1

PTERYGOID
IMPLANT
..Glimpse of hope for management of
atrophic maxilla

Dr. Pallavi D. Yawale;

Dr. Kaustubh S. Thakare;
Dr. Simran Parwani

Innovative Publication Company

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Title Verso Page

Title: PTERYGOID IMPLANT

Authors:
Dr. Pallavi D. Yawale
Dr. Kaustubh S. Thakare
Dr. Simran Parwani

Copyright © 2021 Dr. Pallavi D. Yawale

All rights reserved

No part of this book may be reproduced, or stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, without express written permission of the publisher.

Publisher: Dr. Amit A. Agrawal, C/o Innovative Publication Company,

Address: Nasik, Maharashtra, India 422009
Printer Details: NA (E-book)
Edition: NA
ISBN number: 978-81-953094-5-0
Language of book: English
Country of Publication: India
Product Composition: Single-Component Retail product (00)
Product form: Book (BA)
Date of Publication: 20th May 2021

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 Table of Content

Acknowledgement
INTRODUCTION
SURGICAL ANATOMY OF POSTERIOR MAXILLA
IMPLANT REHABILITATION FOR ATOPHIC MAXILLA
ANOTOMICAL CONSIDERATION OF PTERYGOID PLATE
HISTORY
PTERYGOID IMPLANTS
PATIENT SELECTION
SURGICAL PROTOCOL FOR PTERYGOID IMPLANT PLACEMENT
PROSTHETIC LOADING
COMPLICATIONS
HEALING
SUMMARY
REFERENCES

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 ACKNOWLEDGEMENT

“All praise be to God, the Almighty, the Gracious and the most
Merciful to whom I offer solemn thanks giving for opening the
doors of education with his divine mercy and blessing”

The process of writing book is long and arduous and is certainly

not done single handedly. A great many people have contributed for
its production. Foremost I want to offer this endeavor to my Almighty
for the wisdom he bestowed upon me, the strength and the peace of
mind in order to finish this book.
I would like to express my deepest gratitude to my guide, Dr.
Kaustubh S. Thakare Professor and Guide, Department of
Periodontology, VYWS Dental College & Hospital, Amravati. He has
been the strongest pillar of support throughout my course, continually
mentoring, guiding and motivating me to achieve the greatest heights.
I have learnt the most from my guide in every sense and that has had
a deep impact on me professionally and personally.
“It is the supreme art of the teacher to awaken joy in creative
expression and knowledge” - Albert Einstein
Sir you are endowed with this art. I shall forever be deeply
indebted to you for not just igniting the lamp of knowledge and
enlightening my path but also incessantly inspiring me to meet the
highest standards of ethics in dentistry.
I’m eternally grateful to my inspiration Dr. R. K. Yeltiwar sir for
their invaluable guidance throughout my PG course. His dynamism,

5
vision, sincerity and motivation have deeply inspired me. It was great
privilege and honor to work and study under his guidance.
I am obliged to Dr. Simran Parwani, Professor and HOD,
Department of Periodontology, for her unending encouragement,
support and impeccable advice at all times. Ma’am, I appreciate your
benevolence and caring demeanor from the bottom of my heart.
I would like to offer my special thanks to Dr. Rajesh Gondhalekar,
Dean of our institution for the infrastructure and other facilities made
available in our reputed college. It has contributed in a huge way to
our overall success and well being. I would also like to express a
special thanks to my teachers Dr. Anand Wankhade, Dr. Sameer
Kedia, Dr. Manish Ashtankar, Dr. Shruti Wankhade, Dr. Deepa
Pazare, Dr. Shilpa Wasu.
Special thanks to my batch mate and friend Dr. Nikita Rathi and
Dr. Nikita Tarwani for their praiseworthy support and timely
cooperation in all my endeavors.
My juniors, Dr. Aditi Agrawal, Dr. Minal Ganvir, Dr. Dhanashree
Chaudhari, Dr. Shital Barkhade, Dr. Payal Chandwani have been
great companions and well wishers. Their discerning comments have
time and again spurred healthy debates and discussions which has
immensely honored my sensibilities.
I am extremely grateful to My parents and my sister for their love,
prayers, caring and sacrifice their comfort, for educating and
preparing me for my future.
Dr. Pallavi D. Yawale

