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Int. J. Oral Maxillofac. Surg.

2015; 44: 229238


http://dx.doi.org/10.1016/j.ijom.2014.08.005, available online at http://www.sciencedirect.com

Systematic Review
Dental Implants

Placement of dental implants L. F. dT. P. Lopes1, V. F. da Silva2,


J. F. Santiago Jr.1, S. R. Panzarini2,
E. P. Pellizzer1

in the maxillary tuberosity:


1
Department of Dental Materials and
Prosthodontics, Aracatuba Dental School,
UNESP Universidade Estadual Paulista,
Aracatuba, Sao Paulo, Brazil; 2Department of

a systematic review Surgery and Integrated Clinics, Aracatuba


Dental School, UNESP Universidade
Estadual Paulista, Aracatuba, Sao Paulo,
Brazil

L.F.dT.P. Lopes, V.F. da Silva, J.F. Santiago Jr., S.R. Panzarini, E.P. Pellizzer:
Placement of dental implants in the maxillary tuberosity: a systematic review. Int. J.
Oral Maxillofac. Surg. 2015; 44: 229238. # 2014 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this systematic review was to identify clinical studies on
implants placed in the tuberosity region to determine the survival rate of these
implants when compared to implants placed in other regions of the maxilla. A
search for data published up until March 2014 was undertaken using the PubMed,
Cochrane Library, Embase, and ScienceDirect databases. Eligible studies were
selected according to inclusion and exclusion criteria. The first database search
revealed 310 titles. After inclusion and exclusion criteria were applied, five studies
remained for the detailed analysis. A total of 113 patients were followed for a period
of 6144 months; 289 implants were placed in the patients evaluated. There were
eight failures/losses of dental implants in the tuberosity region; the overall survival
rate was 94.63% for these implants. In controlled studies, the cumulative survival
rates for implants placed in the maxillary tuberosity and other maxillary regions
Key words: dental implants; maxilla; maxillary
were 96.1% and 95%, respectively. In conclusion, implants placed into the sinus; alveolar bone.
maxillary tuberosity are a predictable alternative for the treatment of patients with
insufficient bone volume in the maxillary region. However, randomized trials are Accepted for publication 14 August 2014
needed to assess the effectiveness of this treatment. Available online 26 September 2014

Oral rehabilitation with osseointegrated implant surface,7 immediate or delayed III or IV, characterized by thin cortical bone
implants is a viable option for the treat- loading, prosthesis design, and the occlu- and low density trabecular bone. Further, in
ment of patients with partial or total loss of sal pattern during the healing phase, all of many situations the bone height in this
teeth,1 since the use of implants is consid- which must be considered.8 region is insufficient for proper implant
ered a predictable and reliable treatment.2 However, failures in rehabilitation with placement because of the presence of the
Implant survival is directly related to dental implants should be considered when maxillary sinus. These factors are detri-
primary stability and osseointegration, osseointegrated implants are installed in mental to the achievement of high primary
which are dependent on mechanical areas of poor bone quality, such as in the stability.2,1416 This region tends to show
aspects and the biological response of upper molar region, especially in cases of low success rates,2 not only due to inappro-
tissues,35 such as bone quality and quan- severe bone resorption.7,912 According to priate primary locking, but also because
tity,6 anatomical conditions in the area Lekholm and Zarb,13 bone quality in the short implants may present unfavourable
where the implant is to be installed, the posterior maxillary region is usually type biomechanics. The rehabilitation of this

0901-5027/020229 + 010 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
230 Lopes et al.

