Background:Transcrestal maxillary sinus floor elevation (TSFE) is a key technique for posterior maxillary bone deficiency in implantology, with sinus membrane perforation as the main complication. Accurate risk assessment is critical for improving surgical success and implant survival rates. Findings:TSFE surgical risk is determined by six core factors: bone defect type, elevation height, sinus floor morphology, sinus membrane status, ostium patency, and immediate implant placement. Surgical difficulty can be stratified into Easy/Moderate/Difficult, with matching technical strategies to reduce risks. Conclusions: and RelevanceMultidimensional risk stratification and targeted technique selection effectively control TSFE risks. Surgeons with lateral window technique experience are recommended for TSFE, and multidisciplinary collaboration is advised for high-difficulty cases, providing precise guidance for clinical implant practice.