unlike maxillary sinus , nasal cavity does not undergo process of active pneumatization throughout life . however , alveolar ridge of severely resorbed height in the anterior maxilla can give an indirect impression of nasal cavity encroaching in the inferior direction . although several sinus lift techniques have been developed to overcome the expansion of maxillary sinus for implant placement , no technique is practiced to augment nasal floor for implant placement in atrophied region . both the authors have performed lateral or direct approach and used bone graft as an augmentation material to carry nasal floor augmentation . a 62-year - old female patient with severely atrophied jaws wase planned to treat with immediate loading bi - cortical screw implant and lateral implants . thus it targets mainly crestal and basal cortical bone and if required buccal or lingual cortical bone for support for safe load transmission . nasal floor is considered to have resorption stable cortical bone . unlike conventional implants , these implants are narrower at crest and wider apically , with a smooth polished endosseous surface . part of polished bi - cortical implant can stay in the maxillary sinus or above nasal floor without any risk of infection . bi - cortical screws can be engaged into nasal floor cortex by perforating it , and screwing its thread into thick nasal floor . bi - cortical implant has a polished rounded , noncutting part at the end of the shaft that helps in lifting membrane without perforating it . preoperative panoramic radiograph and computed tomography ( ct ) section of the left side of the anterior maxilla showed more inferior level of the nasal floor compared to that of the right side [ figures 13 ] . osteotomy preparation was carried out without drilling . after attaching path , finder sharp drill to hand grip this was followed by use of 2 mm twist drill corresponding to the diameter of the implant shaft at apex to perforate nasal cortex . preoperative panoramic radiograph preoperative cone beam computerized tomography section of left anterior maxilla- mesial section preoperative cone beam computerized tomography section of left anterior maxilla- distal section three implants from midline to left - side in the anterior maxilla corresponding to the area of 21 - 23 region were found to be extruding much beyond the nasal floor [ figure 4 ] . due to high primary stability of these implants , prosthesis were loaded immediately , within 72 h. figure 4 shows immediate postoperative panoramic radiograph after implant placement that reveals radiolucency around these three implants . this was basically due to indirect lifting of nasal floor membrane with tapping and smooth apical part of the implant . careful attempts were made to lift nasal floor membrane , to achieve primary stability and good torque of insertion for the implants . patient was kept under observation and remained asymptomatic without any nasal problem during the observational period of 1 year . postoperative 1-year follow - up panoramic x - ray also showed evidence of bone formation around the implant without any signs of infection [ figure 5 ] . this finding was confirmed by cone beam ct sections taken 1-year after loading of the prosthesis . the ct sections revealed evidence of new bone formation in the area of the nasal floor after indirect lifting of the nasal membrane with bi - cortical implants [ figures 6 and 7 ] . note area of radiolucency in left anterior maxilla is created by lifting of nasal membrane with three bi - cortical implants post 1-year panoramic radiograph shows formation of bone in the nasal floor around implants post 1-year cone beam computerized tomography sections ( thickness-0.25 mm ) of left anterior maxilla - mesial sections . note it reveals evidence of new bone formation between adjacent bi - cortical implants post 1-year cone beam computerized tomography sections ( thickness 0.25 mm ) of left anterior maxilla - distal sections . evidence of bone formation below nasal membrane has been reported by several authors . however , the approach for achieving this was direct open approach , where nasal membrane was raised after raisng muciperiosteal flap to the nasal floor followed by bone augmentation . recently , mazor et al . in retrospective cohort study documented that nasal floor elevation with the lateral approach serves as a predictable procedure allowing implant placement with increased stability due to the bi - cortical support . similarly , el - ghareeb et al . observed predictable results with nasal floor augmentation with osteo - conductive material . both the authors have performed lateral or direct open approach , and used bone graft as an augmentation material to carry nasal floor augmentation . unlike the lateral approach , this case observed a finding of bone formation below nasal membrane after indirect lifting of the nasal membrane with bi - cortical implants . bone formation in the nasal floor without augmentation material , is an uncommon phenomenon but same can be observed well in sinus lift procedure without using any augmentation material . christopher riben and thor concluded graft - less sinus lift as a reliable technique with higher implant survival rate in such areas . however , in this case evidence of bone formation with indirect nasal floor lift without any graft has been observed . the possible mechanism being formation of the blood clot after lifting nasal membrane could act as a scaffold for new bone formation . this patient post 1-year evaluation did not express any symptoms of nasal dripping or infection , without any signs of implants failure . the preliminary observation from this case draws greater attention towards research with greater number of cases , follow - up period and long term studies with histological evidences of nasal augmentation with or without graft by indirect lifting of nasal membrane . also , the possibility of clot or any augmentation materials getting infected is high in the nasal cavity , and this must not be avoided .
maxillary jaw is restricted superiorly with maxillary sinus in the posterior region and nasal cavity in the anterior region . 
 augmentation of distal maxilla with recessed maxillary sinus has been documented since , last few decades . 
 sinus lifts the procedure either through crestal or lateral approach proves to be an effective way for augmenting bone for the placement of dental implants in atrophied posterior maxilla . 
 however , when it comes to vertically deficient anterior maxilla , lifting of the nasal membrane is not considered . 
 perhaps , recent studies have shown greater success of dental implant placed after augmentation of the nasal floor . 
 this report emphasizes on an observation of significant bone formation after indirect lifting of the nasal membrane with smooth polished surface bi - cortical implants .