region is therefore a challenge to the den-


tist.17
Consequently, grafts utilizing the iliac
crest have been the most commonly used to
increase bone volume in this area. Grafts
with Le Fort I osteotomy, bone grafts for
sinus lifting, zygoma implants, and
implants in the pterygoid region have also
been suggested.1820 However, many of
these techniques have long operative times,
are surgically complex, and may be physi-
cally demanding for the patient, especially
the elderly. Furthermore, from an economic
standpoint, such procedures may be too
expensive for the patient and a burden on
health care resources.21 They may also be
impractical, such as for patients submitted
to severe maxillary surgical resection due
to a tumour or neoplasia.22,23
Implant placement in the maxillary tu-
berosity region, which is the most distal Fig. 1. Schematic diagram of a fixed partial denture supported by two dental implants, one
area in the maxillary alveolar process,24 installed prior to pneumatization of the maxillary sinus and the other in the region of the
posterior to the maxillary sinus,23 has been maxillary tuberosity (after pneumatization of the maxillary sinus).
suggested as an alternative by many
authors.2123,2530 In fact, bone tissue in IV,21,23,25 so firm primary stability should These two techniques have important
the tuberosity region should be less dense be obtained at the surgical stage.26 In anatomical differences (Table 1).20,21,23
than in other areas of the maxilla30; it is addition, appropriate reverse planning is 26,3235
A systematic review indicated a
unclear whether very spongy bone quality very important. 92% survival rate (first year) for implants
provides predictable osseointegration.31 Another recommended technique for placed in the pterygoid region20; however,
However, this alternative relies on the implant placement in the posterior maxilla evidence-based reviews addressing
placement of these implants on an incline, is related to the use of a pterygoid im- implants placed in the tuberosity region
without the use of bone grafts, with the plant.20,32 Pterygoid implant placement are scarce.
implant placed posterior to the maxillary requires passing through the pillar of bone Clinically, there is evidence that
sinus and not invading it (as shown in composed of the maxilla, pyramidal pro- implants positioned in the tuberosity re-
Fig. 1).1,21,22,26,28,29 cess of the palatine bone, and the ptery- gion show suitable outcomes in patients
All procedures in the tuberosity region goid process of the sphenoid.15,20,32,33 with atrophied jaws21,2628,36 and in
should be evaluated carefully, since the Bidra and Huynh-Ba20 stated that implant patients with severe maxillary defects.22
tuberosity region may not always be avail- placement in the pterygoid region involves In addition, easy access and visibility of
able or may have a low amount of bone the tuberosity region; however, implants the site of the tuberosity36 facilitate the
available for implant placement. In this placed in the tuberosity region are not surgical procedure. However, little is
region, the bone is mainly types III and necessarily fixed in the pterygoid plates. known about the long-term results.

Table 1. The concept of implants placed in the tuberosity and in the pterygoid region.a
Points addressed Tuberosity implant Pterygoid implant
Definition Region most distal to the maxillary alveolar This implant passes through a pillar of bone
process.20,24 Bahat23 indicated that the real posterior composed of the maxilla, pyramidal process of the
structure of the maxillary tuberosity is the pyramidal palatine bone, and the pterygoid process of the
process of the palatine bone.26 Therefore, these sphenoid.32,33 Furthermore, it is conceived as implant
implants may involve the pyramidal process of the insertion through the maxillary tuberosity and
palatine bone.20 Finally, Venturelli25 stated that the pterygoid Plate.20,24 Vrielinck et al.34 stated that
posterior border of the maxillary tuberosity is defined The pterygoid implant enters in the region of the
by the pyramidal process of the palatal bone and the former second molar, follows an intrasinusal
anteriorinferior surface of the pterygoid laminae of trajectory in a dorsal and mesio-cranial direction,
the lamellae. where it subsequently perforates the posterior sinusal
wall and the pterygoid plates.
Bone type Bahat23 stated that the bone in this area is very The pyramidal process of the palatine bone and the
cancellous. Different bone types have been reported: pterygoid process of the sphenoid are dense cortical
III and IV,21,25,35 II, III, and IV.23 bone.20,32,35
Vital structures The posterior wall of the maxillary sinus.20,21 Ridell Internal maxillary artery, posterior or superior
et al.21 stated that: Attention must be paid to the alveolar nerve, pterygoid muscles,32 infratemporal
region posteriorly and medially to the tuberosity fossa, pterygopalatine fossa, nasopharynx, and
considering the maxillary artery and its branches sphenoid sinus.20
specifically the greater palatine artery.
Angulation of implants 10208,23 <308,25 and 1535826 45508 angulations32
a 20
Adapted from Bidra and Huynh-Ba.
Implants in the maxillary tuberosity 231

