Comparison of Three Surgical Approaches for Lateral Sinus Floor Elevation

Comparison of Intraoperative Conditions and Schneiderian Membrane Perforation Risk Among Three Surgical Approaches for Lateral Sinus Floor Elevation: A Prospective Comparative Study

This prospective comparative clinical study evaluates three surgical approaches used for lateral sinus floor elevation: the standard rotary technique, an epinephrine-soaked cotton roll assisted technique, and a piezoelectric technique. The study compares intraoperative bleeding, surgical field visibility, procedural simplicity, operation time, and the occurrence of Schneiderian membrane perforation. It also examines whether patient and anatomy related factors, including smoking, residual bone height, sinus membrane thickness, and sinus septa, are associated with membrane perforation. The aim is to determine which factors contribute most strongly to surgical conditions and perforation risk during lateral sinus floor elevation.

This single center prospective comparative clinical study evaluates intraoperative conditions and Schneiderian membrane perforation during lateral sinus floor elevation performed using three surgical approaches. Eligible patients requiring lateral sinus floor elevation for implant rehabilitation are allocated sequentially according to a predefined alternating sequence to the standard procedure (SP), epinephrine-soaked cotton roll assisted procedure (ESCR), or piezoelectric sinus lift (PESL) group.

In the SP group, the lateral window is prepared using conventional rotary instrumentation, and the Schneiderian membrane is elevated using manual sinus instruments. In the ESCR group, after lateral window preparation and initial membrane elevation, a cotton roll soaked with 4% articaine containing 1:100,000 epinephrine is applied to the sinus membrane and lateral window region for approximately 5 minutes before membrane elevation is continued. In the PESL group, piezoelectric instruments are used for lateral window preparation and membrane elevation. Subsequent grafting and implant-related procedures are performed according to the same standard surgical protocol in all groups.

Patient related and anatomical variables, including age, smoking status, side of surgery, residual bone height, Schneiderian membrane thickness, and the presence of sinus septa, are recorded preoperatively. Anatomical measurements are obtained from cone-beam computed tomography images. Intraoperative bleeding, surgical field visibility, and procedural simplicity are assessed using 0-10 visual analogue scales. Operation time is recorded using a stopwatch, and Schneiderian membrane perforation is documented as a binary outcome.

The primary objective is to compare intraoperative conditions and membrane perforation among the three surgical approaches. The secondary objective is to determine whether patient-related, anatomical, and intraoperative factors are associated with membrane perforation. Statistical analyses include between-group comparisons, correlation analyses, and multivariable logistic regression models.

Inclusion Criteria:

• Must be older than 18 years
• Clinical diagnosis of absence of one or more maxillary posterior molars with a healing period of at least 6 months after extraction
• Clinical indication for Lateral Sinus Floor Elevation with either simultaneous or delayed implant placement; residual bone height ≤5 mm at the planned implant site
• Must be confirmed by cone-beam computed tomography (CBCT)
• Must have an availability of complete medical, clinical, and radiographic records.

Exclusion Criteria:

• Pathological sinus mucosal thickening or other radiographic or clinical evidence of sinus disease
• Untreated periapical or periodontal infection adjacent to the maxillary sinus
• Current or previous exposure to antiresorptive agents (e.g., bisphosphonates or denosumab) or antiangiogenic medication
• History of head and neck radiotherapy
• Requirement for additional vertical or horizontal bone augmentation procedures other than LSFE
• Previous LSFE involving the same maxillary sinus.