Bilateral Sinus Solution™ (BSS) — 100 Frequently Asked Questions

It is a basal implantology technique that allows rehabilitating the atrophic upper jaw without bone grafts and without sinus lift. The implants are anchored in the deep basal bone, restoring a complete fixed arch with all molars.

The Nicola Lettera Maxillofacial Team, after over 3,000 cadaver dissections and years of anatomical research started in 1997. The technique was refined on thousands of real clinical cases.

The alveolar bone is the superficial portion that surrounds the teeth and resorbs when the teeth are lost. The basal bone is the deep, stable structure of the facial skeleton that never resorbs: it is where BSS anchors the implants.

No, alveolar bone is not needed because the implants are anchored in the deep basal bone. The technique is indicated precisely for patients with severe atrophy.

The procedure lasts about 2 hours per arch under local anaesthesia. The patient is discharged with the fixed temporary teeth already mounted (immediate loading).

The procedure is performed under local anaesthesia, so the patient does not feel pain during the procedure. The post-operative period is manageable with common painkillers.

Immediately (immediate loading). At the end of the procedure a fixed temporary prosthesis is already mounted that allows eating and smiling right away.

14 teeth per arch (upper and lower), including the complete posterior molars. This is what distinguishes BSS from the All-on-4/6 techniques.

No, absolutely not. The definitive prosthesis (Circolare d'Autore®) is made of zirconia-ceramic completely without fake gum. The teeth emerge from the natural gum.

The costs vary according to the complexity of the case. A specialist visit with the Nicola Lettera Team in Bergamo is necessary to define the personalised treatment plan with an understandable and closed quote.

The main alternatives are: All-on-4/All-on-6 (which often require grafts and do not give posterior molars), Quad-4 zygomatic implants and the traditional techniques with grafts and sinus lifts. BSS avoids all these compromises.

Yes, the temporary prosthesis is mounted immediately and allows eating soft foods right away. A soft diet is recommended for the first days.

BSS is indicated for most patients with upper jaw atrophy. A specialist visit is necessary to evaluate the anatomy and the clinical conditions of every patient.

All-on-4 uses 4 angled anterior implants (2 straight anterior + 2 angled on the premolars) and cannot restore the posterior molars. BSS uses 2 posterior basal implants in 18/28, 2 in 15/25 and custom solutions for the premaxilla, restoring all 14 teeth with molars.

No, All-on-6 uses 6 implants but even in this case the posterior (distal) implants reach at most the premolar area, not the true molars. BSS restores the complete posterior molars with the pterygoid implants in the sphenoid.

No, zygomatic implants (Quad-4) have several limitations: they do not restore the posterior molars, require prostheses with fake gum, cross the sinus with risks of chronic sinusitis and are invasive. BSS achieves the same stability staying in the oral cavity.

The term literally means "cerclage of the maxillary sinus". The implants are placed around the maxillary sinus, bypassing it without manipulating it: no sinus lift, no risks of perforation or sinusitis.

Bicortical anchorage is the fundamental mechanical principle of BSS. The pterygoid implant crosses two distinct bone cortices: the tuber and the cortical plates of the sphenoid, guaranteeing excellent primary stability.

The Circolare d'Autore® is the definitive prosthesis made to measure for BSS patients. It is a fixed zirconia-ceramic prosthesis with 14 teeth, all molars, without fake gum.

The definitive prosthesis (Circolare d'Autore®) is made of zirconia-ceramic. The internal structure is in zirconia (biocompatible, resistant, light) covered with layered aesthetic ceramic.

Right after the placement of the implants, a fixed temporary prosthesis in resin or composite is screwed on. This prosthesis has two functions: immediate chewing and the maintenance of the gingival morphology.

The preservation of the gingival papillae (the triangular spaces of gum between the teeth) is fundamental for the aesthetics. When the teeth are removed and the implants placed, the temporary prosthesis immediately supports the papillae, keeping them in position.

Surgical decontamination is a fundamental phase of the BSS procedure. Before placing the implants, the surgeon removes all the pathological tissues to prepare a healthy site for the osseointegration.

Yes. After removing all the pathological tissues and bone deficits, the missing bone volume is re-grafted with biocompatible apatite bone, recreating the adequate volumes for the aesthetics and the support.

The maintenance of the bone volumes is fundamental for the aesthetics of the final result. Without an adequate bone volume, the definitive prosthesis would not have a natural emergence profile.

