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Table of Contents
ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 35-41

A review of management options for rehabilitation of posterior atrophic maxilla with implants


Department of Prosthodontics, Government Dental College and Research Institute, Victoria Hospital Campus, Fort, Bangalore, India

Date of Web Publication10-May-2013

Correspondence Address:
D R Prithviraj
#7A, Government Dental College and Research Institute, Bangalore, Victoria Hospital Campus, Fort, Bangalore - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.111687

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   Abstract 

Purpose: The placement of implants in the alveolar bone remains a challenge because of the resorption of the residual ridge resulting in insufficient bone volume in one or more dimensions. Need of the hour is to review the various options to rehabilitate posterior atrophic maxilla with/without bone modification procedures.
Study Selection: MEDLINE/PubMed searches were conducted using the terms atrophic maxilla, implants, buttresses, grafts, maxillary sinus, osteotomy as well as combinations of these and related terms. The few articles judged to be relevant were reviewed.
Results: Appropriate treatment planning is crucial and various factors need to be considered before placing implants in atrophic alveolar bone Bone grafting, osseodistraction and sinus lifts are invasive procedures. In addition, they add complexity and increase the number of surgical phases required for implant therapy. Different therapeutic alternatives, such as, short implants, or implants placed in specific anatomical areas like the pterygoid region, the tuber or the zygoma has allowed patient treatment to be expedited and minimally invasive.
Conclusion: Important aspects that need to be considered for implant placement in posterior atrophic maxilla are discussed in this article and both surgical and non-surgical options are suggested. There is no consensus as to which treatment modality is superior to the other in literature. The decision to opt for either of the options, therefore, depends upon patient factors, and ultimately, the expertise and skill of the clinician.

Keywords: Atrophic maxilla, buttresses, grafts, implants, maxillary sinus, osteotomy


How to cite this article:
Prithviraj D R, Vashisht R, Bhalla HK, Prithvi S, Suresh P, Sharma D. A review of management options for rehabilitation of posterior atrophic maxilla with implants. J Dent Implant 2013;3:35-41

How to cite this URL:
Prithviraj D R, Vashisht R, Bhalla HK, Prithvi S, Suresh P, Sharma D. A review of management options for rehabilitation of posterior atrophic maxilla with implants. J Dent Implant [serial online] 2013 [cited 2022 Jan 25];3:35-41. Available from: https://www.jdionline.org/text.asp?2013/3/1/35/111687


   Introduction Top


The reconstruction of edentulous, atrophic jaws according to functional and esthetic factors not only restores chewing function, but leads to positive psychosocial effects and thus also improves the patient's quality of life. [1]

The rehabilitation of edentulous jaws with osseointegrated implants has been proven to be a predictable treatment over the time. A sufficient and long-term stable bone site is the basis of successful implant therapy. [2] However, due to atrophy or periodontal disease, local conditions of edentulous ridges may be unfavorable for implant placement. In particular, severe atrophy of the edentulous maxilla (class VI according to Cawood and Howell 1988 classification), may result in insufficient bone volume and unfavourable vertical, transverse, and sagittal interarch relationship, due to the tridimensional resorption pattern of long-standing maxillary edentulism. Finally, maxillary sinus pneumatization may further reduce the available bone for a safe and reliable implant-supported dental rehabilitation. This may render implant placement impossible or incorrect from a functional and esthetic viewpoint. [3]

During the last 3 decades, several surgical procedures have been developed to increase local bone volume in deficient anatomical regions, including total/segmental bone onlays, Le Forte1 osteotomy with interpositional bone grafts, and grafting of the maxillary sinus with autogenous bone and/or bone substitute. [4]

These techniques pose a series of inconveniences, such as the need for multiple surgical interventions, the use of extraoral bone donor sites (e.g., iliac crest or skull) - with the morbidity involved in surgery of these zones - and the long duration during which patients remain without rehabilitation during the graft consolidation and healing interval. These factors complicate patient acceptance of the restorative treatment and limit the number of procedures carried out.

