Comparison of the Grind-out and Hydraulic Pressure Techniques for Transcrestal Sinus Floor Elevation with Simultaneous Implant Placement: A Clinical Study

Comparison of the Grind-out and Hydraulic Pressure Techniques for Transcrestal Sinus Floor Elevation with Simultaneous Implant Placement: A Clinical Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of the Grind-out and Hydraulic Pressure Techniques for Transcrestal Sinus Floor Elevation with Simultaneous Implant Placement: A Clinical Study Zhen-Ze Yu, Luo-Man Gan, Xing-Wen Wu, Yang Sun, Shu-Chi Xia, You-Cheng Yu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8338371/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Objectives: Our study aimed to compare the clinical efficacy of grind-out and hydraulic pressure techniques for transcrestal sinus floor elevation (TSFE) through a clinical retrospective analysis. Materials and Methods: 40 patients who received TSFE with simultaneous implant placement using either the grind-out or the hydraulic pressure technique were included. We compared the clinical effects of these two methods through following parameters: primary outcomes included bone augmentation volume at Tn (BAV n ), the bone graft volume resorption rate at Tn (BGVRR n-1 ). bone augmentation height at Tn (BAH Tn ), resorption rate of bone graft height at Tn (RRBGH n-1 ). T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery. Secondary outcome included: VAS scores and swelling scores from days 0, 1, 3, 5 and 7 postoperatively. Group differences were assessed using t-tests, Mann–Whitney U tests, and generalized estimating equation. Results: Among 40 patients (21 patients for hydraulic pressure group, 19 patients for grind-out technique group), the BGVRR 1 , BGVRR 2 , RRBGH 1 and RRBGH 2 of the hydraulic pressure group was significantly higher than that in the grind-out technique group ( P < 0.001), whereas no significant differences were observed in BAV 2 , BAV 3 , BAH T2 and BAH T3 between the two groups. The grind-out technique group showing lower VAS and swelling scores than the hydraulic pressure group ( P < 0.05). In both groups, the VAS pain and swelling scores gradually decreased over time. Conclusions: Grind-out and hydraulic techniques are both effective for TSFE and implant placement, but the grind-out method shows less bone resorption and postoperative discomfort. Hydraulic pressure technique grind-out technique transcrestal sinus floor elevation dental implant clinical study Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The posterior teeth play a crucial role in determining masticatory efficiency. The absence of posterior teeth significantly impairs patients’ ability to chew effectively, consequently impacting their quality of life and psychological well-being. Implant denture offers notable advantages, including high chewing efficiency, aesthetically pleasing appearance, and enhanced comfort, making them a popular choice among patients [1,2]. However, insufficient residual alveolar bone height (RBH) in the maxillary posterior region has consistently posed a significant challenge in implant restoration procedures. The maxillary sinus is a pyramidal cavity located within the maxillary bone, which may undergo pneumatization following the loss of posterior maxillary teeth, resulting in a reduction of the vertical distance from the sinus floor to the alveolar crest [3,4]. In addition, pathological factors such as periodontitis and periapical periodontitis, as well as physiological factors including age-related osteoporosis and disuse-induced alveolar bone resorption, can lead to insufficient residual vertical bone height in the alveolar ridge, making it difficult to meet the requirements for conventional implant placement [5]. To tackle this challenging clinical issue, several strategies for implant restoration have been proposed, including the utilization of short implants [6,7], tilted implant placement along the mesial-distal or palatal bone walls [8,9], and the widely adopted maxillary sinus floor elevation (MSFE) procedure. Maxillary sinus elevation typically involves lateral sinus floor elevation (LSFE) and transcrestal sinus floor elevation (TSFE). The International Team of Implantology (ITI) offers specific implant recommendations based on RBH and the morphology of the maxillary sinus floor. TSFE is recommended for patients with RBH＞6mm, adequate alveolar bone width, and a flat maxillary sinus floor, while LSFE is suitable for patients with RBH≤6mm and an oblique maxillary sinus floor[10]. Nowadays, advancements in technology have expanded the application of TSFE to patients with RBH≥4mm. Conventional TSFE utilizes Summers osteotomes to create a greenstick fracture of the maxillary sinus floor, enabling the elevation of the sinus membrane [11]. Nevertheless, repeated percussion not only causes psychological and physiological distress to patients but also heightens the risks of sinus membrane perforation and concussion [12-15]. In recent years, various minimally invasive maxillary sinus floor techniques have been developed to reduce patients’ postoperative complications and enhance surgical comfort. The most prevalent techniques include the hydraulic pressure technique and the cushioned grind-out technique. The hydraulic pressure technique involves elevating the mucoperiosteum of the maxillary sinus floor by injecting saline into the sinus floor after preparing the implant socket using a non-invasive drill pin. Sotiraki et al. [16] recommended the use of the CAS tool kit (Crestal Approach Sinus Kit, Osttem, Korea) for hydraulic maxillary sinus lifting. This kit includes CAS drills and stoppers that facilitate precise preparation of the implant socket in the maxillary sinus floor, safe penetration of the sinus floor bone wall, and simultaneous lifting of the maxillary sinus floor using the hydraulic lifting device. Grind-out technique [17] is a method involving the gradual and delicate grinding of the sinus floor bone wall using a drill bit and stoppers of a specialized maxillary sinus lifting kit. Subsequently, the mucoperiosteum is uniformly stripped and lifted with an instrument of the kit. Gao et al. [18] utilized the grind-out technique for TSFE through DASK (Dentium advanced sinus kit, DASK, South Korea) kit. Following maxillary sinus mucosa stripping and lifting carefully, bone grafting material was applied to elevate the maxillary sinus, resulting in good postoperative implant restoration stability. So far, a large number of articles have conducted research and discussions on the clinical efficacy of these two methods respectively. However, there is still a lack of clinical studies comparing the clinical effects of these two surgical methods. Therefore, the main purpose of this study is to compare the clinical efficacy of these two surgical methods for TSFE through a clinical retrospective analysis, aiming to provide certain theoretical and clinical basis for clinicians in the selection of two minimally invasive maxillary sinus elevation surgical techniques. Materials and Methods 2.1 Patient Selection This study retrospectively analyzed clinical data from patients who underwent single implant placement with a simultaneous maxillary sinus floor elevation surgery at the Department of Stomatology, Zhongshan Hospital Affiliated to Fudan University between January 2022 and December 2022. Approval for this study was obtained from the Ethics Committee of Zhongshan Hospital Affiliated with Fudan University (Approval Number: B2021-767R), and all procedures were conducted in accordance with the Declaration of Helsinki. The inclusion criteria included: Patients ≥18 years of age; Single tooth loss in the maxillary posterior dental area for ≥ 6 months; Patients with residual bone height (RBH) ranges from 5 mm to 9 mm; The maxillary sinus floor exhibited a flat morphology without antral septa; No uncontrollable acute inflammation and cyst in maxillary sinus; Patients who had undergone maxillary posterior TSFE with grind-out technique or hydraulic pressure technique and simultaneous implantation; Reliable and complete case data and photographs could be collected. Exclusion criteria: Patients with a sloping maxillary sinus floor morphology or antral septa in the surgery site; Individuals with maxillary sinus cysts, acute maxillary sinusitis, or unmanageable periodontitis. Patients suffering from uncontrollable systemic diseases or treatment history affecting bone and soft tissue healing; Patients with previous history of maxillary sinus floor elevation; Patients with alcoholism, heavy smoking (>10 cigarettes per day), and severe nocturnal bruxism; Patients with incomplete clinical and imaging medical records. 2.2 Clinical procedures 2.2.1 Preoperative preparation Before operation, a specialized dental implant medical record was created for each patient, encompassing blood tests, maxillofacial and oral examinations, and a thorough patient's medical history was collected to exclude contraindications for implant surgery. An initial implant plan was formulated, patients were informed of the surgical procedure and potential complications, followed by obtaining signed informed consent for the implant surgery. 2.2 Implantation surgery All patients were directed to rinse their mouths with 0.2% chlorhexidine for 1 minute before surgery. Local infiltration anesthesia was applied to the implant site using articaine hydrochloride (Primacaine ® , Pierre Rolland, France). All surgical procedures were conducted by the same chief physician. The Grind-out technique surgery procedure After completing local infiltration anesthesia and disinfection of the surgical area, a mid-crest incision at the alveolar ridge, along with additional incisions in the mesial and distal sulci of the adjacent teeth was made to form a full-thickness flap exposing the alveolar ridge. Subsequently, the implant socket was prepared using pilot drills with depth stop rings from the DASK tool kit (Dentium Advanced Sinus Kit, Dentium, South Korea). The diameter of twist drill was gradually increased until reaching the safe position located around 1mm below the sinus floor. A protective round diamond-grit bur was used to grind the remaining bone at the sinus floor until a slight drop was felt. A doom-shaped elevator was then employed to loosen and elevate the sinus floor mucosa to the predetermined height. The integrity of the maxillary sinus membrane was confirmed using the Valsalva maneuver. Furthermore, bone graft material (Bio-oss collagen ® , Geistlich, Wolhusen, Switzerland) was placed in the maxillary sinus floor, a depth gauge was used to ensure at least 2mm thickness of the graft materials, followed by implant placement, all patients were treated with submerged healing, covering screws were placed and 4-0 sutures were tightly sutured (Figure1 a-h). The Hydraulic Pressure technique surgery procedure Preoperative preparations were as described above. The implant socket was prepared using pilot drills with depth stop rings from the CAS tool kit (Crestal Approach Sinus Kit, Osstem, South Korea). The pilot drill diameter was increased gradually until reaching a safe position approximately 1mm below the sinus floor. 0.5-1ml of saline was injected into maxillary sinus by a hydraulic elevator to gradually and uniformly lift maxillary sinus floor membrane. The integrity of the maxillary sinus membrane was confirmed using the Valsalva maneuver. Subsequently, bone graft material (Bio-oss collagen ® , Geistlich, Wolhusen, Switzerland) was inserted into the maxillary sinus floor. A depth gauge was utilized to confirm a minimum of 2mm thickness of the graft material. Ultimately, all patients underwent submerged healing after implant placement. Covering screws were placed and sutured with 4-0 sutures (Figure1 i-p). All patients received analgesics to control post-surgical pain and peri-operative antibiotic prophylaxis with cefuroxime sodium and tinidazole, which was maintained for 7 days post-operatively. All patients received antibiotic prophylactic with cefuroxime sodium and tinidazole for 7 days after surgery. Analgesics (ibuprofen 400 mg) was used to control post-surgical pain, with instructions on self-administration if needed. Additionally, patients are required to record their pain conditions according to the visual analogue scale (VAS) before using painkillers. 2.2.3 Radiological procedure CBCT scans were obtained from all patients at four time points: before surgery (T0), immediately post-surgery (T1), 6 months post-surgery (T2), 12 months post-surgery (T3). The identical CBCT machine (KaVo, Bieberach an der Riss, Germany) was utilized with consistent parameters, including standard dose, an in-tube voltage of 120kV, an in-tube current of 6mA, a scanning range of 16cm × 13cm, voxel dimensions of 0.5 mm × 0.5 mm × 0.5 mm, an exposure time of 7s, and a slice thickness of 0.2 mm. All data is exported and saved in Dicom format. 2.3 Clinical evaluation 2.3.1 Implant survival rate In accordance with the success criteria proposed by Albrektsson et al.[19], an implant was considered successful when meeting all of the following conditions: (1) no clinical mobility of the individual implant; (2) absence of any peri-implant radiolucency on radiographic examination; (3) vertical bone resorption <2.0 mm during the first year of functional loading, and thereafter not exceeding 0.2 mm annually; and (4) no persistent and/or irreversible clinical symptoms or signs, such as pain, infection, or paresthesia. 2.3.2 Schneiderian membrane perforation rate Valsalva maneuver was used to assess the integrity of the maxillary sinus mucosa. Absence of bubble formation or discharge of bloody fluid from the implant cavity, coupled with the absence of a liquid level in the maxillary sinus floor on immediate postoperative CBCT imaging, indicated intact maxillary sinus mucosa. 