The Circolare d'Autore® in zirconia-ceramic is a permanent prosthesis. Unlike the composite prostheses (All-on-4/6) that wear out and need replacement every 4-5 years, it does not require periodic substitutions.

The main long-term risks of All-on-4/6 are: 1) overload of the anterior implants due to the lack of posterior molars; 2) progressive resorption of the alveolar bone; 3) peri-implantitis favoured by the fake gum; 4) premature failure of the implants.

Peri-implantitis is a bacterial infection that affects the tissues around the dental implants, causing inflammation, bleeding, bone loss and, if not treated, the loss of the implant. BSS prevents it by eliminating the fake gum and the stagnation areas.

Chewing without posterior molars forces the patient to chew only frontally, on the implants in the premaxilla (canine-to-canine area). This overloads the anterior implants, deforms the bone and causes failures over time.

Yes, the Nicola Lettera Team also deals with the removal of failed implants and the subsequent rehabilitation with BSS. It is possible to remove the compromised implants and rebuild the arch on the healthy basal bone.

Absolutely yes. Many patients arrive at the Nicola Lettera Team after the failure of All-on-4/6 or other traditional techniques. BSS rebuilds the complete arch with posterior pillars in 18/28, restoring the full masticatory function.

No, it is very simple. Since there is no fake gum and every tooth is separated from the other like natural teeth, oral hygiene is performed with toothbrush, dental floss and interdental brushes.

Before the procedure the following are needed: a specialist visit with the Nicola Lettera Team, a panoramic radiograph (OPT) to evaluate the bone situation, and a Cone Beam CT for the 3D planning.

No, the procedure is performed under local anaesthesia on an outpatient basis. Conscious sedation is also available for particularly anxious patients.

The post-operative recovery is fast: most patients return to work within 24-48 hours. The residual swelling subsides in 3-5 days.

Yes, BSS is often performed with a transmucosal technique, which means without cuts and without sutures. The implants are inserted through the gum preserving the soft tissues.

The Bilateral Sinus Solution™ (BSS) is specific for the upper arch. For the lower arch other implantology techniques of the Network are used with the same principles.

Yes, the technique is based on over 3,000 cadaver dissections and 25+ years of clinical experience of the Nicola Lettera Maxillofacial Team, with documented results in thousands of cases.

The Circolare d'Autore® in zirconia-ceramic is a definitive prosthesis that, with correct oral hygiene and regular controls, does not need periodic replacement. It is designed to last for decades.

It is advisable to stay in the Bergamo area for at least 24-48 hours after the procedure for the first control. Afterwards it is possible to travel, following the surgeon's indications.

The pneumatisation of the maxillary sinus is exactly the condition where BSS gives its best. The more the sinus is expanded and the less alveolar bone remains, the more the pterygoid implants anchored in the sphenoid plates are the ideal solution.

Yes, completely. The Circolare d'Autore® in zirconia-ceramic is extremely resistant and allows eating any type of food, including hard foods, with a complete and powerful chewing.

Smoking is a risk factor for any implantology procedure because it reduces the vascularisation of the tissues. However, BSS has a high success rate also in smokers thanks to the anchorage in the basal bone.

The absolute contraindications are the same as any oral surgical procedure: severe uncontrolled systemic pathologies (uncontrolled diabetes, severe immunodepression), recent radiotherapy in the head-neck area, drug addiction and pregnancy.

The success rate of the Bilateral Sinus Solution™ (BSS) is above 95% in the long term, as documented by the clinical cases of the Nicola Lettera Team.

Absolutely yes. BSS was specifically designed to completely avoid the maxillary sinus lift. The implants are placed around the sinus, bypassing it without touching the Schneiderian membrane.

Pterygoid implants are long implants (19-21 mm) that are placed with an inclination of 45°-60° through the maxillary tuber, anchoring in the cortical plates of the sphenoid with bicortical anchorage.

In the BSS technique the pterygoid implants have a length between 19 and 21 mm. About 8-10 mm are in the maxillary tuber while the remaining 8-10 mm anchor in the sphenoid plates.

The Circolare d'Autore® is made by a specialised dental technician on prescription of the Nicola Lettera Team. The process involves: intraoral digital scan, CAD design, CNC milling of the zirconia, aesthetic ceramic layering and definitive screwing.

The composite prosthesis (All-on-4/6) is made of composite or acrylic resin, wears out in 4-5 years and must be replaced periodically. The ceramic prosthesis (Circolare d'Autore®) is permanent, does not wear out and does not stain.

