Patients with severe periodontal disease often display severely resorbed ridges in the posterior maxilla. Implant therapy can be a challenge for those patients as available bone height is limited by the maxillary sinus. Although sinus augmentation using subantral or lateral window approaches are routinely used, complications occur that may limit bone augmentation in the sinus after any given procedure. The most common complication during sinus augmentation surgery is tearing of the Schneiderian membrane. This happens in 14–53% of surgeries. History of tobacco use and complex sinus anatomy are the most common risk factors for membrane tears. Membrane tears that develop during the surgery can be managed by placing resorbable membranes over the torn area [1–3]. Although piezoelectric surgery and surgical planning can reduce this complication [4], tears still remain a possible surgical complication and there may be incomplete bone augmentation [5].

One reason for this is that even though piezoelectric surgery can gently remove the overlying bone from the fragile Schneiderian membrane, sinus curettes still may be needed to manually lift the membrane from the interior walls of the sinus. As this procedure can tear the membrane, Dr. Muronoi and others developed an alternative procedure for lifting the Schneiderian membrane using a hemostatic nasal dilating balloon in 2003. For this procedure, the surgeons created a lateral window in the posterior maxilla exposing the Schneiderian membrane, slightly elevate the membrane, insert a dilating balloon, and use hydraulic pressure to inflate the balloon, which then gently separates the membrane from the underlying bone and creates space for bone grafting materials [6]. Other clinicians refined this technique by creating successively smaller access windows and reported complications in less than 10% of cases, only minor patient discomfort and satisfactory bone formation [7–10]. Most recently, several clinicians modified the procedure by further reducing the flap size needed for the procedure, moving the access site to the ridge crest, and limit the access window to an implant osteotomy created with osteotomes [11, 12]. Significantly for our case report, this transcrestal approach reduces the chance of postgrafting complications with patients who have sinus pathology and unusual sinus anatomy while minimizing the chance of membrane tears [13].