2.3.3. Pain assessment The 100-mm visual analogue scale (VAS) was utilized to assess patients' pain levels at postoperative days 0, 1, 3, 5 and 7, respectively. 2.3.4 Swelling assessment The swelling scale (Table 1) was used to assess patients' swelling severity at postoperative days 0, 1, 3, 5 and 7, respectively. 2.4 Radiographic assessment CBCT in Dicom format at T0, T1, T2 and T3 were imported into the 3D reconstruction software Mimics21.0 (Materialise, Leuven, Belgium). Using the threshold tool and mask editing tool in the software, three-dimensional implant models at different time points (T0, T1, T2 and T3) were established. These models were labeled as RM 0 , RM 1 , RM 2, and RM 3 respectively. Subsequently, RM 1 , RM 2 and RM 3 were imported into the RM 0 modeling window, they were superimposed using four anatomical marker points from adjacent teeth in the edentulous region (Figure 2 a-e). 2.4.1 Volume measurement The mask editing tool was utilized to delineate the contour of each layer of the bone graft material. Subsequently, the calculation tool was utilized to merge all the two-dimensional layers of the bone graft material to construct a comprehensive three-dimensional model. This reconstructed model was then imported into 3-Matic Research software (Materialise, Leuven, Belgium) to calculate the volume of the bone graft material (BGMV) at T1, T2, and T3, labeled as BGMV 1 , BGMV 2 , and BGMV 3 respectively. Bone augmentation volume at T1, T2, and T3 labeled as BAV 1 , BAV 2 and BAV 3 respectively. Bone resorption volume at T2 and T3 labeled as BRV 1 and BRV 2 . The bone graft volume resorption rate at T2 (BGVRR 1 )= [(BGMV 1 - BGMV 2 ) / BGMV 1 ] × 100%, the bone graft volume resorption rate at T3 (BGVRR 2 )= [(BGMV 1 – BGMV 3 ) / BGMV 1 ] ×100%. 2.4.2 Peri-implant bone height measurement In the sagittal and coronal views of the RM 0 modeling window (RM 0 , RM 1 , RM 2 and RM 3 had been superimposed), CBCT was adjusted to the maximum implant diameter. Subsequently, the peri-implant bone height at four sites (mesial, distal, buccal, and palatal) were measured. Each measurement was performed three times by the same researcher and then averaged (Figure 3). The variables are defined as follows: MBHI Tn (mesial bone height of the implant at Tn), DBHI Tn (distal bone height of the implant at Tn), BBHI Tn (buccal bone height of the implant at Tn), and PBHI Tn (palatal bone height of the implant at Tn). Taking the mesial bone height around the implant as an illustration, the measurement protocol was as follows: the implant platform and the implant apex were defined as point a and point b respectively. The line ab intersects the maxillary sinus floor at point d, where the length of line ad represents the preoperative mesial alveolar bone height (MBHI T0 ). The residual bone height (RBH) = (MBHI T0 + DBHI T0 + BBHI T0 + PBHI T0 )/4. Bone height around the implant at T n (BHAI Tn ) = (MBHI Tn + DBHI Tn + BBHI Tn + PBHI Tn )/4. Bone augmentation height at Tn (BAH Tn ）= BHAI Tn – RBH. Bone resorption height at T1 (BRH 1 ）= BHAI T1 - BHAI T2 . Bone resorption height at T2 (BRH 2 ）= BHAI T1 - BHAI T3 . Resorption rate of bone graft height at T2 (c) = [(BHAI T1 - BHAI T2 ) / BHAI T1 ] × 100%. Resorption rate of bone graft height at T3 (RRBGH 2 ) = [(BHAI T1 - BHAI T3 ) / BHAI T1 ] × 100%. 2.5. Statistical analysis All statistical analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA). Data normality was assessed using the Shapiro–Wilk test, and Levene’s test was applied for homogeneity of variances. Continuous variables were expressed as mean ± standard deviation (x̄ ± s) or medians (lower quartile, upper quartile). Comparisons between two groups were conducted using the independent samples t-test for normally distributed data with equal variances or the Mann–Whitney U test otherwise. A generalized estimating equation (GEE) model was used to evaluate temporal trends and intergroup differences in VAS scores and swelling scores between the Grind-out technique and hydraulic pressure technique groups. Statistical significance was set at P < 0.05. Results 3.1 Demographics This retrospective study analyzed 127 patients who underwent single implant placement with simultaneous maxillary sinus floor elevation surgery. The procedures were performed using either the hydraulic pressure technique or the grind-out technique in the maxillary molar region between December 2021 and December 2022. A total of 34 patients with maxillary sinus septa and 17 patients with incomplete CBCT data or pain and swelling assessment and 32 patients using tapered implant were excluded, resulting in a final cohort of 44 patients meeting the inclusion criteria. Patients with maxillary sinus mucosal perforation (including 1 implant loss) were further excluded, and a total of 40 patients were included in the analysis. Among them, 21 patients (12 females, 9 males) in the hydraulic pressure group, with an median age of 58 years, 14 Bego implants, 7 Straumann implants, 13 first molars, 8 second molars, and a median RBH of 6.11 mm. In the grind-out technique group, there were 19 cases (10 females, 9 males) with an median age of 57 years. Among them, 14 cases were Bego implants, 5 were Straumann implants, 12 first molars, and 7 second molars, with a median RBH of 6.69 mm. There were no statistically significant differences in age, gender, tooth position, implant type, and implant diameter between the two groups, indicating their comparability (Table 2). 3.2 Implant survival rate Out of the 23 cases in the hydraulic pressure group, one case experienced implant loss, resulting in a survival rate of 96.65%. Conversely, in the grind-out technique group, no implants were lost, resulting in a 100% survival rate. Chi-square test showed that there was no significant difference in implant survival rate between the two groups ( P > 0.05). 3.3 Schneiderian membrane perforation rate During implant surgery, no maxillary sinus mucosal perforation was detected in any of the patients. Post-surgery CBCT revealed maxillary sinus floor mucosa perforation and fluid level in two patients from both groups, respectively. Notably, one patient from the hydraulic pressure group with maxillary sinus mucosa perforation experienced implant loss at 2 months after operation. CBCT examination found that fluid level disappeared in other patients at 3 months after surgery, with no significant impact on sinus bone formation and favorable prognoses observed. Chi-square test was used to compare the maxillary sinus perforation rate between the two groups. The results showed that there was no statistical significance between the two groups ( P > 0.05). The above cases of mucosal perforation and implant loss were excluded in the follow analysis. 3.4 Volume changes and resorption rates of bone graft materials after surgery The Mann-Whitney test was used to compare BGMV 1 , BGMV 2 , BGMV 3 , BAV 1 , BAV 2 , BAV 3 , BRV 1 , BRV 2 , BRV 3 , BGVRR 1 and BGVRR 2 between two groups. The statistical results are as follows (Figure 4 a-b, Table 3): The BGMV 1 and BAV 1 in the hydraulic pressure group were significantly higher than those in the grind-out technique group ( P 0.05). The BRV 1 and BRV 2 in the hydraulic pressure group were also higher than those in the grind-out technique group, and the differences were statistically significant ( P < 0.001). The BGVRR 1 and BGVRR 2 of the hydraulic pressure group was significantly higher than that in the grind-out technique group, and the difference was statistically significant ( P < 0.001). 3.5 Changes and resorption rates of peri-implant bone height The Mann-Whitney test was utilized to make a comparison of BHAI T1 , BHAI T2 , BHAI T3 , BAH T1 , BAH T2 , BAH T3 , BRH 1 , BRH 2 , RRBGH 1 , RRBGH 2 between two groups. The statistical outcomes are presented as follows (Table 4): In the hydraulic pressure group, BHAI T1 and BAH T1 were significantly higher than those in the grind-out technique group ( P 0.05). The levels of BRH1 and BRH2 in the hydraulic pressure group were higher than those in the grind-out technique group, with statistically significant differences ( P < 0.01). Similarly, RRBGH1 and RRBGH2 in the hydraulic pressure group were markedly higher than those in the grind-out technique group, and the differences were statistically significant ( P < 0.01). 3.6 Postoperative Pain Generalized estimating equation (GEE) was applied to analyze the temporal trend of VAS scores and the intergroup differences between the grind-out technique group and the hydraulic pressure group. The results showed that the main effect of time was significant (χ² = 313.704, P < 0.001), the main effect of group was significant (χ² = 21.619, P < 0.001), and the interaction effect between time and group was also significant (χ² = 33.610, P < 0.001). Given the significant interaction, a simple effect analysis was performed. The statistical results indicated that at all time points, there were significant differences in VAS scores between the two groups, with the grind-out technique group showing lower VAS scores than the hydraulic pressure group (P < 0.05). In both groups, the VAS pain scores gradually decreased over time, and the changes were statistically significant (P < 0.05) (Figure 4c and 4e). 3.7 Postoperative Swelling Generalized estimating equation (GEE) was employed to analyze the temporal trend and intergroup differences in swelling scores. The results showed that the main effect of time was significant (χ² = 386.406, P < 0.001), the main effect of group was significant (χ² = 27.706, P < 0.001), and the interaction between time and group was also significant (χ² = 50.723, P < 0.001). Given the significant interaction, a simple effect analysis was conducted. The results indicated that at all time points, there were statistically significant differences in swelling scores between the two group (P 0.05), whereas all other pairwise comparisons across time points showed significant differences (P < 0.05). In contrast, in the grind-out technique group, swelling scores decreased progressively over time, and the differences were statistically significant (P < 0.05) (Figure 4d and 4f). Discussion For patients with severely insufficient RBH in the maxillary posterior region, achieving a stable and minimally invasive implant treatment outcome has become a focal point of clinical research in oral implantology. With advancements in surgical instruments and techniques, the achievable bone augmentation height through TSFE has significantly increased, while the incidence of Schneiderian membrane perforation has markedly decreased. Currently, the minimally invasive techniques for TSFE mainly include hydraulic pressure technique and grind-out technique. Our study compared the clinical outcomes of hydraulic pressure technique and grind-out technique for TSFE in the maxillary posterior region with a RBH ranging from 5 mm to 9 mm. The results demonstrated that both techniques achieved stable bone augmentation, high implant survival rates and low Schneiderian membrane perforation rate during follow-up, indicating that these two techniques are reliable minimally invasive technique for patients with RBH of 5-9 mm. Similar to our research, Lin et al.[20] utilized three-dimensional finite element analysis to establish models of TSFE using the hydraulic pressure technique and two osteotome techniques with different diameters (1.6 mm and 3.0 mm), in order to compare the biomechanical characteristics of the Schneiderian membrane under different approaches. The results showed that with increasing elevation height, the loading force, stress, and strain applied to the Schneiderian membrane all increased significantly. However, the hydraulic pressure technique required the lowest loading force, exhibited the most uniform stress distribution, and produced the greatest horizontal displacement at the same elevation height, indicating that it could achieve a larger membrane detachment area while reducing the risk of membrane perforation. The study demonstrated that the hydraulic pressure technique is safer and more efficient than the conventional osteotome technique. Another study [21] performed TSFE using the hydraulic technique with simultaneous implant placement in 1,100 patients with RBH of 1–5 mm. An 8-year follow-up and retrospective analysis revealed a cumulative implant survival rate of 99.99%, with only eight implants failing during the early osseointegration stage. Gao et al. [22] conducted a retrospective cohort study with a 7-year follow-up comparing patients who underwent osteotome sinus floor elevation and those treated with the cushioned grind-out technique using the DASK kit. The rates of Schneiderian membrane perforation were 6.4% and 5.5%, respectively, with no statistically significant difference between the two groups. The mean sinus floor bone gain was 4.64 mm and 5.31 mm, respectively. Multivariate regression analysis indicated that the minimally invasive TSFE using the DASK kit was an important factor promoting new bone formation within the sinus. In our study, the intramaxillary sinus bone gain was consistent with previous reports, with a mean vertical bone augmentation of 4.38 mm in the hydraulic pressure group and 3.98 mm in the grind-out technique group at 1 year postoperatively. Although both techniques achieved high implant survival rates and acceptable bone augmentation, this study found that under the same grafting material conditions, the hydraulic pressure technique group exhibited significantly higher bone graft volume resorption rates at 6 months and 12 months postoperatively (the median of 47.39% and 54.21%, respectively) compared with the grind-out technique group (the median of 27.75% and 37.98%, respectively), hydraulic pressure technique exhibited a relative limitation in maintaining bone volume stability. Possible factors contributing to this difference include: firstly, this difference may be related to