Immediate loading means that the temporary prosthesis is mounted on the implants within 24-48 hours of the procedure (often in the same session). With BSS the patient leaves with the temporary already without fake gum in 1 hour.

Yes, the Nicola Lettera Team has published videos of procedures and real results. The explanatory video of the technique is available on the YouTube channel Implantologia Network.

Yes, the configuration varies from 6 to 12 implants according to the patient's anatomy. The Nicola Lettera Team decides the number and type of implants based on the Cone Beam CT.

Blade implants are used in the anterior area of the maxilla when the alveolar bone is particularly thin (knife-edge ridge). They adapt to the existing bone without grafts, anchoring in the basal bone.

Sub-nasal implants are implants placed in the area under the nasal fossae (premaxillary), in the anterior part of the hard palate. They stabilise the anterior area of the arch with excellent primary stability.

Patients with controlled diabetes can undergo BSS without problems. The D1-D2 basal bone (used by BSS) has a better vascularisation than the alveolar bone, favouring the healing.

Yes, the Circolare d'Autore® in zirconia-ceramic is a definitive and permanent prosthesis. Unlike the composite resin prostheses (All-on-4/6) that wear out every 4-5 years, it is designed to last for decades.

The first visit with the Nicola Lettera Team in Bergamo includes: 1) patient history; 2) objective examination of the mouth; 3) analysis of the radiographs; 4) explanation of the treatment options with the BSS technique; 5) personalised treatment plan.

Conscious sedation is a relaxation technique that helps anxious patients experience the procedure with serenity. The patient remains conscious, breathes autonomously and does not feel pain.

Certainly. In the Clinical Cases section of our wiki there are 45 documented clinical cases with pre-operative panoramic radiographs and post-operative results.

The Bilateral Sinus Solution™ (BSS) is specifically designed for the upper jaw. For the mandible, the Nicola Lettera Team uses other implantology techniques with the same basal anchorage principles.

The osseointegration rate of the pterygoid implants in BSS is very high thanks to the bicortical anchorage in the D1-D2 basal bone. In the rare cases of failure, the implant is removed and the site is retreated with the same technique.

About 6 months pass between the procedure and the application of the definitive Circolare d'Autore®. This time is necessary to complete the osseointegration and stabilise the soft tissues.

Exactly. This is one of the secrets of the aesthetic success of BSS. The temporary prosthesis screwed immediately after the procedure maintains the gingival morphology, preparing the bed for the definitive prosthesis.

The techniques such as All-on-4/6 and zygomatic implants use the fake gum (artificial gum in pink resin) to hide the fact that the implants are all placed in the anterior area and the arch is shortened without molars.

Yes, it is one of the main problems. The fake gum creates underlying spaces where food and bacteria infiltrate, making hygiene difficult and favouring peri-implantitis.

Certainly yes. The composite or acrylic resin prosthesis used in All-on-4/6 and Toronto Bridge is a soft material subject to wear, stains and fractures: it must be replaced every 4-5 years.

The BSS configuration varies from 6 to 12 personalised implants according to the patient's anatomy. The Nicola Lettera Team decides the number and position of the implants based on the Cone Beam CT.

The pterygoid implants in BSS reach an insertion torque above 50 Ncm, often even 70-80 Ncm. This value, considered excellent in implantology, guarantees immediate loading.

Absolutely yes. The basal bone is of D1-D2 type (dense cortical bone), much more resistant than the alveolar bone (D3-D4). The density of the basal bone guarantees an excellent primary stability.

BSS offers the maximum aesthetic level in implantology because: 1) it has no fake gum; 2) the ceramic/zirconia teeth are indistinguishable from natural ones; 3) the gingival papillae are preserved.

Considering the total long-term cost, BSS is cheaper than All-on-4. All-on-4 requires the replacement of the composite prosthesis every 4-5 years, while the Circolare d'Autore® is permanent.

Yes, the Nicola Lettera Team organises anatomy courses on cadavers for surgeons who want to learn the BSS technique. The courses include theory, dissection and practical exercises.

A first telephone or email contact is possible, but for an accurate diagnosis a visit in presence in Bergamo is necessary. Only the visit allows the analysis of the bone anatomy and the personalised planning.

At the first visit it is useful to bring: 1) radiographs already taken (OPT, Cone Beam CT if available); 2) documentation of any previous procedures; 3) the list of the medications taken.