In order to overcome such limitations, different therapeutic alternatives have been proposed, such as, short implants, or implants placed in specific anatomical areas like the pterygoid region, the tuber or the zygoma. Any of these procedures requires considerable surgical expertise and has its own advantages, limits, surgical risks and complications involving biological and financial costs. [5]

Treatment without bone modification

Since the development of osseointegrated dental implants, the standard procedure has been to place implants vertically within the alveolar bone. However, when the amount of available bone in the maxillary alveolar crest is <10 mm in the vertical aspect and 4 mm in the horizontal aspect, the prognosis for implant treatment is poor. Alternative methods in which the severely resorbed alveolar crest is used for implant placement without bone grafting have been presented and include placement of implants in anatomic buttresses, palatal positioning of implants and the tilted placement of implants along the anterior maxillary sinus wall. [6]

Anatomical buttresses

The skull presents a series of dense bony buttresses that conform a protective frame around the different craniofacial cavities such as orbit, nasal fossae or passages, oral cavity and paranasal sinuses with mostly fragile walls. These buttresses distribute forces through the solid facial bone structure, and are distributed strategically throughout the three facial thirds of the skull. In this context, the middle third portion presents two anterior buttresses namely, frontomaxillary and frontozygomatic buttresses and a posterior pterygomaxillary buttress. [7]

Frontomaxillary or canine buttress

This region normally presents a compact cortical layer and dense medullary bone - thus allowing the placement of long implants with parasinusal angulation. [8] Krekmanov and Rangert introduced implants parallel to the anterior wall of the sinus, combined with vertical implants in the anterior region, in a series of 20 patients. This procedure made it possible to extend the fixed prosthesis ≥9 mm. No implants were lost during the 2 years of follow-up. [9]

Frontozygomatic buttress

This support is located in the region of the upper first molar, forming the so-called zygomatico-alveolar crest, which continues laterally along a concave trajectory to the zygomatic process of the maxillary bone and posteriorly, to the zygomatic bone. [7] Two management options exist in this region.

Implant placement in the palatal vault

This technique involves positioning a tilted implant in the region of the first molar, using palatal bone as anchorage, which is entirely composed of cortical bone. Krekmanov published a series of case reports of 75 implants placed in 22 atrophic upper jaws. Fifty-four implants were tilted. After 4-5 months of follow-up, three nonangulated implants failed to osseointegrate. Implant survival rate of 94.7% was observed with tilted implants after follow-up of 18 months. [10] Perales and Aparicio conducted a retrospective study involving 101 implants of which 59 were in an axial position and 42 were in a tilted position. After a mean follow-up of 33 months, cumulative success rates of 95.2% and 91.3% were recorded for the tilted and axial implants, respectively. Several authors have considered this management approach to be simpler, less costly and faster than the invasive surgical techniques. [11]

Trans zygomatic implants

Trans-zygomatic implantation is a novel technique involving the positioning of two bilateral implants measuring between 35 mm and 55 mm in length, which are anchored to the zygomatic bone following an intrasinusal trajectory. These implants in turn must be combined with a minimum of two implants in the anterior sector and stent-fixated by means of a prosthetic superstructure. [7]

Stella and Warner described a variant of the technique in which the implant was positioned outside the sinus, following the contour of the malar process, and introducing into the zygomatic bone. This approach obviates the need for performing a maxillary sinus window and facilitates implant emergence above the alveolar crest at first molar level, with a more vertical angulation. The authors consider that this variant affords improved contact between the bone and implant, with optimum implant positioning, and a better postoperative course. [12]

Balshi and Wolfinger reported the case of a 20-year-old patient presenting ectodermal dysplasia rehabilitated with two zygomatic implants in combination with four anterior implants and two implants positioned in the pterygomaxillary region - thereby avoiding graft-based maxillary reconstruction. [13] A survival rate of 96-100% has been reported for this treatment modality. [14],[15],[16],[17]