the mechanical stability of the bone graft materials in the early postoperative period. The hydraulic pressure technique elevates the sinus membrane using hydraulic pressure and bone graft materials. Initially, the graft remains in a loose state, with limited compressive and shear strength, making it prone to collapse and shrink under repeated respiratory pressure and masticatory forces. Secondly, the elevation height and the size of the “tenting space” have a direct impact on bone resorption. The hydraulic elevation technique can achieve a greater degree of membrane lifting than the grind-out technique group, however, a larger suspended cavity is more susceptible to collapse and resorption during the bone remodeling process. Kuo et al. [23] reported that the reduction in grafted bone height following TSFE is primarily influenced by the elevation pattern and the tension of the Schneiderian membrane: the greater the vertical elevation height, the larger vertical amount of the implant protrusion, and the steeper the elevation profile, the greater the resorption of the grafted material. This finding suggests that when the elevating force is concentrated in the vertical direction without sufficient lateral expansion or support, the increased membrane tension may lead to collapse of the cavity and resorption of the bone graft material. Accordingly, in the hydraulic sinus elevation technique, the instantaneous vertical pressure generated by the fluid may induce rapid upward displacement of the membrane and localized high tension, resulting in reduced initial stability of the grafting space and accelerated remodeling or resorption of the bone graft material during healing. This phenomenon should not be regarded as an inherent drawback of the hydraulic pressure technique but rather as a consequence of its vertical stress characteristics. The VAS is a commonly used tool for pain assessment. Its advantages include being intuitive and highly accurate, allowing the patient’s postoperative sensations to be reflected directly through numerical values. Therefore, it is widely applied in clinical pain evaluation, postoperative pain management, and efficacy assessment [24]. Similarly, the Swelling Visual Analogue Scale [25] enables a direct numerical representation of the patient’s postoperative swelling condition. Rengo et al.[26] conducted a prospective cohort study and found that pain and swelling commonly occur after LSFE. Postoperative responses were evaluated using VAS and swelling scores. The results showed that pain was most severe on the first postoperative day and gradually improved over time, while swelling typically peaked on the second postoperative day. Praveen et al. [27] compared postoperative responses between minimally invasive antral balloon elevation technique and drill integrated hydrodynamics technique for TSFE. The VAS scores for pain on postoperative day 7 were 4.93 ± 1.038 and 3.77 ± 1.301, respectively. The balloon technique resulted in significantly higher pain scores than the drill integrated hydrodynamics technique group, with the difference being statistically significant. This study found that the hydraulic technique resulted in significantly higher levels of pain and swelling on the day of surgery, as well as on postoperative days 1, 3, and 5, compared with the grind-out technique group. In both groups, pain and swelling gradually decreased starting from the first postoperative day, consistent with findings reported in previous studies. The higher discomfort associated with the hydraulic technique may be attributed to the intraoperative increase in balloon pressure caused by fluid injection, which elevates the Schneiderian membrane through hydraulic force, leading to a sensation of swelling and discomfort in patients. Our study is limited by a small sample size, short follow-up duration, and retrospective design conducted at a single center. In addition, there is a certain degree of recall bias in documenting postoperative VAS scores and swelling assessments. Moreover, the precision of measurements could be compromised by implant artifacts in CBCT 3D reconstructions using Mimics, leading to discrepancies between measured outcomes and clinical application. Further well-designed prospective randomized controlled trials with extended follow-up periods are required to provide stronger evidence regarding the clinical efficacy of these surgical procedures. Conclusions For patients with a single missing maxillary molar, a flat sinus floor without septa, and a RBH ranging from 5 mm to 9 mm, sinus floor elevation using either the hydraulic pressure technique or the grind-out technique with simultaneous bone graft material and implant placement can be reliable techniques with expected clinical outcome. In the first year after surgery, both techniques demonstrate a high implant survival rate, a low incidence of Schneiderian membrane perforation, and favorable bone augmentation outcomes. The grafted bone materials used in both the hydraulic pressure technique and the grind-out technique undergo resorption within 6 months and 12months postoperatively, with the resorption rate significantly higher in the hydraulic pressure group than in the grind-out group. Both the hydraulic pressure and grind-out techniques may cause postoperative pain and swelling to varying degrees; however, compared with the hydraulic pressure approach, the grind-out technique involves less surgical trauma and results in milder postoperative discomfort. Declarations Ethics approval and consent to participate Approval for this study was obtained from the Ethics Committee of Zhongshan Hospital Affiliated with Fudan University (Approval Number: B2021-767R), and all procedures were conducted in accordance with the Declaration of Helsinki. All patients provided written informed consent prior to surgery. Consent for publication Not applicable. Availability of data and materials The data supporting this study’s findings are available from the corresponding author upon reasonable request. Competing interests The authors declare no competing interests. Funding This work was supported by grants from the National Natural Science Foundation of China (NSFC) [82401064, 82170990], Clinical Research Plan of Zhongshan Hospital, Fudan University (ZSLCYJ202320, ZSLCYJ202345), National Natural Science Foundation of Fujian Province [2024J011444]. Authors' contributions ZZY and LMG contributed equally to this work and share first authorship. ZZY and LMG collected the clinical data, performed data analysis, and drafted the manuscript. XWW, YS, and SCX participated in data acquisition and interpretation. YCY and FY conceived and designed the study, supervised the project, and critically revised the manuscript. All authors read and approved the final manuscript. Corresponding authors Correspondence to You-Cheng Yuor Fei Yang. Acknowledgements The authors would like to thank all individuals who participated in this study for their cooperation and support. References Sagheb K, Wentaschek S, Bjelopavlovic M, Berres M, Díaz L, Fan S, Schiegnitz E, Al-Nawas B, (2024) Evaluation of masticatory efficiency and OHRQoL in implant-retained overdenture with different numbers of implant in the edentulous mandible: a one-year follow-up prospective study. INT J IMPLANT DENT 10 (1):12. doi:10.1186/s40729-024-00519-0 Sun X, Zhai J, Liao J, Teng M, Tian A, Liang X (2014) Masticatory efficiency and oral health-related quality of life with implant-retained mandibular overdentures. SAUDI MED J 35 (10):1195-1202 Iwanaga J, Wilson C, Lachkar S, Tomaszewski KA, Walocha JA, Tubbs RS (2019) Clinical anatomy of the maxillary sinus: application to sinus floor augmentation. ANAT CELL BIOL 52 (1):17-24. doi: 10.5115/acb.2019.52.1.17 Sharan A, Madjar D (2008) Maxillary sinus pneumatization following extractions: a radiographic study. The International journal of oral & maxillofacial implants 23 (1):48-56 Chiapasco M, Zaniboni M, Rimondini L (2008) Dental implants placed in grafted maxillary sinuses: a retrospective analysis of clinical outcome according to the initial clinical situation and a proposal of defect classification. CLIN ORAL IMPLAN RES 19 (4):416-428. doi: 10.1111/j.1600-0501.2007.01489.x Shi J, Lai Y, Qian S, Qiao S, Tonetti MS, Lai H (2021) Clinical, radiographic and economic evaluation of short-6-mm implants and longer implants combined with osteotome sinus floor elevation in moderately atrophic maxillae: A 3-year randomized clinical trial. J CLIN PERIODONTOL 48 (5):695-704. doi:10.1111/jcpe.13444 Thoma DS, Cha J, Jung U (2017) Treatment concepts for the posterior maxilla and mandible: short implants versus long implants in augmented bone. J PERIODONTAL IMPLAN 47 (1):2-12. doi: 10.5051/jpis.2017.47.1.2 Ragucci GM, Elnayef B, Criado-Cámara E, Del Amo FS, Hernández-Alfaro F (2020) Immediate implant placement in molar extraction sockets: a systematic review and meta-analysis.INT J IMPLANT DENT 6 (1):40. doi: 10.1186/s40729-020-00235-5 Candel-Marti E, Peñarrocha-Oltra D, Bagán L, Peñarrocha-Diago M, Peñarrocha-Diago M (2015) Palatal positioned implants in severely atrophic maxillae versus conventional implants to support fixed full-arch prostheses: Controlled retrospective study with 5 years of follow-up. Medicina oral, patologia oral y cirugia bucal 20 (3): e357-e364 Scott AR (2012) ITI treatment guide, volume 5: sinus floor elevation procedures. BRIT DENT J 212 (10): 512 Summers RB (1994) A new concept in maxillary implant surgery: the osteotome technique. Compendium (Newtown, Pa.) 15 (2): 152-154 Lin X, Xu S, Chen L, Que G (2025) Comparison of biomechanical characteristics of the Schneiderian membrane with different transcrestal sinus floor elevation techniques using three-dimensional finite element analysis.BMC ORAL HEALTH 25 (1): 146. doi: 10.1186/s12903-025-05499-0 Flanagan D (2004) Labyrinthine concussion and positional vertigo after osteotome site preparation. IMPLANT DENT 13 (2): 129-132 Su GN, Tai P, Su P, Chien H (2008) Protracted benign paroxysmal positional vertigo following osteotome sinus floor elevation: a case report. The International journal of oral & maxillofacial implants 23 (5): 955-959 Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH, Fugazzotto PA (1999) The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. The International journal of oral & maxillofacial implants 14 (6): 853-858 Sotirakis EG, Gonshor A (2005) Elevation of the maxillary sinus floor with hydraulic pressure. The Journal of oral implantology 31 (4):197-204 Gao J, Yin W, Liu Y, Zhao X, Qu Y, Man Y(2023)Effectiveness and complications of transcrestal sinus floor elevation using the cushioned grind-out technique: A retrospective cohort study with up to 7 years of follow-up.J CLIN PERIODONTOL 50 (9):1202-1216. doi: 10.1111/jcpe.13832 Zhang F GWLL (2016) Application and 3–5-year clinical observation of two minimally invasive transalveolar approaches for maxillary sinus floor elevation.Journal of Oral Medical Research 32 (6): 643-647 Albrektsson T, Zarb G, Worthington P, Eriksson AR (1986) The long-term efficacy of currently used dental implants: a review and proposed criteria of success. The International journal of oral & maxillofacial implants 1 (1): 11-25 Lin X, Xu S, Chen L, Que G (2025) Comparison of biomechanical characteristics of the Schneiderian membrane with different transcrestal sinus floor elevation techniques using three-dimensional finite element analysis. BMC ORAL HEALTH 25 (1): 146. doi: 10.1186/s12903-025-05499-0 Chen L, Cha J (2005) An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J PERIODONTOL 76 (3):482-491 Gao J, Yin W, Liu Y, Zhao X, Qu Y, Man Y (2023) Effectiveness and complications of transcrestal sinus floor elevation using the cushioned grind-out technique: A retrospective cohort study with up to 7 years of follow-up. J CLIN PERIODONTOL 50 (9):1202-1216. doi: 10.1111/jcpe.13832 Kuo P, Lin C, Chang C, Wang Y, Pan W (2021) Grafted bone remodeling following transcrestal sinus floor elevation: A cone-beam computed tomography study. BIOMED J 44 (5):627-635. doi: 10.1016/j.bj.2020.05.011 Seymour RA, Charlton JE, Phillips ME (1983) An evaluation of dental pain using visual analogue scales and the Mcgill Pain Questionnaire. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 41 (10): 643-648 Pachipulusu PK, S M (2018) Comparative study of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars. Oral and maxillofacial surgery 22 (3):261-266. doi: 10.1007/s10006-018-0696-8 Rengo C, Fiorino A, Cucchi A, Nappo A, Randellini E, Calamai P, Ferrari M (2021) Patient-reported outcomes and complication rates after lateral maxillary sinus floor elevation: a prospective study. CLIN ORAL INVEST 25 (7):4431-4444. doi: 10.1007/s00784-020-03755-x Praveen AA, Venkadassalapathy S, Victor DJ, Prakash PSG, Umesh SG, Ali Baeshen H, Balaji TM, Patil S, Reda R, Testarelli L (2023) Efficacy of Two Different Hydrodynamic Sinus Lift Systems for Atraumatic Elevation in Immediate Implant Placement. PATIENT PREFER ADHER 17:1197-1207. doi: 10.2147/PPA.S403036 Tables Table 1. Swelling Severity Scale Score Degree of Swelling 0 No swelling: patient experiences no sensation of swelling. 