Therefore, the aim of this systematic tuberosity region. Furthermore, in accor- the requirements of the PRISMA state-
review was to analyze relevant clinical dance with the PRISMA statement,7,37 ment.7,37 The studies were classified into
studies on implants placed in the tuberosi- participants, interventions, comparisons, different levels of evidence. The National
ty region of the maxilla regarding the and outcomes (PICO) were determined Health and Medical Research Council
survival rate and recommendations for this to organize a specific clinical question. (NHMRC, Australia) hierarchy of evidence
technique. The following hypothesis was Participants were patients who had been was utilized to assess the reliability and
tested: the survival rate of dental implants rehabilitated with dental implants in the quality of the selected studies.38,39
placed in the tuberosity region of the posterior maxilla. The intervention was
maxilla is similar to that for other regions dental implants placed in the maxillary
of the maxilla. tuberosity region (without considering im- Data analysis
plant placement in the pterygoid plate The following data were identified for
Table 1). Comparisons were dental each article: first author, year, study type,
Materials and methods
implants placed in other maxillary level of evidence, number of patients,
Procedure regions. The outcomes studied were number of implants, number of implants
the survival rate and recommendations in the tuberosity region, implant geometry
This systematic review was executed in
for the effective use of this technique. (length/width), implant placement in other
accordance with the PRISMA statement37
and followed models proposed in the lit- maxillary regions, follow-up, the survival
erature.7,18,20 The selection of articles was Inclusion/exclusion criteria rate in the tuberosity and other regions,
done individually by two of the authors and marginal bone resorption in the tuber-
Inclusion criteria for the studies were as osity bone and other maxillary regions.
(LFTPL and VFS), and there was no dis-
follows: English language; studies report- Furthermore, qualitative data were ana-
agreement in the selection of articles.
ing clinical series of dental implants lyzed for each article: mean age, imaging
installed in the maxillary tuberosity re- examinations, bone quality, implant man-
Search strategy gion; minimum of five patients. Moreover, ufacturer, type of edentulous arch,
retrospective and prospective studies were osseointegration period, and type of pros-
A search for relevant studies published in included. Implants installed in the tuber- thesis and opposite arch. The data collect-
the English language was conducted using osity region were defined as follows: ed were organized for qualitative and
the following databases: PubMed/MED- implants involving the most distal aspect quantitative analysis.
LINE, Embase, ScienceDirect, and the of the maxillary alveolar process, behind
Cochrane Library. The period covered the maxillary sinus,26 occasionally engag-
was 1967 to 23 March 2014. Two pairs ing the pyramidal process of the palatine Data synthesis
of keywords were employed in the search: bone,20,23,25 and located between the pos-
dental implants AND maxillary tu- The studies collected were compared ex-
teriorinferior surface of the maxillary
berosity and dental implants AND tensively (n = 5). The data were summa-
bone and the anteriorinferior surface of
maxillary tuber. The studies were se- rized for qualitative and quantitative
the pterygoid laminae of the sphenoid
lected by title and abstract and according analysis. The survival rates of implants
bone.23,25
to the inclusion and exclusion criteria. The placed in the tuberosity and other regions
Exclusion criteria were the following:
full-text articles were evaluated by readers were calculated. Failure and survival data
duplicated studies, animal studies, cadaver
using a pilot test form.7 There was no were analyzed using tables and graphs. The
studies, computer simulation and bio-
discord in the selection of articles made failure rate was determined as the percent-
mechanical studies, in vitro studies, mini-
by the independent researchers (kap- age of implants lost relative to the number
implants, orthodontic studies, morpho-
pa = 1). The preparation and discussion of implants inserted for each study.18 Fail-
metric studies, studies analyzing the max-
of data were performed by JFSJR, SRP, ures included implants removed regardless
illary tuberosity as a bone graft donor site,
and EPP. In addition, a manual search was of the osseointegration period. Survival
anatomical and radiological studies, clini-
conducted during the period February represented stable implants without signs
cal studies of implants on humans involv-
2013 to 23 March 2014 in the following of pathology, mobility, resistance to re-
ing the pterygoid and pterygomaxillary
periodicals: Journal of Periodontology, moval torque, pain, or peri-implantitis.18
regions, clinical cases with small sample
Clinical Implant Dentistry and Related sizes (fewer than five patients), clinical
Research, Clinical Oral Implants Re- monitoring for less than 6 months, theo- Results
search, International Journal of Oral & retical studies, implants not placed in the
Maxillofacial Surgery, The Journal of General outcomes
region of the maxillary tuberosity, and
Prosthetic Dentistry, Journal of Prostho- missing data. Systematic reviews were The electronic search of the four databases
dontics, International Journal of Oral & also excluded. identified 310 articles. After an analysis of
Maxillofacial Implants, and Journal of the titles according to the inclusion and
Craniofacial Surgery. The authors of the exclusion criteria and the elimination of
articles were not contacted. Reliability and quality assessment
duplicate references, 25 full-text articles
A group of researchers conducted the de- were assessed for eligibility. Finally, five
velopment of this systematic review. The studies were included in the qualitative and
Study selection
studies were analyzed systematically in quantitative synthesis21,23,2527 (Fig. 2).
Clinical studies were chosen based on order to identify possible biases in the Twenty full-texts were excluded for
their titles and abstracts. Prospective and results and conclusions. The studies were the following reasons: clinical case stud-
retrospective studies were included. The classified by category: prospective or ret- ies,22,2830,36,40,41 biomechanical study,42
selected studies reported the clinical mon- rospective. The assessment of the quality of orthodontic study,43,44 data not local-
itoring of implants placed in the maxillary the methodology was conducted following ized,45 morphometric study,46 in vitro
232 Lopes et al.