Pterygomaxillary buttress

Tulasne in 1989 described the technique for placing implants in this region. According to him, the pterygomaxillary implant should anchor in the pterygoid process or even traverse the latter, avoiding the posterior portion of the sinus and major palatal duct. To accomplish this, the implant should be directed posteriorly, superiorly and medially. The length of the implant is normally between 15 mm and 20 mm. [8] In a study, Pi published the results of 177 pterygomaxillary implants in 136 patients, with a follow-up of 1-10 years. The success rate was 97.2%. [7] As per the various studies the success rate of this technique was between 88% and 98%. [18],[19],[20],[21],[22]

Short implants

An implant is considered as short when presenting a length < 10 mm. [23] Accordingly, in clinical situations with little bone availability, short implants are a viable, simple and alternative treatment modality to bone grafting procedures. [24],[25] Moreover, short implants may present results similar to those of longer implants. [25],[26],[27],[28],[29],[30] Malo et al. stated that short implants of 7 mm and 8.5 mm with modified surfaces and adequate placement technique almost matched the success rates of long implants. [24] Rokni et al.[31] evaluated 199 implants, with short implants of 5 mm and 7 mm and long implants of 9 mm and 12 mm. Long implants showed a greater bone loss of the alveolar ridge in relation to short implants. More recent clinical studies on short implants with rougher surfaces report survival rates similar to implants in general. [32],[33],[34],[35],[36],[37],[38],[39],[40],[41]

Treatment with grafts

The definition of adequate bone width and height requirements for implant placement is based mainly on clinical experience and on physical and mechanical requirements for the actual implant placement process. A minimum width of 5 mm and a height of 7-10 mm of bone are suggested by most clinicians. [42] The minimum height requirement of 10 mm is also supported by several implant survival studies in which higher failure rates were consistently reported for shorter implants. [43],[44]

Thus, various ridge augmentation procedures have been described for the enhancement of both height and width requirements, including block grafts, particulate grafts and ridge expansion techniques. [45]

The use of corticocancellous bone grafts for ridge augmentation in implant dentistry was first reported by Breine and Branemark. [45] Autogenous bone has been successfully used as a grafting material to augment the site and is generally considered to be the best material for bone reconstruction surgery. [46],[47] It is often obtained from intraoral sites such as chin and retromolar area or extraoral sites such as the anterior or posterior iliac crest, the calvarium and the tibia. [48],[49],[50] Extraoral sources were primarily used for the reconstruction of atrophic arches, with immediate or delayed implant placement. Although still indicated for large alveolar ridge defects, extraoral graft sources have the obvious disadvantages of greater morbidity and expense. Intraoral graft sites have therefore been suggested and used for ridge augmentation procedures for smaller defects. [45]

The main advantage of using autogenous bone is related to the osteoconductive and osteoinductive capacities of the graft; the disadvantage is the use of an additional surgical site, with the risk of donor site morbidity. Hence bone substitutes such as calcium phosphates, b-tricalcium phosphates [51],[52] and bioactive glass particles, xenogenic substitutes such as bovinehydroxyapatites (BioOss) and allogenic substitutes such as demineralized freeze-dried human bone have commonly been proposed as and shown to be adequate alternatives for autogenous bone. However, a major drawback of these substitutes is long healing time that is needed before implants can be placed.

In addition, as clinicians often are looking for tools to speed up healing, the effect of using platelet-rich plasma (PRP) has been studied aiming to accelerate bone regeneration, as it has been speculated that growth factors within PRP could enhance healing of the grafts and counteract resorption after augmentation. [53],[54] However, Raghoebar et al.[4] and Schaaf et al. showed that no relevant differences in healing of soft tissues and bone existed between sites reconstructed with autogenous bone and autogenous bone mixed with PRP.

With the need to define improvements in bone augmentation techniques to enhance implant osseointegration, emphasis has been shifting to the use of autologous graft materials such as postnatal stem cells to regenerate new bone.