1 Mild swelling: patient experiences slight swelling sensation without observable facial swelling 2 Moderate swelling: patient has a noticeable sensation of swelling without impeding normal chewing and swallowing 3 Severe swelling: facial swelling is observable and affects normal chewing 4 Very severe swelling: facial swelling is clearly observable, making normal chewing impossible, but mouth-opening is not restricted 5 Extremely severe swelling: facial swelling is markedly observable with limited mouth opening Table 2. Summary of patient demographics (n=40) Characteristics Hydraulic pressure group (n=21) Grind-out technique group (n=19) P Gender (male/female) 12/9 10/9 0.512 Age [years, M（P 25 ,P 75 ）] 58.00 (39.00, 64.00) 57.00 (45.00, 61.50) 0.329 RBH [mm，M（P 25 ,P 75 ）] 6.11 (5.78, 6.96) 6.69 (6.16, 6.97) 0.323 Implant site (first molar/second molar) 13/8 12/7 0.597 Implant brand (Bego/Straumann) 14/7 14/5 0.446 Implant diameter (mm) 4.5 (4.1, 4.5） 4.1 (4.1, 4.5) 0.979 Table 3. Comparison of the bone graft volume and resorption rate between two groups (n=40) Variables Hydraulic pressure group (n=21) Grind-out technique group (n=19) P BGMV 1 (mm 3 ) 766.76 （686.41, 813.64） 532.74 （487.51, 560.22） ＜0.001 BGMV 2 (mm 3 ) 387.91 （354.96, 443.32） 381.17 （353.67, 403.35） 0.375 BGMV 3 (mm 3 ) 331.71 （307.18, 386.19） 324.85 （301.69, 358.22） 0.469 BAV 1 (mm 3 ) 766.76 （686.41, 813.64） 532.74 （487.51, 560.22） ＜0.001 BAV 2 (mm 3 ) 387.91 （354.96, 443.32） 381.17 （353.67, 403.35） 0.375 BAV 3 (mm 3 ) 331.71 （307.18, 386.19） 324.85 （301.69, 358.22） 0.469 BRV 1 (mm 3 ) 351.46 （262.45, 441.19） 139.69 （122.19, 163.49） ＜0.001 BRV 2 (mm 3 ) 404.85 （321.53, 486.80） 190.85 （171.83, 208.795） ＜0.001 BGVRR 1 (%) 47.39 (38.24, 54.37) 27.75 (22.36, 32.08) ＜0.001 BGVRR 2 (%) 54.21 (46.46, 61.58) 37.98 (33.60, 40.26) ＜0.001 BGMV 1 : bone graft material volume at T1, BGMV 2 : bone graft material volume at T2, and BGMV 3 : bone graft material volume at T3, BAV 1 : bone augmentation volume at T1, BAV 2 : Bone augmentation volume at T2, BAV 3 : bone augmentation volume at T3, BRV 1 : bone resorption volume at T2, BRV 2 : bone resorption volume at T3, BGVRR 1 : the bone graft volume resorption rate at T2, BGVRR 2 : the bone graft volume resorption rate at T3. T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery. Table 4. Comparison of bone height changes and resorptionrate around implants between two groups (n=40) Variables Hydraulic pressure group (n=21) M (P 25 , P 75 ) Grind-out technique group (n=19) M (P 25 , P 75 ) Z P BHAI T1 (mm) 13.70 （12.14, 14.21） 12.14 （11.70, 12.34） -2.76 ＜0.01 BHAI T2 (mm) 11.00 （10.54, 11.16） 10.55 （10.29, 11.61） -1.124 0.261 BHAI T3 (mm) 10.69 （10.33, 10.92） 10.32 （10.08, 11.32） -1.124 0.261 BAH T1 (mm) 6.54 （5.79, 8.23） 5.06 （4.62, 5.63） -3.074 ＜0.01 BAH T2 (mm) 4.61 （4.19, 5.19） 3.92 （3.40, 4.48） -0.989 0.323 BAH T3 (mm) 4.38 （3.76, 4.86） 3.98 （3.51, 4.64） -1.029 0.303 BRH 1 (mm) 2.14 （1.35, 2.94） 1.19 （0.76, 1.72） -2.939 ＜0.01 BRH 2 (mm) 2.4 (1.55, 3.41) 1.5 (1.11, 1.96 ) -2.880 ＜0.01 RRBGH 1 (%) 15.93 (9.91, 20.64) 9.89 (6.26, 13.69) -2.749 ＜0.01 RRBGH 2 (%) 18.22 (11.71, 23.54) 12.08 (9.15, 15.58) -2.722 ＜0.01 BHAIT1: bone height around the implant at T1. BHAIT2: bone height around the implant at T2. BHAIT3: bone height around the implant at T3. BAHT1: bone augmentation height at T1. BAHT2: bone augmentation height at T2. BAHT3: bone augmentation height at T3. BRH1: bone resorption height at T2. BRH2: bone resorption height at T3(12 months after surgery). RRBGH 1 : resorption rate of bone graft height at T2. RRBGH 2 : resorption rate of bone graft height at T3. T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 02 Feb, 2026 Reviews received at journal 31 Jan, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor invited by journal 18 Dec, 2025 Editor assigned by journal 17 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 11 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8338371","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583630771,"identity":"5924c004-f099-4e85-9199-529274eb32f2","order_by":0,"name":"Zhen-Ze Yu","email":"","orcid":"","institution":"Shanghai Jing‐an Dental Clinic","correspondingAuthor":false,"prefix":"","firstName":"Zhen-Ze","middleName":"","lastName":"Yu","suffix":""},{"id":583630772,"identity":"2df0d25e-7d2c-4b24-b5ed-f6d2d50bbe48","order_by":1,"name":"Luo-Man Gan","email":"","orcid":"","institution":"Shanghai Jiao Tong University","correspondingAuthor":false,"prefix":"","firstName":"Luo-Man","middleName":"","lastName":"Gan","suffix":""},{"id":583630773,"identity":"9db1642a-7d56-4d2f-bf63-900479b11af1","order_by":2,"name":"Xing-Wen Wu","email":"","orcid":"","institution":"Zhongshan Hospital Affiliated to Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Xing-Wen","middleName":"","lastName":"Wu","suffix":""},{"id":583630774,"identity":"7885acf4-42ef-4702-83e4-b0b34da5be3f","order_by":3,"name":"Yang Sun","email":"","orcid":"","institution":"Zhongshan Hospital Affiliated to Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Sun","suffix":""},{"id":583630775,"identity":"1bfcbccf-2999-4cab-9394-89b4c44b12e2","order_by":4,"name":"Shu-Chi Xia","email":"","orcid":"","institution":"Zhongshan Hospital Affiliated to Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Shu-Chi","middleName":"","lastName":"Xia","suffix":""},{"id":583630776,"identity":"f22813e3-3efc-4e5b-abde-20faaac39460","order_by":5,"name":"You-Cheng Yu","email":"","orcid":"","institution":"Zhongshan Hospital Affiliated to Fudan University","correspondingAuthor":false,"prefix":"","firstName":"You-Cheng","middleName":"","lastName":"Yu","suffix":""},{"id":583630777,"identity":"f363a2db-a73c-4497-865d-a1066046709a","order_by":6,"name":"Fei Yang","email":"data:image/png;base64,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","orcid":"","institution":"Zhongshan Hospital Affiliated to Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Fei","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2025-12-11 15:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8338371/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8338371/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101639427,"identity":"1d3dec5c-e117-442f-b51b-654f005132e2","added_by":"auto","created_at":"2026-02-02 07:17:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13180823,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical procedure of grind-out and hydraulic pressure techniques for transcrestal sinus floor elevation with simultaneous implant placement. (a) Grind-out technique procedure: preoperative view of the implant site; (b) Gingival incision and flap elevation; (c) Implant socket preparation guided by a depth stop rings;(d) Sinus membrane elevation and detachment assessed with a depth gauge; (e) Placement of bone substitute material; (f) Implant placement; (g) Placement of the cover screw; (h) \u0026nbsp;Tight and precise suturing; (i) Hydraulic technique procedure: preoperative view of the implant site; (j) Gingival incision and flap elevation; (k) Implant socket preparation guided by a depth stop rings; (l) hydraulic technique elevation of the Schneiderian membrane; (m) Placement of bone substitute material; (n) Implant placement; (o) Placement of the cover screw; (p) Tight and precise suturing.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8338371/v1/d90821549b53bcfc37e17fe1.png"},{"id":101639429,"identity":"55625923-f491-4ae0-a51f-fca6cf00c82a","added_by":"auto","created_at":"2026-02-02 07:17:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":31659764,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eReconstruction and superimposition of three-dimensional models.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(a) T0, yellow contour, represents the preoperative reconstructed 3D models for both groups, the model was labeled as RM\u003csub\u003e0\u003c/sub\u003e; (b) T1, blue contour, represents the immediate postoperative reconstructed 3D models for both groups, the model was labeled as RM\u003csub\u003e1\u003c/sub\u003e; (c) T2, green contour, represents the reconstructed 3D models for both groups at 6 months postoperatively, the model was labeled as RM\u003csub\u003e2\u003c/sub\u003e; (d) T3, red contour, represents the reconstructed 3D model for both groups at 12 months postoperatively, the model was labeled as RM\u003csub\u003e3\u003c/sub\u003e; (e) Using consistent anatomical landmarks, the reconstructed models at T0, T1, T2, and T3 were superimposed for comparative analysis.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8338371/v1/69612931442031c57cbd969f.png"},{"id":101639425,"identity":"33074439-fe03-4c70-bace-202843f17b2e","added_by":"auto","created_at":"2026-02-02 07:17:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":812828,"visible":true,"origin":"","legend":"\u003cp\u003eMeasurement of Mesial Bone Height of Implant at Tn. (a) Measurement schematic diagram, blue line: contour of bone graft material at T1 (immediately after surgery), green line: contour of bone graft material at time T2 (6 months after surgery); ad: implant mesial bone height at T0 (MBHI\u003csub\u003eT0\u003c/sub\u003e); ac1: implant mesial bone height immediately at T1 (MBHI\u003csub\u003eT1\u003c/sub\u003e); ac2: implant mesial bone height at T2 (MBHI\u003csub\u003eT2\u003c/sub\u003e) (b) CBCT measurement diagram of MBHI\u003csub\u003eT0\u003c/sub\u003e. (c) CBCT measurement diagram of MBHI\u003csub\u003eT1\u003c/sub\u003e. (d) CBCT measurement diagram of MBHI\u003csub\u003eT2\u003c/sub\u003e. (e) CBCT measurement diagram of MBHI\u003csub\u003eT3\u003c/sub\u003e.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8338371/v1/922e6191c6cd115daf33b45e.png"},{"id":101753042,"identity":"eded5997-2515-40b0-92ad-8b8751e5975e","added_by":"auto","created_at":"2026-02-03 10:38:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":315043,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparison of the bone graft volume resorption rate and post-operative reactions between the two groups\u003c/strong\u003e. T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery. Days 0, 1, 3, 5 and 7 postoperatively, labeled as D0, D1, D3, D5, and D7, respectively. BGVRR\u003csub\u003e1\u003c/sub\u003e: the bone graft volume resorption rate at T2, BGVRR\u003csub\u003e2\u003c/sub\u003e: the bone graft volume resorption rate at T3. (a): Bone graft volume resorption rate of different groups from T0 to T2. (b): The Mann-Whitney test results of BGVRR1 and BGRRV2. (c): VAS scores of different groups from D0 to D7. (d): Swelling scores of different groups from D0 to D7. (e): Generalized estimating equation results of VAS scores. (f): Generalized estimating equation results of swelling scores.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-8338371/v1/78c3270048339ab536f164bf.png"},{"id":101755712,"identity":"3cfbb19e-aa18-432a-9806-a0eb688c62f6","added_by":"auto","created_at":"2026-02-03 10:54:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":67536721,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8338371/v1/7c77fbc3-b424-45e4-bd2b-727d8543bd3a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the Grind-out and Hydraulic Pressure Techniques for Transcrestal Sinus Floor Elevation with Simultaneous Implant Placement: A Clinical Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe posterior teeth play a crucial role in determining masticatory efficiency. The absence of posterior teeth significantly impairs patients’ ability to chew effectively, consequently impacting their quality of life and psychological well-being. Implant denture offers notable advantages, including high chewing efficiency, aesthetically pleasing appearance, and enhanced comfort, making them a popular choice among patients\u0026nbsp;[1,2].\u003c/p\u003e\n\u003cp\u003eHowever, insufficient residual alveolar bone height (RBH) in the maxillary posterior region has consistently posed a significant challenge in implant restoration procedures. The maxillary sinus is a pyramidal cavity located within the maxillary bone, which may undergo pneumatization following the loss of posterior maxillary teeth, resulting in a reduction of the vertical distance from the sinus floor to the alveolar crest\u0026nbsp;[3,4].\u0026nbsp;In addition, pathological factors such as periodontitis and periapical periodontitis, as well as physiological factors including age-related osteoporosis and disuse-induced alveolar bone resorption, can lead to insufficient residual vertical bone height in the alveolar ridge, making it difficult to meet the requirements for conventional implant placement\u0026nbsp;[5].\u003c/p\u003e\n\u003cp\u003eTo tackle this challenging clinical issue, several strategies for implant restoration have been proposed, including the utilization of short implants\u0026nbsp;[6,7], tilted implant placement along the mesial-distal or palatal bone walls\u0026nbsp;[8,9],\u0026nbsp;and the widely adopted maxillary sinus floor elevation (MSFE) procedure. Maxillary sinus elevation typically involves lateral sinus floor elevation (LSFE) and transcrestal sinus floor elevation (TSFE). The International Team of Implantology (ITI) offers specific implant recommendations based on RBH and the morphology of the maxillary sinus floor. TSFE is recommended for patients with RBH＞6mm, adequate alveolar bone width, and a flat maxillary sinus floor, while LSFE is suitable for patients with RBH≤6mm and an oblique maxillary sinus floor[10]. Nowadays, advancements in technology have expanded the application of TSFE to patients with RBH≥4mm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConventional TSFE utilizes Summers osteotomes to create a greenstick fracture of the maxillary sinus floor, enabling the elevation of the sinus membrane\u0026nbsp;[11]. Nevertheless, repeated percussion not only causes psychological and physiological distress to patients but also heightens the risks of sinus membrane perforation and concussion\u0026nbsp;[12-15]. In recent years, various minimally invasive maxillary sinus floor techniques have been developed to reduce patients’ postoperative complications and enhance surgical comfort. The most prevalent techniques include the hydraulic pressure technique and the cushioned grind-out technique.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe hydraulic pressure technique\u0026nbsp;involves elevating the mucoperiosteum of the maxillary sinus floor by injecting saline into the sinus floor after preparing the implant socket using a non-invasive drill pin. Sotiraki et al.