diameter implant (4 mm) (eight cases)


without any new drilling.
The region of the tuberosity was cate-
gorized predominantly as bone type III
and IV.21,23,25 Adequate primary stability
of the implants was indicated as an impor-
tant condition.21,25,26 The minimum peri-
od of osseointegration was 4 months.
In relation to the type of prosthesis,
there was a prevalence of fixed prosthe-
ses21,23,26; one study suggested the use of a
reinforced acrylic resin provisional resto-
ration initially (6 months), and after this,
fixed partial dentures were made for the
patients.25 The rehabilitation treatment
was acceptable to the patients. Kramer
et al.27 reported that the prosthesis could
equalize soft tissue and bony defects,
resulting in an aesthetically and function-
ally satisfactory restoration. Riddell
et al.21 asserted that there were no reported
complications with the prostheses, no pro-
blems related to the components of the
implant system, and no inflammatory
reactions of the oral soft tissues; other
studies did not provide specific informa-
tion.
Regarding the opposite arch, there was a
prevalence of natural teeth and fixed pros-
theses.21,23,25 Venturelli25 indicated that
no significant difference was related to
the type of opposing arch. However, the
authors showed that no direct contact was
allowed between the distal implant and the
Fig. 2. Flow diagram of the literature search strategy. opposing arch.
None of the studies analyzed reported
implant mobility, a radiolucent area at the
study,47 anatomical and radiological of 6144 months (mean 52.08 months) implant apex, or prosthetic mobility. The
study,35,48 and implants not placed in (Table 3). The mean age of patients was marginal bone loss of implants placed in
the region of the tuberosity or missing 55.1 years.21,25,26 All studies presented the maxillary tuberosity remained within
data.4953 Since there are few studies elderly patients in the sample (Table 4). acceptable limits.21,26,27 All data above
addressing the topic, relevant excluded A total of 289 implants were placed in are given in Tables 2 and 3.
clinical studies are summarized in the patients evaluated (Table 3); 149
Table 2.22,28,29,36,41 These studies indicate implants were placed in the region of
Quantitative analyses
a high predictability of implants placed in the tuberosity21,23,2527 and 140 implants
the tuberosity region; the survival rate was were installed in other regions of the A total of 289 dental implants were placed
100%.22,28,29 maxilla.21,2527 The studies predominantly in the 113 patients, and the mean follow-up
The inter-reviewer agreement for all indicated the placement of long implants was 52.08 months (range 6144 months).
studies (kappa = 1.0) and the abstract (kap- in the region of the tuberosity.21,23,25,26 From this sample, a total of 149 implants
pa = 1.0) indicated no disagreement. The An important surgical detail observed were placed in the tuberosity region and
five studies included in this systematic was the need for angulations of the 140 implants were placed in other regions
review were published from 1992 to implants placed in the tuberosity region. of the maxilla. There were eight failures/
2010. Tables 3 and 4 summarize the However, this inclination was reduced as losses of dental implants in the tuberosity
main data collected in the systematic re- much as possible.25 The degrees of angu- region and the survival rate was 94.63%
view.21,23,2527 lation were variable: 10208,23 <308,25 (Fig. 3 and Table 5). The lowest interval
and 15358.26 survival rate was 97.26% due to the loss of
