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Histomorphometric evaluation of different graft associations for maxillary sinus elevation in wide antral cavities: a randomized controlled clinical trial



Pneumatization of the maxillary sinus can make it difficult, if not impossible, to install osseointegrated implants, and undertake their eventual functional rehabilitation, which may ultimately require regenerative techniques to achieve. This randomized controlled study proposed conducting a histological evaluation of the behavior of different graft materials in wide maxillary sinuses, at a height of 8 to 10 mm from the alveolar ridge, combined with bone remnants less than 3mm.

Materials and methods

Thirty-six patients underwent a sinus elevation procedure through the lateral window. The sinuses were randomly filled with the following materials (n=12/group): group 1, xenogenic bone + autogenous bone (ratio 70:30, respectively); group 2, xenogenic bone + L-PRF; and group 3, xenogenic bone. At 8 months, bone biopsies of engrafted sites were harvested and analyzed histomorphometrically in order to quantify newly formed bone tissue.


The results showed a greater area of newly formed bone for G1, averaging 2678.37 (1116.40) μm2, compared with G2 at 984.87 (784.27) μm2, and G3 at 480.66 (384.76) μm2 (p < 0.05). Additionally, fewer xenogenic bone particles and a large amount of connective tissue were observed in G2.


In maxillary sinuses with large antral cavities, autogenous bone combined with xenogenic bone seems to demonstrate better graft remodeling and improve bone formation, compared with the addition of L-PRF.

Clinical relevance

L-PRF produces few advantages regarding new bone formation in the wide maxillary sinuses.

Trial registration

Brazilian Clinical Trials Registry (REBEC) number RBR-2pbbrvg.

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The authors would like to acknowledge NCristina Martorana for promptly volunteering to review this manuscript regarding its English language content, and Dr. Rafael Bovi Ambrosano for helping with the statistical analysis of the data.

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Authors and Affiliations



M.M.H., T.B.S., and E.F.M. conceived the ideas; M.M.H. performed all the surgical procedures and collected the data; M.M.H, T.B.S., P.G.M., L.N.T., A.V., and E.F.M. analyzed the data; and M.M.H. and E.F.M. managed the writing of the manuscript. All the authors revised the article critically.

Corresponding author

Correspondence to Elizabeth Ferreira Martinez.

Ethics declarations

Ethical approval

All procedures performed in the studies involving human participants complied with the ethical standards of the institutional and/or national research committee, and with the 1964 Helsinki declaration, and its later amendments or comparable ethical standards. This study was approved by the Research Ethics Committee of the Faculdade São Leopoldo Mandic (Campinas, São Paulo, Brazil), under protocol number 3.575.313.

Informed consent

Informed consent was obtained individually from all the participants in the study.

Conflict of interest

The authors declare no competing interests.

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Supplementary information



S1 Images from the clinical case of the different groups studied. Group 1: autogenous bone + Bio-Oss; Group 2: Bio-Oss combined with L-PRF; Group 3: Bio-Oss. A= initial CBCT, B= osteotomy, C= maxillary sinus filling, D= final CBCT, E= open flap, F= implant installation. (PNG 4927 kb)

High resolution (TIF 17849 kb)

S1_G2 (PNG 5886 kb)

High resolution (TIF 18009 kb)

S1_G3 (PNG 6118 kb)

High resolution (TIF 18008 kb)


S2. Photomicrographs of the redefined samples of the maxillary sinus trephine of all the patients included in the study. Caption: Group 1: autogenous bone + Bio-Oss; Group 2: Bio-Oss combined with L-PRF; Group 3: Bio-Oss. Bar = 1000μm. (PNG 25425 kb)

High resolution image (TIF 60617 kb)

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Harlos, M.M., da Silva, T.B., Montagner, P.G. et al. Histomorphometric evaluation of different graft associations for maxillary sinus elevation in wide antral cavities: a randomized controlled clinical trial. Clin Oral Invest 26, 1–9 (2022).

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