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 INTRODUCTION

“Better life starts with a beautiful smile”

Prosthetic Loading during the last decade, Implantology has
become an indispensable part of main stream dentistry, helping to
improve the quality of life.
Whilst implant treatment could often be a convenient alternative to
conventional treatment options: in certain cases it is the first choice
of treatment for rehabilitation of severe functional, anatomical or
aesthetic problem arising from tooth loss. This is most probably most
striking in treatment of severely atrophic maxilla.
The loss of maxillary posterior teeth is found to be associated with
occlusal alterations that result in occlusal instability, functional
masticatory deficiency and local bone loss, among other
consequences (Araújo M et.al 2010).1
Employment of implants for the rehabilitation of the posterior
maxilla may pose various challenges owing to maxillary sinus
pneumatization, alveolar bone resorption, inaccessibility, poor
osseous quantity and insufficient osseous density, especially in long-
term edentulous patients (Tulsane JF 1989).2 This may culminate in
higher propensity for implant failure (Fischer K et. al 2009).3
To overcome these deficiencies, several surgical procedures such
as sinus lift, bone augmentation, tilted implants, short implants and
zygomatic implants were tried. These procedures have their own
limitations such as tearing of the sinus membrane, dislocation of
bone grafts into the sinus cavities, rejection of bone grafts, screw

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loosening of tilted implants and morbidity associated with the usage
of general anesthesia for zygomatic implants.
In view of these limitations, pterygomaxillary region (that is the
posterior most area of the maxilla near the tuberosity and behind the
maxillary sinus) has been suggested as an excellent area for
placement of implant and rehabilitation of posterior maxilla (Balaji VR
et.al 2017).4
Tulasne, inspired by Paul Tessier, first described the pterygoid
implants in 1992 as an alternative to conventional dental implants.2,5
Glossary of Oral and Maxillofacial Implants (GOMI) defines a
pterygoid implant a ‘an implant placed through the maxillary
tuberosity and into the pterygoid plate.6 Placement of these implants
involves their origin in the tuberosity region and follows an oblique
mesiocranial direction proceeding posteriorly toward the pyramidal
process of palatine bone. It subsequently proceeds upward between
both the wings of pterygoid process of sphenoid bone.
Owing to their long path, the length of pterygoid implants ranges
from 15 to 20 mm.2,4 Angulation of these implants ranges from 45 to
50 degrees to the maxillary plane.7
Short implants placed only in the maxillary tuberosity, tilted
implants inserted into the tuberosity or in the pterygomaxillary region
and implants shorter than 13 mm that are not inserted into the dense
cortical pterygoid plate should not be considered pterygoid but rather
pterygomaxillary implants.6
One of the most important reasons and advantages for the use of
pterygoid implants is the elimination of the need for sinus lift
surgeries or bone grafts, thereby decreasing the associated morbility

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as well the treatment time, as it has been proved that the
osseointegration of such implants can occur in only 2 to 3 months.5
Unlike maxillary tuberosity implants, pterygoid implants anchor in
cortical bone, allowing a better primary stabilization which is known to
be a critical factor for long-term success. Bicortical stabilization of the
implants reduces implant micromotion during osseointegration and
enhances the implant survival rate.8,9 From a prosthetic viewpoint, it
can minimize the time upto rehabilitation, bypass the need for a distal
cantilever as well as allow for immediate prosthetic loading, if
indicated.6
Once osseointegrated reports have shown that these implants
resist all axial and non-axial forces better than any other implants
placed in the maxilla, and hence present a predictable treatment
option.4
However, the pterygoid implants also present some
inconveniences. The learning is convoluted compared to conventional
dental implants, access for surgeons and oral rehabilitators is
complex and serious injuries can occur in sectioning the maxillary
artery or invading the pterygomaxillary fossa.2
Pterygomaxillary region morphology has a wide range of variation
between individuals, and every time a pterygoid implant is planned to
be placed in this area, a personalized pre-surgical radiological
assessment should be performed.10
Various factors such as dental status (edentulous patients
presented an inferior density), age (density decreased as age
progressed) and gender (female subjects had statistically less