In relation to the diameter, only three four implants during the third period (12
Qualitative analyses
studies detailed the use of implants with a 24 months) (Table 5). The main factor
The selected studies were classified as regular diameter (3.754 mm).21,25,26 related to the failure/loss of these dental
retrospective21,26 and prospective.23,25,27 Venturelli25 emphasized that when mini- implants was a lack of osseointegration
Non-randomized studies were located in mal instability in dental implants was (three implants); Kramer et al.27 related
the sample. The levels of evidence for observed during the surgical procedure, that the reason for these failures was pene-
these studies were III-2 and III-3. A total the implant was removed (3.75 mm) tration of the maxillary sinus during im-
of 113 patients were followed for a period and replaced immediately with a larger plantation. In the study of Bahat23,
Table 2. Clinical cases of implant placement in the maxillary tuberosity: excluded studies.
Survival Marginal
rate in the bone
Number of Length of the Width of the Implants Length of Width of the tuberosity/ resorption in
implants in implants in implants in in others the implants implants in other regions tuberosity
Number of the tuberosity the tuberosity the tuberosity regions in others the tuberosity Follow-up (number of implant/other
Author Year patients region region (mm) region (mm) (maxilla) regions (mm) region (mm) (months) failures) regions
Shirota et al.29 2011 1 2 10 4.0 4 35; 40a Not reported 24 100% Zygomatic implants showed
a marginal bone loss of 3 to 4
threads. Two conventional
implants demonstrated a
marginal bone shift of one
thread or less
Leles et al.22 2010 1 2 11; 13 3.75 3 9; 11; 13 3.75 24 100%/66.6% (1) No radiographic signs of
significant bone loss around
implants
Alves and 2009 1 2 14 4.1; 4.8 6 12 4.1 36 100% Follow-up appointment
Neves28 showed acceptable bone
levels
Markt41 2003 1 4 10; 13 3.75 2 18 50% None reported. The patient
has worn the prostheses
without complications for 18
months
Nocini et al.36 2000 1 2 6 100% Radiographic evaluation was
obtained pre- and post-
implant placement
a
Zygomatic implant.

Table 3. Data summary for the five studies selected reporting dental implants inserted in the tuberosity region.

Implants in the maxillary tuberosity


Survival rate Marginal
Number tuberosity bone
implants Length/width Implants Length/width region/other resorption in
Level Number Number in the of the implants in other of the implants Follow-up regions tuberosity
of of of tuberosity in the tuberosity regions in other in months, (number region/other
Author Year Study type evidence patients implants region region (mm) (maxilla) regions (mm) mean (range) of failures) regions (mm)
Park and Cho26 2010 Retrospective III-2 7 17 7 11.515.0/3.754 10 1015.0/3.754 84 (1284) 100% 0.93
Ridell et al.21 2009 Retrospective III-2 20a 86 22 13.020/3.754 64 Not reported 96 (12144) 100%/96.87% (2) 1.6/1.9
Venturelli25 1996 Prospective III-2 29 42 29 1020/3.754 13 1020 40 (3648) 100%/92.3% (1) Not reported
Bahat23 1992 Prospective III-3 45 72 72 Not reported 0 Not reported 21.4 93% (5) Not reported
Kramer et al.27 1992 Prospective III-2 11 72b 19b Not reported 53b Not reported 19 (660) 84.21% (3)/92.45% (4) 2.5 (M)/2.4 (D)
2.4 (M)/2.5 (D)
M, mesial; D, distal.
a
One patient died (initial sample = 21).
b
The study began with 66 implants, but after an initial loss of six implants (three in the tuberosity region and three in other regions), there was further surgery for implant placement (according to