\u0026nbsp;[16]\u0026nbsp;recommended the use of the CAS tool kit (Crestal Approach Sinus Kit, Osttem, Korea) for hydraulic maxillary sinus lifting. This kit includes CAS drills and stoppers that facilitate precise preparation of the implant socket in the maxillary sinus floor, safe penetration of the sinus floor bone wall, and simultaneous lifting of the maxillary sinus floor using the hydraulic lifting device.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGrind-out technique [17] is a method involving the gradual and delicate grinding of the sinus floor bone wall using a drill bit and stoppers of a specialized maxillary sinus lifting kit. Subsequently, the mucoperiosteum is uniformly stripped and lifted with an instrument of the kit. Gao et al.\u0026nbsp;[18]\u0026nbsp;utilized the grind-out technique for TSFE through DASK (Dentium advanced sinus kit, DASK, South Korea) kit. Following maxillary sinus mucosa stripping and lifting carefully, bone grafting material was applied to elevate the maxillary sinus, resulting in good postoperative implant restoration stability.\u003c/p\u003e\n\u003cp\u003eSo far, a large number of articles have conducted research and discussions on the clinical efficacy of these two methods respectively. However, there is still a lack of clinical studies comparing the clinical effects of these two surgical methods. Therefore, the main purpose of this study is to compare the clinical efficacy of these two surgical methods for TSFE through a clinical retrospective analysis, aiming to provide certain theoretical and clinical basis for clinicians in the selection of two minimally invasive maxillary sinus elevation surgical techniques.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1 Patient Selection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study retrospectively analyzed clinical data from patients who underwent single implant placement with a simultaneous maxillary sinus floor elevation surgery at the Department of Stomatology, Zhongshan Hospital Affiliated to Fudan University between January 2022 and December 2022.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproval for this study was obtained from the Ethics Committee of Zhongshan Hospital Affiliated with Fudan University (Approval Number: B2021-767R), and all procedures were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria included:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePatients\u0026nbsp;\u0026ge;18 years of age;\u003c/li\u003e\n \u003cli\u003eSingle tooth loss in the maxillary posterior dental area for \u0026ge; 6 months;\u003c/li\u003e\n \u003cli\u003ePatients with residual bone height (RBH) ranges from 5 mm to 9 mm;\u003c/li\u003e\n \u003cli\u003eThe maxillary sinus floor exhibited a flat morphology without antral septa;\u003c/li\u003e\n \u003cli\u003eNo uncontrollable acute inflammation and cyst in maxillary sinus;\u003c/li\u003e\n \u003cli\u003ePatients who had undergone maxillary posterior TSFE with grind-out technique or hydraulic pressure technique and simultaneous implantation;\u003c/li\u003e\n \u003cli\u003eReliable and complete case data and photographs could be collected.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eExclusion criteria:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003ePatients with a sloping maxillary sinus floor morphology or antral septa in the surgery site;\u003c/li\u003e\n \u003cli\u003eIndividuals with maxillary sinus cysts, acute maxillary sinusitis, or unmanageable periodontitis.\u003c/li\u003e\n \u003cli\u003ePatients suffering from uncontrollable systemic diseases or treatment history affecting bone and soft tissue healing;\u003c/li\u003e\n \u003cli\u003ePatients with previous history of maxillary sinus floor elevation;\u003c/li\u003e\n \u003cli\u003ePatients with alcoholism, heavy smoking (\u0026gt;10 cigarettes per day), and severe nocturnal bruxism;\u003c/li\u003e\n \u003cli\u003ePatients with incomplete clinical and imaging medical records.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2 Clinical procedures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2.1 Preoperative preparation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore operation, a specialized dental implant medical record was created for each patient, encompassing blood tests, maxillofacial and oral examinations, and a thorough patient\u0026apos;s medical history was collected to exclude contraindications for implant surgery. An initial implant plan was formulated, patients were informed of the surgical procedure and potential complications, followed by obtaining signed informed consent for the implant surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2 Implantation surgery\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients were directed to rinse their mouths with 0.2% chlorhexidine for 1 minute before surgery. Local infiltration anesthesia was applied to the implant site using articaine hydrochloride (Primacaine\u003csup\u003e\u0026reg;\u003c/sup\u003e, Pierre Rolland, France). All surgical procedures were conducted by the same chief physician.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eGrind-out technique\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;surgery procedure\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter completing local infiltration anesthesia and disinfection of the surgical area, a mid-crest incision at the alveolar ridge, along with additional incisions in the mesial and distal sulci of the adjacent teeth was made to form a full-thickness flap exposing the alveolar ridge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubsequently, the implant socket was prepared using pilot drills with depth stop rings from the DASK tool kit (Dentium Advanced Sinus Kit, Dentium, South Korea). The diameter of twist drill was gradually increased until reaching the safe position located around 1mm below the sinus floor. A protective round diamond-grit bur was used to grind the remaining bone at the sinus floor until a slight drop was felt. A doom-shaped elevator was then employed to loosen and elevate the sinus floor mucosa to the predetermined height. The integrity of the maxillary sinus membrane was confirmed using the Valsalva maneuver.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, bone graft material (Bio-oss collagen\u003csup\u003e\u0026reg;\u003c/sup\u003e, Geistlich, Wolhusen, Switzerland) was placed in the maxillary sinus floor, a depth gauge was used to ensure at least 2mm thickness of the graft materials, followed by implant placement, all patients were treated with submerged healing, covering screws were placed and 4-0 sutures were tightly sutured (Figure1 a-h).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe Hydraulic Pressure technique\u0026nbsp;surgery procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative preparations were as described above. The implant socket was prepared using pilot drills with depth stop rings from the CAS tool kit (Crestal Approach Sinus Kit, Osstem, South Korea). The pilot drill diameter was increased gradually until reaching a safe position approximately 1mm below the sinus floor. 0.5-1ml of saline was injected into maxillary sinus by a hydraulic elevator to gradually and uniformly lift maxillary sinus floor membrane. The integrity of the maxillary sinus membrane was confirmed using the Valsalva maneuver.\u003c/p\u003e\n\u003cp\u003eSubsequently, bone graft material (Bio-oss collagen\u003csup\u003e\u0026reg;\u003c/sup\u003e, Geistlich, Wolhusen, Switzerland) was inserted into the maxillary sinus floor. A depth gauge was utilized to confirm a minimum of 2mm thickness of the graft material. Ultimately, all patients underwent submerged healing after implant placement. Covering screws were placed and sutured with 4-0 sutures (Figure1 i-p).\u003c/p\u003e\n\u003cp\u003eAll patients received analgesics to control post-surgical pain and peri-operative antibiotic prophylaxis with cefuroxime sodium and tinidazole, which was maintained for 7 days post-operatively.\u003c/p\u003e\n\u003cp\u003eAll patients received antibiotic prophylactic with cefuroxime sodium and tinidazole for 7 days after surgery. Analgesics (ibuprofen 400 mg) was used to control post-surgical pain, with instructions on self-administration if needed. Additionally, patients are required to record their pain conditions according to the visual analogue scale (VAS) before using painkillers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.2.3 Radiological procedure\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBCT scans were obtained from all patients at four time points: before surgery (T0), immediately post-surgery (T1), 6 months post-surgery (T2), 12 months post-surgery (T3).\u003c/p\u003e\n\u003cp\u003eThe identical CBCT machine (KaVo, Bieberach an der Riss, Germany) was utilized with consistent parameters, including standard dose, an in-tube voltage of 120kV, an in-tube current of 6mA, a scanning range of 16cm \u0026times; 13cm, voxel dimensions of 0.5 mm \u0026times; 0.5 mm \u0026times; 0.5 mm, an exposure time of 7s, and a slice thickness of 0.2 mm. All data is exported and saved in Dicom format.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3 Clinical evaluation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3.1 Implant survival rate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn accordance with the success criteria proposed by Albrektsson et al.[19], an implant was considered successful when meeting all of the following conditions: \u003cstrong\u003e(1)\u003c/strong\u003e no clinical mobility of the individual implant; \u003cstrong\u003e(2)\u003c/strong\u003e absence of any peri-implant radiolucency on radiographic examination; \u003cstrong\u003e(3)\u003c/strong\u003e vertical bone resorption \u0026lt;2.0 mm during the first year of functional loading, and thereafter not exceeding 0.2 mm annually; and \u003cstrong\u003e(4)\u003c/strong\u003e no persistent and/or irreversible clinical symptoms or signs, such as pain, infection, or paresthesia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3.2 Schneiderian membrane perforation rate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eValsalva maneuver was used to assess the integrity of the maxillary sinus mucosa. Absence of bubble formation or discharge of bloody fluid from the implant cavity, coupled with the absence of a liquid level in the maxillary sinus floor on immediate postoperative CBCT imaging, indicated intact maxillary sinus mucosa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3.3. Pain assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 100-mm visual analogue scale (VAS) was utilized to assess patients\u0026apos; pain levels at postoperative days 0, 1, 3, 5 and 7, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.3.4 Swelling assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe swelling scale (Table 1) was used to assess patients\u0026apos; swelling severity at postoperative days 0, 1, 3, 5 and 7, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.4 Radiographic assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCBCT in Dicom format at T0, T1, T2 and T3 were imported into the 3D reconstruction software Mimics21.0 (Materialise, Leuven, Belgium). Using the threshold tool and mask editing tool in the software, three-dimensional implant models at different time points (T0, T1, T2 and T3) were established. These models were labeled as RM\u003csub\u003e0\u003c/sub\u003e, RM\u003csub\u003e1\u003c/sub\u003e, RM\u003csub\u003e2,\u003c/sub\u003e and RM\u003csub\u003e3\u003c/sub\u003e respectively. Subsequently, RM\u003csub\u003e1\u003c/sub\u003e, RM\u003csub\u003e2\u003c/sub\u003e and RM\u003csub\u003e3\u003c/sub\u003e were imported into the RM\u003csub\u003e0\u0026nbsp;\u003c/sub\u003emodeling window, they were superimposed using four anatomical marker points from adjacent teeth in the edentulous region (Figure 2 a-e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.4.1 Volume measurement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mask editing tool was utilized to delineate the contour of each layer of the bone graft material. Subsequently, the calculation tool was utilized to merge all the two-dimensional layers of the bone graft material to construct a comprehensive three-dimensional model. This reconstructed model was then imported into 3-Matic Research software (Materialise, Leuven, Belgium) to calculate the volume of the bone graft material (BGMV) at T1, T2, and T3, labeled as BGMV\u003csub\u003e1\u003c/sub\u003e, BGMV\u003csub\u003e2\u003c/sub\u003e, and BGMV\u003csub\u003e3\u003c/sub\u003e respectively. Bone augmentation volume at T1, T2, and T3 labeled as BAV\u003csub\u003e1\u003c/sub\u003e, BAV\u003csub\u003e2\u003c/sub\u003e and BAV\u003csub\u003e3\u003c/sub\u003e respectively. Bone resorption volume at T2 and T3 labeled as BRV\u003csub\u003e1\u003c/sub\u003e and BRV\u003csub\u003e2\u003c/sub\u003e. The bone graft volume resorption rate at T2 (BGVRR\u003csub\u003e1\u003c/sub\u003e)= [(BGMV\u003csub\u003e1\u003c/sub\u003e - BGMV\u003csub\u003e2\u003c/sub\u003e) / BGMV\u003csub\u003e1\u003c/sub\u003e] \u0026times;\u0026nbsp;100%, the bone graft volume resorption rate at T3 (BGVRR\u003csub\u003e2\u003c/sub\u003e)= [(BGMV\u003csub\u003e1\u003c/sub\u003e \u0026ndash; BGMV\u003csub\u003e3\u003c/sub\u003e) / BGMV\u003csub\u003e1\u003c/sub\u003e] \u0026times;100%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.4.2 Peri-implant bone height measurement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the sagittal and coronal views of the RM\u003csub\u003e0\u003c/sub\u003e modeling window (RM\u003csub\u003e0\u003c/sub\u003e, RM\u003csub\u003e1\u003c/sub\u003e, RM\u003csub\u003e2\u003c/sub\u003e and RM\u003csub\u003e3\u003c/sub\u003e had been superimposed), CBCT was adjusted to the maximum implant diameter. Subsequently, the peri-implant bone height at four sites (mesial, distal, buccal, and palatal) were measured. Each measurement was performed three times by the same researcher and then averaged (Figure 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe variables are defined as follows: MBHI\u003csub\u003eTn\u003c/sub\u003e (mesial bone height of the implant at Tn), DBHI\u003csub\u003eTn\u003c/sub\u003e (distal bone height of the implant at Tn), BBHI\u003csub\u003eTn\u003c/sub\u003e (buccal bone height of the implant at Tn), and PBHI\u003csub\u003eTn\u003c/sub\u003e (palatal bone height of the implant at Tn).