinus floor

More recently, Straumann released ultra-
short 4-mm implants. There are no long-
term results for these implants so far and
thus they are rarely used, and only under
exceptional circumstances when a SFE pro-
cedure must be avoided (Fig. 5). Such ultra-
short implants must always be splinted to
longer implants. In such short implants, the
crown-to-implant (C/I) ratio is often greater
than 2. However, evidence has shown that
implant restorations with C/I ratios between
2 and 3 can be successfully used in posterior
implant sites (Blanes et al. 2007, Garaicoa-
Pazmino et al. 2014). Nonetheless, caution
must be exercised in patients with para-
functional habits, like bruxers, where the
crestal stress could trigger implant failure
(Chrcanovic et al. 2016).
In summary, case selection and the optimal
treatment approach are crucial for the
long-term success of short implants. While
for 6-mm short implants, a ridge height
of roughly 7 mm should be present at the
future implant site for standard implant
placement without SFE, for 4-mm ultra-short
implants, an alveolar ridge height of 5 mm
is necessary.
2. The lateral window technique
The lateral window technique goes back
to the 1980s (Boyne & James 1980; Tatum
1986), and has been the standard technique
for SFE since then. The principles of this
surgical technique have not changed sig-
nificantly, but modifications were made
for the preparation of the window by using
piezoelectric instruments in an attempt
to reduce intra-operative complications,
such as the perforation of the Schneiderian
membrane (Wallace et al. 2007). In addition,
a paradigm shift took place with the surface
technology of dental implants in the late
1990s (Albrektsson & Wennerberg 2004;
Buser 1999). This initiated a change from
machined to micro-rough implant surfaces,
which significantly improved the survival
rates of dental implants placed simul-
taneously with SFE in the posterior maxilla
(Pjetursson et al. 2008; Del Fabbro et
al. 2008).
Simultaneous vs. staged approach
The lateral window technique can be used
with a simultaneous or a staged approach.
From the patient’s perspective, a simul-
taneous approach is preferable, since this
approach requires only one open flap pro-
cedure. The most important parameter for
the surgeon’s decision is the primary implant
stability, which depends on the ridge height
and bone density at the potential implant
site, the shape and the diameter of the
inserted implant, and the precise prepar-
ation of an implant bed. In ITI Treatment
Guide Volume 5, Katsuyama & Jensen (2011)