Mesenchymal stem cells were shown to differentiate to osteoblasts when being introduced into an environment prone to the formation of bone. Pieri et al. investigated whether mesenchymal stem cells and PRP seeded on a fluorhydroxyapatite scaffold can improve bone formation and bone to implant contact in maxillary sinus grafting. They showed that sinus augmentation with mesenchymal stem cells may enhance bone formation and osseointegration of dental implants in minipigs. Also, McAllister et al. showed that treatment with mesenchymal stem cells has a positive effect on bone formation.

Furthermore, Herten et al. evaluated the influence of different bone substitutes (BioOss) on the viability of human bone marrow mesenchymal stem cells in vitro and concluded that hydroxyapatite (BioOss) supports cell viability and allow cell proliferation. [55] In recent animal studies, it has been shown that seeding BioOss with mononuclear stem cells derived from concentrated non mineralized tissue may result in bone-forming kinetics comparable with bone-forming kinetics in a region solely reconstructed with autogenous bone. [56] In addition, in an in vitro study osteoblast-like cells were cultured on various alloplastic biomaterials used for augmentation and for reconstruction of bone defects in dental and craniomaxillofacial surgery which offered suitable growth and proliferation conditions. [57]

Sinus floor elevation

The sinus lift operation has been used since the early 1980s to gain vertical bone height in atrophic regions of the posterior maxilla, prior to the placement of dental implants (Boyne and James 1980). [58] Two techniques used are: The classical approach through a lateral window and for less severe bone loss, the osteotome technique (Summers Sinus floor elevation).

The lateral window osteotomy is the most commonly used and reported technique for sinus augmentation, in which a fenestration is made through the buccal bone, the Schneiderian membrane is freed from the maxilla and elevated. During this elevation procedure, the space created between the residual maxillary ridge and the elevated Schneiderian membrane is filled with a grafting material. This way, a bone volume is created that may allow for implant placement, either simultaneously with the elevation procedure when the residual ridge allows for primary implant stability or at a second stage after healing of the grafted site. [59] The lateral approach to sinus augmentation is a successful procedure, with percentages of success close to 100%. [60],[61],[62]

An alternative to the most commonly used lateral (major) window approach involves the apical displacement of crestal bone using the osteotome technique. The Summers Sinus floor elevation procedure, introduced by Summers (1994) is less invasive, less time-consuming and reduces post-operative discomfort to the patient. [63] The procedure consists of elevating the Schneiderian membrane with osteotomes through a crestal approach, placing simultaneously the bone grafting material and the implant. After a healing period of 3-6 months, implants are osseointegrated and become surrounded with bone over the implant apex. [64]

Osteotomy and guided bone regeneration

Various treatment options devised over the years for inadequate ridge width are, increase of width by augmentation, bone expansion and ridge splitting.

The Le Fort I osteotomy, first proposed by Obwegeser (1969), was accurately described by Bell et al. (1977) as the surgical technique to move the maxilla of edentulous patients forward, making adequate prosthetic rehabilitation possible. [65] Displacement of the osseous segment results in positioning of a healthy portion of bone into a previously deficient site. A regeneration chamber is left at the natural location of the segment which has a natural capacity to heal by filling with bone instead of fibrous tissue. As a result the alveolar housing including the osseous and soft tissue components are enlarged in a single process. This technique permits placement of regular sized implants through the expanded ridge crest. This bone segment is not regenerated using grafted tissue, it is native bone, which provides an ideal situation to deal with. [66]

Bone expansion/splitting may be done by means of osteotomes or chisels. When bone width >3-4 mm, osteotomes are used and when <3-4 mm, the ridge splitting is done with sharp blade like chisels.

Another technique proposed with the aim of reconstructing the resorbed maxillae for more successful implant surgery was the guided bone regeneration (GBR) technique, which was developed by Dahlin et al. (1989): The authors showed that a barrier membrane makes it possible to maintain a free space and prevents the ingrowth of surrounding soft tissue, which could disturb bone healing. [65] Many studies have demonstrated the predictability of using both techniques in improving bone volume and reducing bone resorption after autologous or heterologous bone grafts. The combination of both techniques, namely Le Fort I osteotomy and GBR, was first attempted by Stetzer et al.[67] during a study on rabbits; the authors reported 40% more new bone if the osteotomy site was covered with a barrier membrane than if it was left uncovered.