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTaking the mesial bone height around the implant as an illustration, the measurement protocol was as follows: the implant platform and the implant apex were defined as point a and point b respectively. The line ab intersects the maxillary sinus floor at point d, where the length of line ad represents the preoperative mesial alveolar bone height (MBHI\u003csub\u003eT0\u003c/sub\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe residual bone height (RBH) = (MBHI\u003csub\u003eT0\u003c/sub\u003e + DBHI\u003csub\u003eT0\u0026nbsp;\u003c/sub\u003e+ BBHI\u003csub\u003eT0\u003c/sub\u003e + PBHI\u003csub\u003eT0\u003c/sub\u003e)/4.\u003c/p\u003e\n\u003cp\u003eBone height around the implant at T\u003csub\u003en\u003c/sub\u003e (BHAI\u003csub\u003eTn\u003c/sub\u003e) = (MBHI\u003csub\u003eTn\u003c/sub\u003e + DBHI\u003csub\u003eTn\u0026nbsp;\u003c/sub\u003e+ BBHI\u003csub\u003eTn\u003c/sub\u003e + PBHI\u003csub\u003eTn\u003c/sub\u003e)/4.\u003c/p\u003e\n\u003cp\u003eBone augmentation height at Tn (BAH\u003csub\u003eTn\u003c/sub\u003e）= BHAI\u003csub\u003eTn\u003c/sub\u003e \u0026ndash; RBH.\u003c/p\u003e\n\u003cp\u003eBone resorption height at T1 (BRH\u003csub\u003e1\u003c/sub\u003e）= BHAI\u003csub\u003eT1\u0026nbsp;\u003c/sub\u003e- BHAI\u003csub\u003eT2\u003c/sub\u003e.\u003c/p\u003e\n\u003cp\u003eBone resorption height at T2 (BRH\u003csub\u003e2\u003c/sub\u003e）= BHAI\u003csub\u003eT1\u0026nbsp;\u003c/sub\u003e- BHAI\u003csub\u003eT3\u003c/sub\u003e.\u003c/p\u003e\n\u003cp\u003eResorption rate of bone graft height at T2 (c) = [(BHAI\u003csub\u003eT1\u003c/sub\u003e - BHAI\u003csub\u003eT2\u003c/sub\u003e) / BHAI\u003csub\u003eT1\u003c/sub\u003e] \u0026times; 100%.\u003c/p\u003e\n\u003cp\u003eResorption rate of bone graft height at T3 (RRBGH\u003csub\u003e2\u003c/sub\u003e) = [(BHAI\u003csub\u003eT1\u003c/sub\u003e - BHAI\u003csub\u003eT3\u003c/sub\u003e) / BHAI\u003csub\u003eT1\u003c/sub\u003e] \u0026times; 100%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.5. Statistical analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using SPSS version 21.0 (IBM Corp., Armonk, NY, USA). Data normality was assessed using the Shapiro\u0026ndash;Wilk test, and Levene\u0026rsquo;s test was applied for homogeneity of variances. Continuous variables were expressed as mean \u0026plusmn; standard deviation (x̄ \u0026plusmn; s) or medians (lower quartile, upper quartile). Comparisons between two groups were conducted using the independent samples t-test for normally distributed data with equal variances or the Mann\u0026ndash;Whitney U test otherwise. A generalized estimating equation (GEE) model was used to evaluate temporal trends and intergroup differences in VAS scores and swelling scores between the Grind-out technique and hydraulic pressure technique groups. Statistical significance was set at \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.1\u0026nbsp;\u0026nbsp;Demographics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study analyzed 127 patients who underwent single implant placement with simultaneous maxillary sinus floor elevation surgery. The procedures were performed using either the hydraulic pressure technique or the grind-out technique in the maxillary molar region between December 2021 and December 2022. A total of 34 patients with maxillary sinus septa and 17 patients with incomplete CBCT data or pain and swelling assessment and 32 patients using tapered implant were excluded, resulting in a final cohort of 44 patients meeting the inclusion criteria.\u003c/p\u003e\n\u003cp\u003ePatients with maxillary sinus mucosal perforation (including 1 implant loss) were further excluded, and a total of 40 patients were included in the analysis. Among them, 21 patients (12 females, 9 males) in the hydraulic pressure group, with an median age of 58 years, 14 Bego implants, 7 Straumann implants, 13 first molars, 8 second molars, and a median RBH of 6.11 mm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the grind-out technique group, there were 19 cases (10 females, 9 males) with an median age of 57 years. Among them, 14 cases were Bego implants, 5 were Straumann implants, 12 first molars, and 7 second molars, with a median RBH of 6.69 mm. There were no statistically significant differences in age, gender, tooth position, implant type, and implant diameter between the two groups, indicating their comparability (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.2\u0026nbsp;\u0026nbsp;Implant survival rate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of the 23 cases in the hydraulic pressure group, one case experienced implant loss, resulting in a survival rate of 96.65%. Conversely, in the grind-out technique group, no implants were lost, resulting in a 100% survival rate. Chi-square test showed that there was no significant difference in implant survival rate between the two groups (\u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.3\u0026nbsp;\u0026nbsp;Schneiderian membrane perforation rate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring implant surgery, no maxillary sinus mucosal perforation was detected in any of the patients. Post-surgery CBCT revealed maxillary sinus floor mucosa perforation and fluid level in two patients from both groups, respectively. Notably, one patient from the hydraulic pressure group with maxillary sinus mucosa perforation experienced implant loss at 2 months after operation. CBCT examination found that fluid level disappeared in other patients at 3 months after surgery, with no significant impact on sinus bone formation and favorable prognoses observed. Chi-square test was used to compare the maxillary sinus perforation rate between the two groups. The results showed that there was no statistical significance between the two groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). The above cases of mucosal perforation and implant loss were excluded in the follow analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.4\u0026nbsp;\u0026nbsp;Volume changes and resorption rates of bone graft materials after surgery\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Mann-Whitney test was used to compare BGMV\u003csub\u003e1\u003c/sub\u003e, BGMV\u003csub\u003e2\u003c/sub\u003e, BGMV\u003csub\u003e3\u003c/sub\u003e, BAV\u003csub\u003e1\u003c/sub\u003e, BAV\u003csub\u003e2\u003c/sub\u003e, BAV\u003csub\u003e3\u003c/sub\u003e, BRV\u003csub\u003e1\u003c/sub\u003e, BRV\u003csub\u003e2\u003c/sub\u003e, BRV\u003csub\u003e3\u003c/sub\u003e,\u0026nbsp;BGVRR\u003csub\u003e1\u003c/sub\u003e and BGVRR\u003csub\u003e2\u003c/sub\u003e between two groups. The statistical results are as follows (Figure 4 a-b, Table 3):\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe BGMV\u003csub\u003e1\u003c/sub\u003e and BAV\u003csub\u003e1\u003c/sub\u003e in the hydraulic pressure group were significantly higher than those in the grind-out technique group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), whereas no significant differences were observed in BGMV\u003csub\u003e2\u003c/sub\u003e, BGMV\u003csub\u003e3\u003c/sub\u003e, BAV\u003csub\u003e2\u003c/sub\u003e, and BAV\u003csub\u003e3\u003c/sub\u003e between the two groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). The BRV\u003csub\u003e1\u003c/sub\u003e and BRV\u003csub\u003e2\u003c/sub\u003e in the hydraulic pressure group were also higher than those in the grind-out technique group, and the differences were statistically significant (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eThe BGVRR\u003csub\u003e1\u003c/sub\u003e and BGVRR\u003csub\u003e2\u003c/sub\u003e of the hydraulic pressure group was significantly higher than that in the grind-out technique group, and the difference was statistically significant (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.5\u0026nbsp;\u0026nbsp;Changes and resorption rates of peri-implant bone height\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Mann-Whitney test was utilized to make a comparison of BHAI\u003csub\u003eT1\u003c/sub\u003e, BHAI\u003csub\u003eT2\u003c/sub\u003e, BHAI\u003csub\u003eT3\u003c/sub\u003e, BAH\u003csub\u003eT1\u003c/sub\u003e, BAH\u003csub\u003eT2\u003c/sub\u003e, BAH\u003csub\u003eT3\u003c/sub\u003e, BRH\u003csub\u003e1\u003c/sub\u003e, BRH\u003csub\u003e2\u003c/sub\u003e, RRBGH\u003csub\u003e1\u003c/sub\u003e, RRBGH\u003csub\u003e2\u003c/sub\u003e between two groups. The statistical outcomes are presented as follows (Table 4):\u003c/p\u003e\n\u003cp\u003eIn the hydraulic pressure group, BHAI\u003csub\u003eT1\u003c/sub\u003e and BAH\u003csub\u003eT1\u003c/sub\u003e were significantly higher than those in the grind-out technique group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01), while there were no significant differences in BHAI\u003csub\u003eT2\u003c/sub\u003e, BHAI\u003csub\u003eT3\u003c/sub\u003e, BAH\u003csub\u003eT2\u003c/sub\u003e, and BAH\u003csub\u003eT3\u003c/sub\u003e between the two groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). The levels of BRH1 and BRH2 in the hydraulic pressure group were higher than those in the grind-out technique group, with statistically significant differences (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01). Similarly, RRBGH1 and RRBGH2 in the hydraulic pressure group were markedly higher than those in the grind-out technique group, and the differences were statistically significant (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.6\u0026nbsp;\u0026nbsp;Postoperative Pain\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneralized estimating equation (GEE) was applied to analyze the temporal trend of VAS scores and the intergroup differences between the grind-out technique group and the hydraulic pressure group. The results showed that the main effect of time was significant (χ² = 313.704, P \u0026lt; 0.001), the main effect of group was significant (χ² = 21.619, P \u0026lt; 0.001), and the interaction effect between time and group was also significant (χ² = 33.610, P \u0026lt; 0.001). Given the significant interaction, a simple effect analysis was performed.\u003c/p\u003e\n\u003cp\u003eThe statistical results indicated that at all time points, there were significant differences in VAS scores between the two groups, with the grind-out technique group showing lower VAS scores than the hydraulic pressure group (P \u0026lt; 0.05). In both groups, the VAS pain scores gradually decreased over time, and the changes were statistically significant (P \u0026lt; 0.05) (Figure 4c and 4e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e3.7\u0026nbsp;\u0026nbsp;Postoperative Swelling\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGeneralized estimating equation (GEE) was employed to analyze the temporal trend and intergroup differences in swelling scores. The results showed that the main effect of time was significant (χ² = 386.406, P \u0026lt; 0.001), the main effect of group was significant (χ² = 27.706, P \u0026lt; 0.001), and the interaction between time and group was also significant (χ² = 50.723, P \u0026lt; 0.001). Given the significant interaction, a simple effect analysis was conducted.\u003c/p\u003e\n\u003cp\u003eThe results indicated that at all time points, there were statistically significant differences in swelling scores between the two group (P \u0026lt; 0.05). Within the hydraulic pressure group, swelling scores at D0 and D7 did not differ significantly (P \u0026gt; 0.05), whereas all other pairwise comparisons across time points showed significant differences (P \u0026lt; 0.05). In contrast, in the grind-out technique group, swelling scores decreased progressively over time, and the differences were statistically significant (P \u0026lt; 0.05) (Figure 4d and 4f).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFor patients with severely insufficient RBH in the maxillary posterior region, achieving a stable and minimally invasive implant treatment outcome has become a focal point of clinical research in oral implantology. With advancements in surgical instruments and techniques, the achievable bone augmentation height through TSFE has significantly increased, while the incidence of Schneiderian membrane perforation has markedly decreased.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCurrently, the minimally invasive techniques for TSFE mainly include\u0026nbsp;hydraulic pressure technique and grind-out technique. Our study compared the clinical outcomes of hydraulic pressure technique and grind-out technique for TSFE in the maxillary posterior region with a RBH ranging from 5 mm to 9 mm. The results demonstrated that both techniques achieved stable bone augmentation, high implant survival rates and low Schneiderian membrane perforation rate during follow-up, indicating that these two techniques are reliable minimally invasive technique for patients with RBH of 5-9 mm.\u003c/p\u003e\n\u003cp\u003eSimilar to our research, Lin et al.