10 Forum Implantologicum

Fig. 5a: In this 76-year-old female patient with multiple medical risk factors,
a SFE was contra-indicated. An ultra-short, 4-mm implant has been used to bypass
a SFE procedure. The post-operative radiograph shows a 4-mm TL implant placed
with an 8-mm TL implant
defined a ridge height of 5 mm to be the
minimum threshold level for a simultaneous
approach with the lateral window technique.
Our group used the same threshold for
many years, but a few years ago we reduced
the minimum height for the simultaneous
approach to 4 mm, as did others as well
(Pjetursson et al. 2008).
Selection of appropriate bone grafts and
bone substitutes
In the 1990s, the dental implant community
started to examine bone grafts and bone
substitutes not only for GTR and GBR pro-
cedures, but also for SFE (Jensen et al. 1998;
Lundgren et al. 1996). Ideally, a grafting
material for SFE should not only accelerate
new bone formation in the defect area,
but it should also provide good volume
stability over time. Currently, there is still
no bone filler available that fulfills both
characteristics. Thus, composite grafts are
mainly preferred by our group for SFE using
autologous bone chips combined with a
bone substitute with a low substitution rate.
Autograft chips as osteogenic bone filler
can accelerate new bone formation in the
defect area, whereas a low-substitution filler
is used for good volume stability (Jensen
et al. 1996; Buser et al. 1998a; Schlegel
et al. 2003; Jensen et al. 2006). Today,
autologous bone chips are locally harvested
to minimize morbidity for the patient,
resulting in small cortical bone chips of
1.5 to 2.0 mm in size (Miron et al. 2013).
Recent in-vitro studies showed the release
of growth factors and other proteins into
TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW
Fig. 5b: The 2-year follow-up radiograph shows stable bone crest levels
at both implants. As usual, the two crowns are splinted
the surrounding area (Caballe-Serrano et
al. 2014). For the bone filler, deproteinized
bovine bone mineral (DBBM, Bio-Oss®,
Geistlich, Wolhusen, Switzerland), and Bone
Ceramic® (Straumann, Basel, Switzerland)
have both demonstrated a low substitution
rate in various pre-clinical and clinical
studies (Cordaro et al. 2008; Jensen et al.
2012; Jensen et al. 2013; Schmitt et al. 2013;
Schmitt et al. 2015; Danesh-Sani et al. 2016).
The utilization of autograft chips offers a
reduction in the healing period, in particular
when it is combined with a hydrophilic,
micro-rough implant surface.
Other bone fillers have also proven their
efficacy for SFE procedures, as long as
a sufficient healing period is respected
(Chiapasco et al. 2009; Monje et al. 2017).
The use of a resorbable collagen membrane
is preferred by our group to protect the
applied composite graft against the in-
growth of soft tissue cells of the buccal flap
during initial healing. A systematic review
showed better implant survival in patients,
when the lateral window had been covered
by a membrane (Pjetursson et al. 2008).
Selection of an appropriate implant
When the clinician selects an implant for
the posterior maxilla with insufficient
bone height and a planned SFE procedure,
he/she must carefully consider the following
issues: (i) implant shape (tapered/conical
vs. parallel walled), (ii) implant diameter,
and (iii) the implant surface. The first two
aspects influence – besides the local
anatomy – the primary stability of the
inserted implant, which is an important
prerequisite for the achievement of os-
seointegration, as demonstrated in the early
days of modern implant research (Schroeder
et al. 1981; Albrektsson et al. 1981). Primary
stability can be optimized with a tapered
or conical implant shape, which can be pres-
ent in the entire length of the implant, or
solely in the crestal area. A similar effect can
be obtained with large diameter implants,
since they offer a larger surface area in
the existing bone. Recent studies reported
on better primary stability with the tapered
effect implant design, especially in situa-
tions of grafted sites (Romanos et al. 2014;
Schiegnitz et al. 2016).
In posterior sites, our group has a clear
preference for Straumann tissue level (TL)
implants, since this hybrid implant design
showed excellent long-term results in
several long-term studies (Buser et al. 1997;
Buser et al. 2012; Fischer & Stenberg, 2012;
Fischer & Stenberg 2013; Chappuis et al.
2013; Roccuzzo et al. 2014; Chappuis et al.
2017). The recent 9-year study by Derks
et al. confirmed the excellent long-term
performance of TL implants (Derks et al.
2015), and their superiority when compared
to bone level implants of other implant
brands. The superiority of TL in posterior
sites was also shown in a recent study by
Chiapasco et al. (Chiapasco et al. 2014).
The tapered (TE) design of the Straumann
implant system is slightly conical in the
crestal area, which helps to improve primary
Volume 13 / Issue 1 / 2017 11
TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW

stability. A similar effect can be achieved Authors (year) Follow-up Placement Bone filler Patients Implants Survival
(months) Approach (n) (n) rate
with the parallel-walled standard SL implant,
when it is inserted deeper into the implant Bornstein et al. 60 Staged AB+DBBM 56 100 98.0 %
(2008)
bed, locating the border of the micro-rough
SLA surface 1.5 to 2.0 mm below the crest. Lutz et al. 60 Staged AB/DBBM 47 168 95.8%
(2015)
This insertion technique improves primary
stability, since the tulip-shape of the implant Beretta et al. 3 up to Staged AB+DBBM 218 589 98.8%
(2015) 186
neck increases the friction fit in the crestal
area of the ridge. Zinser et al. Up to 168 Simultane- AB, Alloge- 224 1045 93.3%
(2013) ous/staged neic, DBBM

The third aspect – the implant surface – is
important for the dynamics and quantity
of new bone apposition to the implant during
initial wound healing. That aspect is clini-
cally relevant not only for the quality of the
implant anchorage, but also for the duration
of the required healing period prior to load-
ing. Today, micro-rough implant surfaces
are clearly preferred in SFE sites, since they
show much better survival rates than the
original Brånemark type implants with the
machined surface as was determined at
the 4th ITI Consensus Meeting in Stuttgart
Table 3: Long-term studies on implants with SFE using the lateral window technique
(Chiapasco et al. 2009). Micro-rough implant
surfaces were introduced to the market in
the late 1990s based on preclinical studies
demonstrating significantly faster bone inte-
gration (Buser et al. 1991; Buser et al. 1998b;
Cochran et al. 1998; Wennerberg et al.
1998). In the mid-2000s, a new hydrophilic,
micro-rough implant surface showed
even better results in pre-clinical studies
(Buser et al. 2004; Schwarz et al. 2007a;
Schwarz et al. 2007b). This SLActive®
titanium surface (Straumann, Basel, Switzer-
land) is preferred in the posterior maxilla
to profit from even shorter healing periods.
In regard to the implant outcomes in SFE,
advancements in surface treatment have
significantly improved the survival rate