233
Table 1 of the article).
234 Lopes et al.

fixed partial denture (39),


osseointegration of five implants failed

occlusal surfaces) (8),

fixed plus implant (4)


during a follow-up of 12 months in different

lacked occlusion (8)


Opposite arch

fixed prosthesis (2),


types of bone (type II, 2; type III, 1; type IV,

dentures (ceramic

removable partial

Natural teeth (2),


Teeth (7), fixed
2). Four of these implants were placed in

partial dentures
(gold occlusal
Not specified

denture (10)b
surfaces) (4),

Not reported
patients with parafunction. Furthermore,

fixed partial
Teeth (11),
these patients used fixed partial dentures
or fixed partial dentures plus implants.23
The five studies did not indicate a rela-
tionship between the total number of
implants and an increased failure rate.
Screwed prosthesis

Reinforced acrylic

restoration; fixed
Figure 4 shows the studies arranged by

resin provisional
NiCr alloy fixed
Porcelain fused

partial denture

partial denture
prosthesis

Metal-ceramic
the number of implants placed in the
Type of

(29); O-ring

Removable
tuberosity region, the number of implant
failures, and failure rates. Only two studies
bridge

indicated implant failures in the tuberosity


region; Kramer et al.27 showed a higher
failure rate (15.78% surgical technique)
integration

when compared with Bahat23 (6.94%).


(months)
Osseo-

period

reported
Four studies involving 217 implants

660
placed in the tuberosity region (n = 77)
68

68

Not
6

and in other maxillary regions (n = 140)


were analyzed separately (control group).
Not reported

Not reported
2540 N cm

The cumulative survival rate for implants


Primary
locking

Adequate

Adequate
stability

stability
primary

primary

placed in the maxillary tuberosity was


96.1% and in the other maxillary regions
was 95% (Fig. 5). Therefore, these data
Table 4. Qualitative data from the five studies selected reporting dental implants inserted in the tuberosity region.

indicate that implants installed in the tu-


Edentulous arch
(partially/fully)

berosity region may be suitable for oral


Partially and

Partially and

Not reported

rehabilitation.
Regarding marginal bone resorption,
Partially

Partially

two studies did not indicate these data23,25


fully

fully

and two studies presented a mean bone


loss of <2 mm21,26 during 12144 months
of follow-up. Finally, Kramer et al.27
Nobel Biocare,

Nobel Biocare,
manufacturer

showed marginal bone resorption similar


Innovations
Implant

Cylindrical
Branemark

Branemark

IMZ type

for implants installed in the tuberosity and


Implant

in other regions of the maxilla (mean


CSM

2.45 mm) during 19 months of follow-


up (Table 3).
II (9), III (35),
Bone qualitya
Not reported

Not reported
and IV (28)
III (12) and

Discussion
III and IV

IV (16)a

The survival rate of implants installed in the


tuberosity region was high (94.63%). These
results are similar to those reported in other
systematic reviews that have evaluated
Serial parallel
examinations

Not specified

Not specified
conventional
tomography

implants placed in regions of low bone


radiographs
peri-apical,
Panoramic,
Imaging

panoramic

density7 and in the pterygoid region.20


Digital

The tested hypothesis was accepted: the


scans

survival rate of dental implants placed in


the tuberosity region of the maxilla (96.1%)
Lekholm and Zarb13 classification.

was found to be similar to that of other


age, years,

(range)
Patient

All >80

regions of the maxilla (95%)21,2527


mean

(4365)

(4279)

(3862)

4768

(Fig. 5). There are important considerations


52.3

63

50

to be noted in relation to the surgery and the


No statistical difference.

prosthesis as reported in the studies evalu-


2010

2009

1996

1992

1992
Year

ated (Table 6).15,21,23,25,26,28,29


This systematic review followed the
PRISMA statement in order to obtain
Park and Cho26

