Lateral or crestal sinus lift: a review of 19 studies (2012-2024)

Posterior maxillary rehabilitation: challenges and objectives of sinus surgery

Implant rehabilitation of the posterior maxillary sector is a complex clinical equation where alveolar ridge resorption and sinus pneumatization drastically limit residual bone height. This systematic review, synthesizing 19 studies published between 2012 and 2024, critically analyzes the different sinus lift techniques to define their indications, clinical outcomes, and major complications. The objective is to evaluate the benefit-risk balance between the conventional lateral window approach, recommended for severe atrophy, and trans-alveolar crestal techniques, known to be less invasive.

The authors question the predictability of implant survival rates according to the chosen protocol (one or two stages) and the impact of sinus anatomy on the surgical outcome. The central hypothesis suggests that therapeutic success depends on a rigorous selection of the technique based on the initial bone morphology, with the major challenge being to minimize operative morbidity — primarily the perforation of the Schneiderian membrane — while ensuring optimal primary stability in bone that is often of low density.

Review design and methodology

This systematic review was designed to evaluate implant rehabilitation protocols for the atrophied posterior maxilla through the analysis of 19 studies published between 2012 and 2024. The research protocol targeted English-language publications indexed in the PubMed, Google Scholar, Cochrane Library, MEDLINE, and EBSCO Host databases.

The selection process was based on predefined inclusion and exclusion criteria, specifically focusing on sinus augmentation procedures and associated implant clinical outcomes. The data were synthesized to compare two major surgical approaches:

• The lateral window approach: primarily evaluated for cases of severe atrophy of the posterior maxilla.
• The crestal approach technique: analyzed for its minimally invasive nature, including hydraulic, piezoelectric, and balloon-assisted variants.

The authors systematically analyzed indications, implant survival rates, clinical benefits as well as intraoperative complications, with particular attention paid to the integrity of the Schneiderian membrane. The analysis also distinguished loading protocols according to a one-stage approach (simultaneous implantation) or a two-stage approach (prior bone grafting).

Summary of the 19 published studies (2012-2024)

Systematic analysis of the compiled data indicates that sinus augmentation is a reliable procedure for implant rehabilitation of the posterior maxilla. The results show that both primary approaches — lateral window and crestal approach — achieve high implant survival rates and predictable clinical outcomes.

Evaluation of minimally invasive approaches

The data extracted from this review highlight the effectiveness of minimally invasive techniques, including hydraulic approaches, balloon assistance, and piezoelectric techniques. These methods are associated with favorable outcomes and, importantly, lower complication rates compared to more invasive conventional techniques.

Complications and anatomical considerations

In terms of quality and safety, the analysis of complications reported in the included studies highlights the following points:

• Schneiderian membrane perforation: This is the most frequently documented complication during sinus lift procedures.
• Anatomical precision: The Schneiderian membrane has an average thickness of 0.8 mm, which requires extremely delicate handling to maintain its integrity.
• Work volume: The average volume of the maxillary sinus is 15 cc, a reference measurement for the pre-surgical evaluation of the required graft volume.

The authors conclude that the selection of the technique must be dictated by the residual bone height and individual sinus anatomy to ensure the success of bone regeneration.

Predictability confirmed by 12 years of clinical follow-up

This systematic review, analyzing 19 studies published between 2012 and 2024, validates the predictability of sinus augmentation techniques for the rehabilitation of the atrophic posterior maxilla. The compiled data indicate that the success of implantology in this complex area relies on a rigorous selection of the technique based on the patient's residual bone height and sinus anatomy.

Lateral approach versus crestal approach: the clinical dilemma

The authors report a clear decisional binarity in clinical outcomes. The lateral window approach stands out as the gold standard solution for maxillae presenting severe atrophy, allowing for direct management of the sub-sinus space. Conversely, the crestal approach, although limited by access, offers a significant reduction in surgical morbidity and postoperative complications, promoting better patient comfort. Analysis of the results shows high implant survival rates for both approaches when the indication is respected.

Securing the Schneiderian membrane: the benefits of a minimally invasive approach

The study highlights that Schneiderian membrane perforation remains the most frequently encountered complication in the practice. However, the emergence of minimally invasive techniques — including hydraulic protocols, balloon-assisted elevation, and piezosurgery — shows a favorable trend toward lower complication rates. These methods allow for a more controlled elevation of the sinus mucosa, whose average thickness remains around 0.8 mm, thereby reducing the risks of oro-antral communications.

Limits of synthesis

This review is limited to English-language publications. Although it covers a 12-year period, the heterogeneity of the grafting materials mentioned (autologous bone versus synthetic substitutes) and the variations in surgical protocols between the included studies serve as a reminder that clinical success also depends on the practitioner's technical expertise and the quality of the recipient site.

Summary of results

This systematic review of 19 studies published between 2012 and 2024 confirms the high predictability of sinus lift techniques, both via lateral and crestal approaches, with high implant survival rates. The lateral window approach remains the gold standard for severely atrophic maxillae, while minimally invasive methods — including hydraulic, balloon, or piezoelectric aids — show reduced complication rates, with Schneiderian membrane perforation remaining the most frequent adverse event.

In concrete terms, for the practitioner:

• Adapt the technique to the residual volume: systematically prioritize the crestal approach to limit morbidity and patient discomfort, while reserving lateral window access for extreme posterior atrophies.
• Secure your elevation protocols by integrating hydraulic or piezoelectric technologies; these methods significantly reduce the risk of Schneiderian membrane tearing compared to conventional rotary instruments.

Technical lexicon of the study

Schneiderian membrane: Pseudostratified ciliated epithelium lining the inside of the maxillary sinus, with a normal thickness of approximately 0.8 mm, whose integrity is crucial for the success of sinus augmentation.

Pneumatization: Physiological process of maxillary sinus expansion resulting in an increase in its volume with age, often accelerated by the loss of posterior teeth and the reduction of functional load.

Centripetal resorption: Natural pattern of bone remodeling occurring after dental extraction, contributing with pneumatization to the reduction of available alveolar bone height.

Trapdoor osteotomy: Fenestration performed in the lateral wall of the maxillary sinus allowing access to the Schneiderian membrane to elevate it and create a space intended for the graft material.

Crestal approach: Minimally invasive trans-alveolar technique, typically performed via the Summers osteotome method, allowing for sinus floor elevation without requiring extensive surgical access.

Oro-antral communication: Potential complication of sinus surgery defined by a pathological opening creating a communication between the oral cavity and the maxillary sinus.

Lateral window technique: Conventional surgical approach involving a crestal incision and releasing incisions to expose the lateral sinus wall, recommended in cases of severe posterior bone atrophy.

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