Fig. 6a: Extended edentulous space in the right maxilla. Fig. 6b: Due to the oblique sinus floor, a lateral window Fig. 6c: Following application of the first portion
The peri-apical radiograph shows insufficient ridge technique was preferred to gain additional bone of a composite graft, two TL implants were inserted.
height. In the pre-molar area, a simultaneous SFE is height. Following window preparation, the Schneide- As usual, the border to the SLA surface was located
feasible, but in area 16, a staged approach is necessary rian membrane was carefully elevated 1–2 mm below the crest

Fig. 6d: The remaining space was filled with the Fig. 6e: The window was then covered with a Fig. 6f: The SFE surgery was completed with a primary
composite graft as a mixture of locally harvested resorbable collagen membrane (Bio-Gide®) to avoid wound closure to protect the inserted implants against
autologous bone chips and a low-substitution ingrowth of soft tissue cells into the defect area loading forces during healing
bone filler (Bone Ceramic®) during initial wound healing

12 Forum Implantologicum
 TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW

reaching comparable results to implants

placed in pristine bone as shown in review
papers (Del Fabbro et al. 2008; Del Fabbro
et al. 2013; Chiapasco et al. 2009; Pjetursson
et al. 2008). Data obtained from long-term
studies (≥5 years of follow-up) showed
survival rates between 93–98% (Table 3).

Two typical case reports with SFE using

the lateral window technique are shown
in Figs 6 and 7. Fig. 6g: The post-surgical radiograph shows the two Fig. 6h: Clinical status at the 6-year follow-up. No ad-
inserted implants in position 14 and 15. Note the ditional implant was inserted. The two implant crowns
deep insertion technique of the TL implants providing were splinted and a distal cantilever unit added. The
3. The transalveolar osteotome technique additional primary implant stability due to the tulip peri-implant soft tissues are healthy
The transalveolar osteotome technique implant shape in the crestal area
was first described by Summers (1994).
The main goal was to simplify the surgical
technique and to reduce morbidity for
the patient. In the past 20 years, it has been
established as a well documented surgical
technique, if the anatomic conditions are
present (Pjetursson & Lang 2014). Our group
utilizes the osteotome technique only
in combination with simultaneous implant
placement (simultaneous approach).
Two clinical conditions must be present:
(i) The sinus floor at the potential site(s) Fig. 6i: The 6-year follow-up radiograph shows Fig. 6j: The 12-year follow-up radiograph confirms
should be flat in the mesio-distal and oro- excellent bone crest levels at both TL implants. excellent stability in the crestal area at both implants
The peri-implant bone structure has remodeled
facial directions, and (ii) the available ridge nicely over the years
height and bone density should provide
sufficient primary stability for the inserted
implant. The osteotome technique has a
major advantage, since it offers reduced
post-operative morbidity when compared to
the lateral window technique. However,
the potential gain in bone height is limited
to 3–5 mm. Therefore, we normally use this
technique with a ridge height of 5–8 mm.
A typical case report is shown in Fig. 8.

However, despite appearing to be less Fig. 7a: Severe atrophic posterior maxilla with Fig. 7b: Radiographic status at the 20-year follow-up.
difficult than the lateral window technique, a minimal bone height of less than 2 mm in area 26. The bone crest levels are excellent around the two
This required a staged SFE procedure with TL implants. In the mid-1990s, crowns were routinely
it should only be performed by experienced the window technique using a composite graft splinted following a SFE procedure. Today,
implant surgeons who master the lateral such splinting is only done with short implants
window approach. If an intra-surgical
complication like a perforation of the sinus
membrane or dislocation of graft material
occurs during the osteotome technique,
the solution is most likely to be found by
changing to the lateral window technique
(Katsuyama & Jensen 2011).