Kramer et al.27

the best available evidence for the clinical


Ridell et al.21

Venturelli25

outcome of implants placed in the tuber-


osity region. The level of evidence pre-
Bahat23
Author

sented in the studies included in this


b
a

review was low; no randomized controlled


Implants in the maxillary tuberosity 235

the maximum number of studies. Four


databases were searched by independent
researchers. Moreover, a manual search
was done. The excluded clinical cases
are presented in Table 2, adding further
information for the reader, since few stud-
ies were included in the qualitative and
quantitative analyses (n = 5).
The technique of implant placement in
the maxillary tuberosity region follows the
same basic principles as the installing of
conventional implants, through milling or
by using bone condensation through
osteotomes. All studies presented a
high success rate, reaching an average
of 100% in three studies.21,25,26 The mean
follow-up was 52.08 months, ranging
from 12 months21,26 to 12 years,21 show-
ing that this technique was viable in all
Fig. 3. Cumulative survival rate (%) of dental implants in the five studies selected.21,23,2527 studies.21,23,2527
This technique is a conservative choice
for restorations in the posterior maxilla
Table 5. Life-table survival analysis showing the cumulative survival rate of tuberosity implants with large bone loss, since it does not
for the five selected studies. require the bone grafting usually neces-
Number of Number of sary in the upper molar region, an area
implants in failures in with maxillary sinus pneumatization and
Follow-up each interval each interval high bone resorption. Despite the great
intervals of in the in the Survival rate Cumulative advantages offered by cone beam comput-
the study, tuberosity tuberosity within each survival ed tomography (CBCT), which is gaining
months region region interval (%) rate (%) headway in modern dentistry, implant
06 149 3 97.98 97.98 placement in the maxillary tuberosity
612 146 0 100 97.98 is a technique that can be performed
1224 146 4 97.26 95.30 with panoramic and peri-apical
2436 142 0 100 95.30
radiographs22,26; however, we encourage
3648 142 1 99.29 94.63
4860 141 0 100 94.63 the use of CT scans to improve reverse
planning.21,28,29
Rigorous planning for implant place-
trials (RCT) were included. The literature to assisting in the synthesis of data and ment in this tuberosity region is highly
indicates that certain clinical questions in performance of the treatment utilized. Fur- relevant, and adequate bone mapping
implant dentistry cause difficulty in the thermore, these studies indicate deficien- should be considered. CBCT should be
development of well-designed studies, for cies in certain areas of implantology and used whenever possible.23,30 Moreover,
example, type of treatment and limited can therefore direct the execution of new a radiopaque marker placed on a surgical
choice of randomization.20 However, these well-designed clinical trials.20 guide or provisional acrylic resin guide at
systematic reviews can provide a contem- The inclusion criteria for this systematic the level of the edentulous ridge will help
porary view of the topic studied, in addition review were organized in order to obtain locate the implantation site.23
Although this region is considered a
treatment option, other regions are avail-
able for the placement of endosseous
implants as an alternative: implants may
be placed in blocks of autogenous bone
grafts in other areas, as well as the floor of
the maxillary sinus, or implants may be
placed in the zygomatic and pterygoid
regions.18,20,21 Finally, the bone tissue
must be evaluated mesiodistally and buc-
colingually to determine if it can accom-
modate an implant. Bone defects in the
buccal and lingual aspects of the tissue
may result in dehiscence and fenestration
defects around an implant, increasing the
probability of failure.23
The studies included in this review
Fig. 4. Number of implants in the tuberosity at each follow-up interval according to implant reported a period of osseointegration rang-
failure for the five selected studies.21,23,2527 ing from 4 to 8 months (Table 4), probably
236 Lopes et al.