[20] utilized three-dimensional finite element analysis to establish models of TSFE using the hydraulic pressure technique and two osteotome techniques with different diameters (1.6 mm and 3.0 mm), in order to compare the biomechanical characteristics of the Schneiderian membrane under different approaches. The results showed that with increasing elevation height, the loading force, stress, and strain applied to the Schneiderian membrane all increased significantly. However, the hydraulic pressure technique required the lowest loading force, exhibited the most uniform stress distribution, and produced the greatest horizontal displacement at the same elevation height, indicating that it could achieve a larger membrane detachment area while reducing the risk of membrane perforation. The study demonstrated that the hydraulic pressure technique is safer and more efficient than the conventional osteotome technique. Another study [21] performed TSFE using the hydraulic technique with simultaneous implant placement in 1,100 patients with RBH of 1–5 mm. An 8-year follow-up and retrospective analysis revealed a cumulative implant survival rate of 99.99%, with only eight implants failing during the early osseointegration stage. Gao et al. [22] conducted a retrospective cohort study with a 7-year follow-up comparing patients who underwent osteotome sinus floor elevation and those treated with the cushioned grind-out technique using the DASK kit. The rates of Schneiderian membrane perforation were 6.4% and 5.5%, respectively, with no statistically significant difference between the two groups. The mean sinus floor bone gain was 4.64 mm and 5.31 mm, respectively. Multivariate regression analysis indicated that the minimally invasive TSFE using the DASK kit was an important factor promoting new bone formation within the sinus. In our study, the intramaxillary sinus bone gain was consistent with previous reports, with a mean vertical bone augmentation of 4.38 mm in the hydraulic pressure group and 3.98 mm in the grind-out technique group at 1 year postoperatively.\u003c/p\u003e\n\u003cp\u003eAlthough both techniques achieved high implant survival rates and acceptable bone augmentation, this study found that under the same grafting material conditions, the hydraulic pressure technique group exhibited significantly higher bone graft volume resorption rates at 6 months and 12 months postoperatively (the median of 47.39% and 54.21%, respectively) compared with the grind-out technique group (the median of 27.75% and 37.98%, respectively), hydraulic pressure technique exhibited a relative limitation in maintaining bone volume stability. Possible factors contributing to this difference include: firstly, this difference may be related to the mechanical stability of the bone graft materials in the early postoperative period. The hydraulic pressure technique elevates the sinus membrane using hydraulic pressure and bone graft materials. Initially, the graft remains in a loose state, with limited compressive and shear strength, making it prone to collapse and shrink under repeated respiratory pressure and masticatory forces.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Secondly, the elevation height and the size of the “tenting space” have a direct impact on bone resorption. The hydraulic elevation technique can achieve a greater degree of membrane lifting than the grind-out technique group, however, a larger suspended cavity is more susceptible to collapse and resorption during the bone remodeling process. Kuo et al.\u0026nbsp;[23]\u0026nbsp;reported that the reduction in grafted bone height following TSFE is primarily influenced by the elevation pattern and the tension of the Schneiderian membrane: the greater the vertical elevation height, the larger vertical amount of the implant protrusion, and the steeper the elevation profile, the greater the resorption of the grafted material. This finding suggests that when the elevating force is concentrated in the vertical direction without sufficient lateral expansion or support, the increased membrane tension may lead to collapse of the cavity and resorption of the bone graft material. Accordingly, in the hydraulic sinus elevation technique, the instantaneous vertical pressure generated by the fluid may induce rapid upward displacement of the membrane and localized high tension, resulting in reduced initial stability of the grafting space and accelerated remodeling or resorption of the bone graft material during healing. This phenomenon should not be regarded as an inherent drawback of the hydraulic pressure technique but rather as a consequence of its vertical stress characteristics.\u003c/p\u003e\n\u003cp\u003eThe VAS is a commonly used tool for pain assessment. Its advantages include being intuitive and highly accurate, allowing the patient’s postoperative sensations to be reflected directly through numerical values. Therefore, it is widely applied in clinical pain evaluation, postoperative pain management, and efficacy assessment\u0026nbsp;[24]. Similarly, the Swelling Visual Analogue Scale\u0026nbsp;[25]\u0026nbsp;enables a direct numerical representation of the patient’s postoperative swelling condition. Rengo et al.[26] conducted a prospective cohort study and found that pain and swelling commonly occur after LSFE. Postoperative responses were evaluated using VAS and swelling scores. The results showed that pain was most severe on the first postoperative day and gradually improved over time, while swelling typically peaked on the second postoperative day. Praveen et al. [27] compared postoperative responses between minimally invasive antral balloon elevation technique and drill integrated hydrodynamics technique for TSFE. The VAS scores for pain on postoperative day 7 were 4.93 ± 1.038 and 3.77 ± 1.301, respectively. The balloon technique resulted in significantly higher pain scores than the drill integrated hydrodynamics technique group, with the difference being statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study found that the hydraulic technique resulted in significantly higher levels of pain and swelling on the day of surgery, as well as on postoperative days 1, 3, and 5, compared with the grind-out technique group. In both groups, pain and swelling gradually decreased starting from the first postoperative day, consistent with findings reported in previous studies. The higher discomfort associated with the hydraulic technique may be attributed to the intraoperative increase in balloon pressure caused by fluid injection, which elevates the Schneiderian membrane through hydraulic force, leading to a sensation of swelling and discomfort in patients.\u003c/p\u003e\n\u003cp\u003eOur study is limited by a small sample size, short follow-up duration, and retrospective design conducted at a single center. In addition, there is a certain degree of recall bias in documenting postoperative VAS scores and swelling assessments. Moreover, the precision of measurements could be compromised by implant artifacts in CBCT 3D reconstructions using Mimics, leading to discrepancies between measured outcomes and clinical application. Further well-designed prospective randomized controlled trials with extended follow-up periods are required to provide stronger evidence regarding the clinical efficacy of these surgical procedures.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFor patients with a single missing maxillary molar, a flat sinus floor without septa, and a RBH ranging from 5 mm to 9 mm, sinus floor elevation using either the hydraulic pressure technique or the grind-out technique with simultaneous bone graft material and implant placement can be reliable techniques with expected clinical outcome. In the first year after surgery, both techniques demonstrate a high implant survival rate, a low incidence of Schneiderian membrane perforation, and favorable bone augmentation outcomes.\u003c/p\u003e\n\u003cp\u003eThe grafted bone materials used in both the hydraulic pressure technique and the grind-out technique undergo resorption within 6 months and 12months postoperatively, with the resorption rate significantly higher in the hydraulic pressure group than in the grind-out group. Both the hydraulic pressure and grind-out techniques may cause postoperative pain and swelling to varying degrees; however, compared with the hydraulic pressure approach, the grind-out technique involves less surgical trauma and results in milder postoperative discomfort.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval for this study was obtained from the Ethics Committee of Zhongshan Hospital Affiliated with Fudan University (Approval Number: B2021-767R), and all procedures were conducted in accordance with the Declaration of Helsinki. All patients provided written informed consent prior to surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study’s findings are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the National Natural Science Foundation of China (NSFC) [82401064, 82170990], Clinical Research Plan of Zhongshan Hospital, Fudan University (ZSLCYJ202320, ZSLCYJ202345), National Natural Science Foundation of Fujian Province [2024J011444].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZZY and LMG contributed equally to this work and share first authorship. ZZY and LMG collected the clinical data, performed data analysis, and drafted the manuscript. XWW, YS, and SCX participated in data acquisition and interpretation. YCY and FY conceived and designed the study, supervised the project, and critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCorresponding authors\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCorrespondence to\u0026nbsp;You-Cheng Yuor Fei Yang.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all individuals who participated in this study for their cooperation and support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSagheb K, Wentaschek S, Bjelopavlovic M, Berres M, D\u0026iacute;az L, Fan S, Schiegnitz E, Al-Nawas B, (2024) Evaluation of masticatory efficiency and OHRQoL in implant-retained overdenture with different numbers of implant in the edentulous mandible: a one-year follow-up prospective study. 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J CLIN PERIODONTOL 50 (9):1202-1216. doi: 10.1111/jcpe.13832\u003c/li\u003e\n\u003cli\u003eKuo P, Lin C, Chang C, Wang Y, Pan W (2021) Grafted bone remodeling following transcrestal sinus floor elevation: A cone-beam computed tomography study. BIOMED J 44 (5):627-635. doi: 10.1016/j.bj.2020.05.011\u003c/li\u003e\n\u003cli\u003eSeymour RA, Charlton JE, Phillips ME (1983) An evaluation of dental pain using visual analogue scales and the Mcgill Pain Questionnaire. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 41 (10): 643-648\u003c/li\u003e\n\u003cli\u003ePachipulusu PK, S M (2018) Comparative study of primary and secondary closure of the surgical wound after removal of impacted mandibular third molars. Oral and maxillofacial surgery 22 (3):261-266. doi: 10.1007/s10006-018-0696-8\u003c/li\u003e\n\u003cli\u003eRengo C, Fiorino A, Cucchi A, Nappo A, Randellini E, Calamai P, Ferrari M (2021) Patient-reported outcomes and complication rates after lateral maxillary sinus floor elevation: a prospective study. CLIN ORAL INVEST 25 (7):4431-4444. doi: 10.1007/s00784-020-03755-x\u003c/li\u003e\n\u003cli\u003ePraveen AA, Venkadassalapathy S, Victor DJ, Prakash PSG, Umesh SG, Ali Baeshen H, Balaji TM, Patil S, Reda R, Testarelli L (2023) Efficacy of Two Different Hydrodynamic Sinus Lift Systems for Atraumatic Elevation in Immediate Implant Placement. PATIENT PREFER ADHER 17:1197-1207. doi: 10.2147/PPA.S403036\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Swelling Severity Scale\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"106%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eDegree of Swelling\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eNo swelling: patient experiences no sensation of swelling.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eMild swelling: patient experiences slight swelling sensation without observable facial swelling\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eModerate swelling: patient has a noticeable sensation of swelling without impeding normal chewing and swallowing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eSevere swelling: facial swelling is observable and affects normal chewing\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eVery severe swelling: facial swelling is clearly observable, making normal chewing impossible, but mouth-opening is not restricted\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1414%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85.8586%;\"\u003e\n \u003cp\u003eExtremely severe swelling: facial swelling is markedly observable with limited mouth opening\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Summary of patient demographics (n=40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003eHydraulic pressure group (n=21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003eGrind-out technique group\u003c/p\u003e\n \u003cp\u003e(n=19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eGender (male/female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e12/9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e10/9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.512\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[years, M（P\u003csub\u003e25\u003c/sub\u003e,P\u003csub\u003e75\u003c/sub\u003e）]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e58.00 (39.00, 64.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e57.00 (45.00, 61.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.329\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eRBH\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[mm，M（P\u003csub\u003e25\u003c/sub\u003e,P\u003csub\u003e75\u003c/sub\u003e）]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e6.11 (5.78, 6.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e6.69 (6.16, 6.