Dental implantology is generally considered aesthetic/rehabilitative dentistry and is not always covered by health insurances. The Team offers installment financing plans.

Yes, it is biomechanically proven. The molar masticatory forces are about 5-6 times higher than those of the anterior teeth. If the molars are missing, all the force discharges on the anterior implants, damaging them.

Yes, the implants used in BSS are in grade 5 titanium (Ti-6Al-4V), the gold standard material in implantology. Titanium is biocompatible, does not corrode and osseointegrates excellently.

Often yes. Many patients with a Toronto prosthesis (Toronto Bridge) with fake gum turn to the Nicola Lettera Team to eliminate the fake gum and improve aesthetics and function with the Circolare d'Autore®.

The Toronto Bridge prosthesis is a fixed prosthesis on implants that takes its name from the University of Toronto, where it was developed. It is characterised by the presence of fake gum and often by the absence of true posterior molars.

Traditional implants are placed in the alveolar bone (superficial) and require sufficient bone in volume and density. If the bone is resorbed, grafts are needed. Basal implants anchor in the deep basal bone, without grafts.

The Sinus Lift involves significant risks: perforation of the sinus membrane (up to 30% of cases), infections, chronic sinusitis, months of waiting and results not guaranteed. BSS completely avoids it.

The post-operative pain is generally mild and manageable with normal painkillers (paracetamol or NSAIDs) for 24-48 hours. The absence of cuts and sutures in the transmucosal technique reduces the discomfort.

It is advisable to rest for 24-48 hours after the procedure. Light sporting activities can be resumed after 3-4 days. Contact sports require a wait of at least 2 weeks.

Yes, the procedure for the upper arch lasts about 2 hours under local anaesthesia. If both arches must be treated, they are generally done in two sessions.

In the first 3-5 days a diet of soft and cold/lukewarm foods is recommended: yogurt, smoothies, soups, vegetable purees, mashed potatoes, gelatin. Avoid hard, crunchy or spicy foods.

Yes, BSS is particularly indicated for patients with advanced periodontitis who have lost the alveolar bone due to the disease. The basal bone is not affected by the periodontitis and offers a healthy anchorage.

Before the procedure the following may be required: complete blood count (red and white cells, platelets), prothrombin time and PTT (coagulation), blood glucose and the tests indicated by the clinical history.

The post-operative swelling peaks at 24-48 hours after the procedure and gradually subsides in 3-5 days. The application of ice in the first 24 hours is recommended.

Occasionally small bruises (ecchymosis) may appear in the procedure area. They are completely normal and resorb spontaneously within 7-10 days.

If the procedure was performed under local anaesthesia only, it is possible to drive after a few hours. If conscious sedation was used, it is advisable not to drive for 24 hours.

Absolutely yes. BSS is particularly indicated for patients over 70 who often have significant bone atrophies and cannot or do not want to undergo grafts or sinus lifts.

Titanium allergies (implant material) are extremely rare (<1%). Zirconia allergies (definitive prosthesis) are practically non-existent. The materials used are biocompatible and hypoallergenic.

The temporary prosthesis is cleaned like natural teeth: brushing after every meal with a soft-bristle toothbrush and toothpaste. An antiseptic mouthwash can be used on the surgeon's indication.

Yes, the 3D Cone Beam CT is fundamental to plan the BSS procedure. It allows: 1) studying the anatomy of the maxillary sinus; 2) measuring the bone volumes; 3) planning the exact position of the implants.

Computer-guided implantology uses 3D planning software based on the Cone Beam CT to design on the computer the position, axis and depth of every implant, increasing the safety and precision of the procedure.

The osseointegration (the fusion process of the bone with the implant surface) requires about 4-6 months to complete. In this period the temporary prosthesis is worn.

The Bilateral Sinus Solution™ (BSS) is a personalised and artisanal technique that has no "economical" or "standardised" versions. Every case is planned individually on the patient's anatomy.

According to the Nicola Lettera Team, the future of implantology is in basal implantology and in the vicarious techniques (that use the deep bone structures), abandoning the grafts and the sinus lifts in favour of biological and minimally invasive solutions.

To book a specialist visit in Bergamo with the Nicola Lettera Maxillofacial Team: Telephone / WhatsApp: +39 388 7527525 — Email: consultidentali@gmail.com. Free consultation, answer within 24 hours.