Long-term findings show that the transal-

veolar osteotome technique is an effective
Fig. 7c: The clinical status at the 20-year follow-up. Fig. 7d: The CBCT shows excellent peri-implant
surgical procedure in terms of implant The peri-implant soft tissues are healthy bone volume in the area of the former bone atrophy,
survival rates if performed under the afore- and an intact buccal bone wall

Volume 13 / Issue 1 / 2017 13

TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW

Fig. 8a: Single tooth gap in area 26 with a slight buccal Fig. 8b: The 6 months periapical radiograph showed Fig. 8c: Following flap elevation, an initial implant bed
flattening 6 months post-extraction a flat anatomy of the maxillary sinus and a bone preparation is done with the #1 spiral drill to a sink
height of 5–6 mm depth of 5 mm. A depth gauge was used to confirm the
proximity to the sinus floor

Fig. 8d: The periapical radiograph confirmed Fig. 8e: Then, implant bed preparation was Fig. 8f: As a composite graft, a mixture of locally
the correct depth of the preparation completeted and the floor of the sinus fractured harvested autologous bone chips and DBBM particles
with the osteotome instrument were used to push up the Schneiderian membrane
with this transalveolar technique

Fig. 8g: Status following insertion of a Wide Neck Fig. 8h: Status following adaptation of the wound Fig. 8i: The post-surgical radiograph shows the inserted
implant, fitting well into this first molar site margins allowing for non-submerged healing Wide Neck implants. The grafting material is clearly
visible in the periapical area

Fig. 8j: Clinical status at the 10-year follow-up. Fig. 8k: The periapical radiograph at the 10-year
The implant crown is integrating well, and shows follow-up examination shows excellent peri-implant
healthy peri-implant soft tissues bone crest levels and a good periapical bone volume
in the area of the former defect

14 Forum Implantologicum
 TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW

mentioned conditions. A recent systematic Authors (year) Follow-up Placement Bone filler Patients Implants Survival
(months) Approach (n) (n) crate
review estimated a 3-year survival rate
of 92.8% (Pjetursson & Lang 2014). Several Soardi et al. 60 Simultaneous DBBM/ 538 376 94.9 %
(2013) DFDBA
studies with a 5-year follow up showed
survival rates between 90.0–94.9% (Table 4). Nedir et al. 60 Simultaneous DBBM/- 12 20 90.0 %
(2016)

Grafting vs. non-grafting in SFE procedures Ferrigno et al. 12–144 Simultaneous AB+DBBM 323 588 94.8%
(2006) (mean 60)
In recent years, a few groups have proposed
performing SFE procedures without the Table 4: Long-term studies on implants with SFE using the transalveolar technique
use of bone grafting material. The technique
includes merely elevating the Schneiderian
membrane at the time of implant insertion Authors (year) Follow-up SFE Placement Patients Implants Survival
(Lundgren et al. 2017). This tenting effect (months) approach Approach (n) (n) rate

creates a void space in which blood clot Riben & Thor 12–84m Lateral Simultaneous 36 87 94.3%
formation occurs, followed by a partial fill (2016) (mean 55) window

with newly formed bone. In Table 5, recently Cricchio et al. 12–72 Lateral Simultaneous 84 239 98.7 %
published studies are listed with survival (2011) window

rates between 90.6 and 100%. Stefanski et al. 40 Lateral Simultaneous 19 28 100.0 %
(2016) window