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eImplant site (first molar/second molar)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e13/8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e12/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eImplant brand (Bego/Straumann)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e14/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e14/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.446\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29.1139%;\"\u003e\n \u003cp\u003eImplant diameter (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e4.5 (4.1, 4.5）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.7414%;\"\u003e\n \u003cp\u003e4.1 (4.1, 4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9.40325%;\"\u003e\n \u003cp\u003e0.979\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Comparison of the bone graft volume and resorption rate between two groups (n=40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003eHydraulic pressure group (n=21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003eGrind-out technique group\u003c/p\u003e\n \u003cp\u003e(n=19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBGMV\u003csub\u003e1\u003c/sub\u003e\u003csub\u003e\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003csub\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e766.76\u003c/p\u003e\n \u003cp\u003e（686.41, 813.64）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e532.74\u003c/p\u003e\n \u003cp\u003e（487.51, 560.22）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBGMV\u003csub\u003e2\u003c/sub\u003e\u003csub\u003e\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e387.91\u003c/p\u003e\n \u003cp\u003e（354.96, 443.32）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e381.17\u003c/p\u003e\n \u003cp\u003e（353.67, 403.35）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBGMV\u003csub\u003e3\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e331.71\u003c/p\u003e\n \u003cp\u003e（307.18, 386.19）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e324.85\u003c/p\u003e\n \u003cp\u003e（301.69, 358.22）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e0.469\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBAV\u003csub\u003e1\u003c/sub\u003e\u003csub\u003e\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e766.76\u003c/p\u003e\n \u003cp\u003e（686.41, 813.64）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e532.74\u003c/p\u003e\n \u003cp\u003e（487.51, 560.22）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBAV\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e387.91\u003c/p\u003e\n \u003cp\u003e（354.96, 443.32）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e381.17\u003c/p\u003e\n \u003cp\u003e（353.67, 403.35）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e0.375\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBAV\u003csub\u003e3\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e331.71\u003c/p\u003e\n \u003cp\u003e（307.18, 386.19）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e324.85\u003c/p\u003e\n \u003cp\u003e（301.69, 358.22）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e0.469\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBRV\u003csub\u003e1\u003c/sub\u003e\u003csub\u003e\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e351.46\u003c/p\u003e\n \u003cp\u003e（262.45, 441.19）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e139.69\u003c/p\u003e\n \u003cp\u003e（122.19, 163.49）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBRV\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e(mm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e404.85\u003c/p\u003e\n \u003cp\u003e（321.53, 486.80）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e190.85\u003c/p\u003e\n \u003cp\u003e（171.83, 208.795）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBGVRR\u003csub\u003e1\u003c/sub\u003e\u003csub\u003e\u0026nbsp;\u003c/sub\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e47.39\u003c/p\u003e\n \u003cp\u003e(38.24, 54.37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e27.75\u003c/p\u003e\n \u003cp\u003e(22.36, 32.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.4513%;\"\u003e\n \u003cp\u003eBGVRR\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.7545%;\"\u003e\n \u003cp\u003e54.21\u003c/p\u003e\n \u003cp\u003e(46.46, 61.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.7004%;\"\u003e\n \u003cp\u003e37.98\u003c/p\u003e\n \u003cp\u003e(33.60, 40.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0939%;\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBGMV\u003csub\u003e1\u003c/sub\u003e:\u0026nbsp;bone graft material volume at T1, BGMV\u003csub\u003e2\u003c/sub\u003e: bone graft material volume at T2, and BGMV\u003csub\u003e3\u003c/sub\u003e: bone graft material volume at T3, BAV\u003csub\u003e1\u003c/sub\u003e: bone augmentation volume at T1, BAV\u003csub\u003e2\u003c/sub\u003e: Bone augmentation volume at T2, BAV\u003csub\u003e3\u003c/sub\u003e: bone augmentation volume at T3, BRV\u003csub\u003e1\u003c/sub\u003e: bone resorption volume at T2, BRV\u003csub\u003e2\u003c/sub\u003e: bone resorption volume at T3, BGVRR\u003csub\u003e1\u003c/sub\u003e:\u0026nbsp;the bone graft volume resorption rate at T2,\u0026nbsp;BGVRR\u003csub\u003e2\u003c/sub\u003e: the bone graft volume resorption rate at T3. T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Comparison of bone height changes and resorptionrate around implants between two groups (n=40)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 168px;\"\u003e\n \u003cp\u003e\u0026nbsp; Hydraulic pressure group\u003c/p\u003e\n \u003cp\u003e(n=21)\u003c/p\u003e\n \u003cp\u003eM (P\u003csub\u003e25\u003c/sub\u003e, P\u003csub\u003e75\u003c/sub\u003e)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 155px;\"\u003e\n \u003cp\u003eGrind-out technique group\u003c/p\u003e\n \u003cp\u003e(n=19)\u003c/p\u003e\n \u003cp\u003eM (P\u003csub\u003e25\u003c/sub\u003e, P\u003csub\u003e75\u003c/sub\u003e)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBHAI\u003csub\u003eT1\u003c/sub\u003e\u003csub\u003e\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e13.70\u003c/p\u003e\n \u003cp\u003e（12.14, 14.21）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e12.14\u003c/p\u003e\n \u003cp\u003e（11.70, 12.34）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBHAI\u003csub\u003eT2\u003c/sub\u003e (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e11.00\u003c/p\u003e\n \u003cp\u003e（10.54, 11.16）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e10.55\u003c/p\u003e\n \u003cp\u003e（10.29, 11.61）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-1.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBHAI\u003csub\u003eT3\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e10.69\u003c/p\u003e\n \u003cp\u003e（10.33, 10.92）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e10.32\u003c/p\u003e\n \u003cp\u003e（10.08, 11.32）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-1.124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.261\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBAH\u003csub\u003eT1\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e6.54\u003c/p\u003e\n \u003cp\u003e（5.79, 8.23）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e5.06\u003c/p\u003e\n \u003cp\u003e（4.62, 5.63）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-3.074\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBAH\u003csub\u003eT2\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4.61\u003c/p\u003e\n \u003cp\u003e（4.19,\u0026nbsp;5.19）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e3.92\u003c/p\u003e\n \u003cp\u003e（3.40, 4.48）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-0.989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBAH\u003csub\u003eT3\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e4.38\u003c/p\u003e\n \u003cp\u003e（3.76, 4.86）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e3.98\u003c/p\u003e\n \u003cp\u003e（3.51, 4.64）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-1.029\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e0.303\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eBRH\u003csub\u003e1\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e2.14\u003c/p\u003e\n \u003cp\u003e（1.35, 2.94）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003cp\u003e（0.76, 1.72）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e-2.939\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eBRH\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e(mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003cp\u003e(1.55, 3.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp; 1.5\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;(1.11, 1.96 )\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-2.880\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eRRBGH\u003csub\u003e1\u0026nbsp;\u003c/sub\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e15.93\u003c/p\u003e\n \u003cp\u003e(9.91, 20.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;9.89\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; (6.26, 13.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-2.749\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eRRBGH\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 165px;\"\u003e\n \u003cp\u003e18.22\u003c/p\u003e\n \u003cp\u003e(11.71, 23.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 169px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 12.08\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;(9.15, 15.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-2.722\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 52px;\"\u003e\n \u003cp\u003e＜0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBHAIT1: bone height around the implant at T1. BHAIT2: bone height around the implant at T2. BHAIT3: bone height around the implant at T3.\u0026nbsp;BAHT1: bone augmentation height at T1. BAHT2: bone augmentation height at T2. BAHT3: bone augmentation height at T3. BRH1: bone resorption height at T2. BRH2: bone resorption height at T3(12 months after surgery). RRBGH\u003csub\u003e1\u003c/sub\u003e: resorption rate of bone graft height at T2. RRBGH\u003csub\u003e2\u003c/sub\u003e: resorption rate of bone graft height at T3. T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hydraulic pressure technique, grind-out technique, transcrestal sinus floor elevation, dental implant, clinical study","lastPublishedDoi":"10.21203/rs.3.rs-8338371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8338371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e Our study aimed to compare the clinical efficacy of grind-out and hydraulic pressure techniques for transcrestal sinus floor elevation (TSFE) through a clinical retrospective analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods: \u003c/strong\u003e40 patients who received TSFE with simultaneous implant placement using either the grind-out or the hydraulic pressure technique were included. We compared the clinical effects of these two methods through following parameters: primary outcomes included bone augmentation volume at Tn (BAV\u003csub\u003en\u003c/sub\u003e), the bone graft volume resorption rate at Tn (BGVRR\u003csub\u003en-1\u003c/sub\u003e). bone augmentation height at Tn (BAH\u003csub\u003eTn\u003c/sub\u003e), resorption rate of bone graft height at Tn (RRBGH\u003csub\u003en-1\u003c/sub\u003e). T0: before surgery, T1: immediately post-surgery, T2: 6 months post-surgery, T3: 12 months post-surgery. Secondary outcome included: VAS scores and swelling scores from days 0, 1, 3, 5 and 7 postoperatively. Group differences were assessed using t-tests, Mann–Whitney U tests, and generalized estimating equation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among 40 patients (21 patients for hydraulic pressure group, 19 patients for grind-out technique group), the BGVRR\u003csub\u003e1\u003c/sub\u003e, BGVRR\u003csub\u003e2\u003c/sub\u003e, RRBGH\u003csub\u003e1\u003c/sub\u003e and RRBGH\u003csub\u003e2\u003c/sub\u003e of the hydraulic pressure group was significantly higher than that in the grind-out technique group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001), whereas no significant differences were observed in BAV\u003csub\u003e2\u003c/sub\u003e, BAV\u003csub\u003e3\u003c/sub\u003e, BAH\u003csub\u003eT2\u003c/sub\u003e and BAH\u003csub\u003eT3 \u003c/sub\u003ebetween the two groups. The grind-out technique group showing lower VAS and swelling scores than the hydraulic pressure group (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). In both groups, the VAS pain and swelling scores gradually decreased over time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Grind-out and hydraulic techniques are both effective for TSFE and implant placement, but the grind-out method shows less bone resorption and postoperative discomfort.\u003c/p\u003e","manuscriptTitle":"Comparison of the Grind-out and Hydraulic Pressure Techniques for Transcrestal Sinus Floor Elevation with Simultaneous Implant Placement: A Clinical Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 07:17:36","doi":"10.21203/rs.3.rs-8338371/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-02T09:58:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-31T21:02:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263131477537724426737182014774179388000","date":"2026-01-31T17:40:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78708879679359330955129562675871549635","date":"2026-01-30T02:21:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T15:43:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-18T08:20:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-17T05:18:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T05:17:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-12-11T15:28:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fcd76ff4-e1f3-4943-96a7-76255a6e41f2","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T07:17:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 07:17:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8338371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8338371","identity":"rs-8338371","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}