Distraction osteogenesis

Distraction osteogenesis, first described in the treatment of long bone fractures by Ilizarov, is a procedure based on the gradual separation of a mobile but fully vascularized bone segment from the basal bone, leading to the formation of an intervening soft callus which gradually transforms to mature bone. [68] Chin and Toth and Hidding et al. were the first to report clinical use of distraction osteogenesis for alveolar ridge augmentation. The technique involves freeing a bone segment (the transport segment) from the basal bone, but retaining attachment via the lingual periosteum. [69] Gaggl et al. have described a simplified technique for alveolar ridge augmentation using "distraction implants", which do not require subsequent removal. Studies have indicated that when implants are well fixed in the distracted bone and basal bone, they survive as long as implants in native bone and also the vertical bone loss, if any, was similar to that reported for implants placed in native bone. Although failures of implants have been reported in implants placed in distracted bone, most authors consider implantation following distraction to be a highly effective and useful technique. [70]

Procedural complications

The adjunctive procedures described above to augment bone and deal with anatomical structures have their own challenges. Bone grafting, osseodistraction and sinus lifts are invasive procedures. In addition, they add complexity and increase the number of surgical phases required for implant therapy. They are also not without the possibility of complications resulting from these procedures themselves. Bone grafting, whether autogenous or allogenous, carries with it a risk of complications that include the harvesting procedure itself (for autogenous grafts) and the possibility of graft infection, poor flap closure, dehiscence and resorption of the graft. Esposito et al. reviewed 10 randomized controlled clinical trials on ridge augmentation published prior to January 2008 where treatment was reported on at least up until the placement of abutments. They determined from their review that ridge augmentation by major autogenous bone grafting may be unjustifiable, and it was also not clear if any specific technique for ridge augmentation was superior to others. [71] Although high and predictable success rates can be achieved with alveolar ridge augmentation, onlay bone grafts were found in one review to be associated with a 9.6% failure rate of implants subsequently placed at these sites, and alveolar ridge augmentation is considered to be a factor in possible long-term failure of implants. [72],[73] GBR using membranes and autogenous bone grafting is much less commonly performed in these situations and has also been found to result in complications - including exposure of the membrane and wound dehiscence - in up to 45% of cases. [74],[75]

Although high successs rates have been reported for implants placed in the augmented sinus, clinicians have experienced various complications, including perforation of the sinus membrane, excessive bleeding, hematoma, swelling, maxillary cyst, infection of the grafted sinuses, development of an oro-antral fistula, infraorbital nerve laceration and failure of the bone formation during and after sinus augmentation.postoperative acute maxillary sinusitis may cause implant and graft failures. The reported cases of maxillary sinusitis developed after the lift procedure are all associated with the external techniques. On the contrary, internal procedure appears to be a safer method with rare complications. [76]

The reported complications associated with zygomatic implants include postoperative sinusitis, oroantral fistula formation, periorbital and subconjunctival hematoma or edema, lip lacerations, pain, facial edema, temporary paresthesia, epistaxis, gingival inflammation, and orbital penetration/injury. Postoperative concerns regarding difficulty with speech articulation and hygiene caused by the palatal emergence of the zygomatic implant and its effect on the prosthesis suprastructure have been reported. [77]


   Conclusion Top


The reconstruction of edentulous, atrophic jaws according to functional and esthetic factors not only restores chewing function, but leads to positive psychosocial effects and thus also improves the patient's quality of life. Appropriate treatment planning is crucial and various factors need to be considered before placing implants in atrophic alveolar bone. Important aspects that need to be considered for implant placement in posterior atrophic maxilla are discussed in this article and both surgical and non-surgical options are suggested. There is no consensus as to which treatment modality is superior to the other in literature. The decision to opt for either of the options, therefore, depends upon patient factors, and ultimately, the expertise and skill of the clinician.

 
   References Top

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