Our group does not favor this surgical ap- Zill et al. 60 Osteotome Simultaneous 113 233 92.7 %
(2016)
proach. The technique does not really
offer a clinical advantage, since pain and Si et al. 48 to 102 Osteotome Simultaneous 80 96 90.6%
(2016) (mean 66)
morbidity are not reduced for the patient.
In addition, the lack of autogenous bone Nedir et al. 60 Osteotome Simultaneous 9 17 94.1%
(2016a)
chips during initial healing does not allow
for the short healing periods that we can Nedir et al. 120 Osteotome Simultaneous 17 25 100.0 %
(2016b)
often offer our patients nowadays.
Table 5: Clinical studies on implants placed with simultaneous SFE without grafting material
Current healing periods for implants placed
with simultaneous SFE
Concerning the healing periods for implants
placed simultaneously with SFE, significant the hydrophilic SLActive® surface, since
progress has been made in the past 5 years. both accelerate new bone formation during
A recent case series study by Kuchler et al. initial healing. The 17% of implants with
(2017) examined in more than 100 consecu- ISQ values <70 were left to heal for 12 or
tive implants how often an 8-week healing even 16 weeks. The study confirmed that
period is possible in patients with implant RFA is a reliable method to objectively
placement and simultaneous SFE using a examine implant stability to help the clin-
lateral window technique. Grafting was done ician make a good decision for the suitable
with a composite graft with locally har- time point of loading.
vested autograft chips and DBBM particles
(50:50%). Implant stability was measured at SFE combined with horizontal or even
implant placement (day 0) and 8 weeks later vertical ridge augmentation
using Resonance Frequency Analysis (RFA) In patients with significant horizontal and/or
providing an ISQ (implant Stability Quotient) vertical ridge atrophy, the SFE procedure
value (Kuchler et al. 2017). Standard TL can be combined with horizontal and/or ver-
implants with a chemically modified SLA tical ridge augmentation. The main surgical
surface (SLActive®; Straumann, Basel, procedure applied is the GBR technique. In
Switzerland) were used. In this study, 83% such situations, not frequently encountered,
of the implants reached the threshold a staged approach is most often needed
level of ISQ ≥ 70 after 8 weeks of healing, requiring multiple surgeries and extended
and hence, allowed for an early loading healing periods. The complexity of these
protocol. The early failure rate was at 0.9%. surgical procedures is also increasing, requir-
These favorable results can be attributed to ing a specialist who can master such delicate
the utilization of autograft chips and surgical procedures.

Volume 13 / Issue 1 / 2017 15

TREATMENT OPTIONS FOR THE POSTERIOR EDENTULOUS JAW
CONCLUSIONS
• The posterior maxilla is a challenging
area for implant therapy, mainly
due to the anatomy related to the
maxillary sinus
• In the majority of potential implant
sites, the residual ridge height is
less than 8 mm, and the implant sur-
geon needs to select one of the three
well-documented surgical options
available to deal with this scenario
• The surgeon needs to choose a surgical
procedure that offers a successful
outcome with high predictability and
good prospects for long-term stability
(>20 years)
• In addition, the surgical procedure
should offer low morbidity and the
least number of surgical interventions
• In some cases, the utilization of short
implants can be an attractive solu-
tion. 6-mm implants are well docu-
mented, when they can be splinted to
other implants. The ultra-short 4-mm
implants need to be documented
first with mid-term studies, before they
can be recommended for widespread
application
• When a SFE procedure is indicated,
the transalveolar and the lateral window
techniques are both well documented
with survival rates clearly above 90%
for a 5- to 10-year follow-up period
• The transalveolar osteotome technique
offers less morbidity and is more
patient friendly. However, the increase
in bone height is limited to 3–5 mm.
The surgical technique is demanding,
since the surgeon has no visual control
during surgery
• The transalveolar osteotome technique
should only be considered when
the remaining ridge height is 5–8 mm,
and when the sinus floor shows a flat
configuration
• With the lateral window technique,
more bone gain is feasible, since the
surgeon has direct visual access to
the surgical site. This technique is used
as a simultaneous or staged approach.
A ridge height of 4 mm is necessary
to perform a simultaneous approach
16 Forum Implantologicum
• Both surgical techniques are done
with bone grafting using a composite
graft. For that, autogenous bone chips
and a bone filler with a low substitu-
tion rate are preferred. Autograft chips
are locally harvested to minimize
morbidity. The lateral window is
routinely covered with a resorbable
collagen membrane
• This synergistic combination offers
accelerated bone formation during
initial healing and better volume stabil-
ity over time
• Tissue level implants with their hybrid
design are preferred. The insertion
technique, locating the micro-rough
implant surface 1–2 mm below the
crest, offers enhanced primary stability
due to the pressfitting of the tulip
shape in the crestal area
• Today, rather short healing periods
are possible. In a recent case series
study, more than 80% of the implants
could be restored after 8 weeks of
healing
• The selection of the surgical approach
is also influenced by the personal
preference and experience of the
surgeon. It should, however, not be
influenced by the qualifications and
skills of the implant surgeon.
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