The lateral window sinus elevation procedure has become a routine and highly successful preprosthetic procedure that is used to increase bone volume in the posterior maxilla for the placement of dental implants. Many surgical techniques have been proposed that provide access to the maxillary sinus through the lateral wall to allow for elevation of the sinus membrane. Among these are the multiple variations of the hinge and complete osteotomy techniques, which make use of rotary cutting instruments for the antrostomy. The most common intraoperative complication with these surgical approaches is perforation of the schneiderian membrane, with perforation rates of 14% to 56% reported in the literature. In most instances, perforation occurs either while using rotary instruments to make the window or when using hand instruments to gain initial access to begin the elevation of the membrane from the sinus walls. This article presents an alternative approach that uses a piezoelectric instrument for the sinus elevation procedure. Although new to the United States, this approach has been used successfully in Europe for many years. The membrane perforation rate in this series of 100 consecutive cases using the piezoelectric technique has been reduced from the average reported rate of 30% with rotary instrumentation to 7%. Furthermore, all perforations with the piezoelectric technique occurred during the hand instrumentation phase and not with the piezoelectric inserts. (Int J Periodontics Restorative Dent 2007; 27:413–419.)