Surgery for the placement of implants in


the region of the tuberosity should be
performed by experienced surgeons.
Moreover, knowledge of the anatomy of
the posterior maxilla is essential to the
success of this technique,21,23 in particular
knowledge of the region posterior and
medial to the tuberosity, with special con-
sideration given to the maxillary artery
and its branches, specifically the greater
palatine artery21 (as shown in Table 1).
Thus, Ridell et al.21 suggest that a possible
technique is the preparation of an inspec-
tion window in the maxillary sinus to
Fig. 5. Survival rates for implants placed in the maxillary tuberosity and in other maxillary areas further ensure correct fixture placement.
in the four studies reporting these data.21,2527 Studies have indicated the prevalence of
types III and IV bone in the tuberosity
region.21,23,25 This warrants the use of a
due to poor bone quality in the area, which Unlike other authors, Shirota et al.29 and more favourable geometry for a primary
would hinder the primary locking and Leles et al.,22 in case reports (Table 2), used lock.28 Furthermore, an appropriate surface
osseointegration. However, Alves and the technique of implants placed in the treatment is relevant for implants placed in
Neves,28 in a case report study, indicated maxillary tuberosity associated with other bone of low density.7 In this regard, the
immediate loading for tapered implant implants for the rehabilitation of patients studies did not provide a detailed analysis
placement in the maxillary tuberosity with severe bone loss caused by tumours; of the surface type used in these implants.
but emphasized that more studies should this does not exhibit the best conditions for Ridell et al.21 used turned Branemark
be done to confirm this technique. prosthetic rehabilitation, thus showing the implants and no failures were reported.
Although there was great divergence effectiveness of this technique in rehabili- However, a strict protocol was adopted;
among the types of opposing dentition tating such patients satisfactorily, both aes- the authors used adequate primary stability,
presented by the patients in the studies, thetically and functionally. careful management of bone tissue, and a
Ridell et al.21 stated that 75% of dentate In cases of partial fixed prostheses, the minimum length of 13 mm for implants,
patients presented natural dentition in splinting of these implants placed in the and finally all implants were fully sub-
their opposing arch, which does not atten- maxillary tuberosity with another implant merged and allowed to osseointegrate
uate the masticatory forces as for remov- installed in the area of the first molar was unloaded for 68 months. On the other
able prostheses, demonstrating that this often reported. Thus this treatment option hand, Nocini et al.,36 in a case report, stated
technique would also be viable under is suggested for rehabilitating first and that corticalization of an implant with suit-
these conditions. On the other hand, Ven- second molars adding the third molar able surface treatment reduces the need for
turelli25 reported that no direct contact was along the prosthesis (implant in tuberosi- bicortical anchorage in the pterygoid pro-
permitted between the distal implant and ty), instead of installing only one implant cesses, thus reducing the risk of tuberosity
the opposing arch. Thus, it is important to in the first molar area and rehabilitating fracture. Longitudinal clinical studies
emphasize that adequate planning should the second in a cantilever situation due to should be performed in order to analyze
be done in relation to the opposite arch for the lack of bone tissue for installing an the geometry and surface treatment of
implants placed in the tuberosity region, implant in that region; this would generate implants for the posterior maxillary region.
presenting fixed prostheses with a larger a lever arm and might even result in failure Reverse planning should be utilized in
extent. of the prosthesis over the medium term. surgery for the placement of an implant in

Table 6. Summary of the main points covered for implants placed in the bone of the tuberosity.
Phases Pre-surgical planning Surgical planning Post-surgery planning
Surgery Correction of pathoses and Internally irrigated drills25 Enough healing time for maturation of
periodontal lesions23,26 Reduced speed of instrument25 host bone (68 months)21,26
Radiography and CBCT21,23 Minimal use of countersinking23,25 Possible surgery in mucosal tissue29
Detailed study of anatomy/ Bone compaction28, modified osteotomes36
potential site30 Achievement of bicortical fixation23,25,30
App. 35 mm opening: site/ Drilling sequence to maximize stabilization
opposing teeth23,25,30 Maximum primary stability21,25
Implant diameter larger and length longer26,30
Favourable geometry of implant28
Prosthesis Opposing arch/load23 Elimination of occlusal loading in Prevent non-axial loading23
Parafunction must be controlled23 osseointegration23 Occlusal scheme, avoid
Space availability for the implant overloading23,30
and crown23 Occlusion and oral hygiene
Quality and dimensions of the soft periodically23
tissues23 Access to the posterior oral cavity23;
careful manipulation of instruments
CBCT, cone beam computed tomography.
Implants in the maxillary tuberosity 237

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Not required.
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