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density) have an impact on bone density in the pterygomaxillary
region.10
Nevertheless, it has been shown that the internal maxillary artery
crosses 1 cm above the pterygopalatine suture as it enters the
pterygopalatine fossa. Therefore, the distance from the artery to the
lower end of the pterygomaxillary suture is 25 mm.
Because of the absence of vital structures in the insertion area, it is
a safe working area for the surgeon. Any bleeding in this region will
be from the veins of the pterygoid muscle, and it can be stopped
quickly once the intraosseous fixation is inserted and will not restart
once the implant is stabilized.11 An average marginal bone loss of
0.71 mm is seen after the surgery and a year after loading, with
excellent implant survival rates.11
Pterygoid implants have high success rates, similar bone loss
levels to those of conventional implants, minimal complications and
good acceptance by patients. Therefore, they constitute a reliable
alternative for treating patients with atrophic posterior maxilla. Also,
the bone density of the pterygoid process is always greater than the
bone density of the maxillary tuberosity, and therefore, it should be
the choice for implant anchoring in atrophic maxillae.10

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 SURGICAL ANATOMY OF POSTERIOR MAXILLA

The posterior maxilla includes the region of the upper jaw from the
first premolar tooth to the pterygoid process. The posterior maxilla is
formed by a fusion of several bones:

The maxillary bone,

The palatine bone,
The zygomatic bone, and
The pterygoid plates of the sphenoid bone
(Cheung et.al 1998)12

Fig1: Outline of the posterior maxilla (Dotted line): oMa - Alveolar process of
maxilla, Sphenoid bone, ZB – Zygomatic bone, ZMA- Zygomaticomaxillary arch
(zygomatic buttress), ZMS – Zygomaticomaxillary suture.

From a lateral view, the alveolar process of the maxilla is clearly

visible together with the zygomatic buttress overlying the first molar
roots (Fig.2). The posterior or infratemporal surface of the maxilla
forms the anterior wall of the infratemporal fossa (du Toit and Nortjé

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2003)13. The present chapter focuses mainly on the posterior alveolar
process of the maxilla and its neighboring structures.
Though upper third molars are much less frequently removed than
lower third molars, the posterior maxilla is an important area for local
anesthesia and surgical procedures including orthognathic surgery,
removal of posterior maxillary teeth/roots or cysts, surgical
maintenance of posterior maxillary teeth (apical surgery, root
resections, periodontal surgery), and placement of dental or
orthodontic implants.
A profound knowledge of the anatomy of the posterior maxilla is
required to successfully perform anesthetic and surgical interventions
and to avoid problems associated with the neurovascular anatomy in
that region. Special care should be taken because the posterior
maxilla is the most common site of hemorrhage in maxillary
osteotomies (Cheung et al. 1998)12.

Fig 2: Left side of a dry skull showing details of the posterior maxilla. Dotted line-
pterygomaxillary fissure. M 1 - First Molar, MT – Maxillary Tuberosity,OM, os
Maxilla, OMa Alveolar Process of os Maxilla,PPF - Pterygopalatine Fossa, PSAA
for foramina for entrance of Posterior Superior Alveolar Arteries (PSAA),PTP -
Pterygoid Process of Sphenoid Bone, ZB - Zygomatic Bone,

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 Fig 3: Posteroinferior view of the infratemporalsurface (*) of maxilla in a dry skull.
IFS - Inferior Orbital Fissure, PPF - Pterygopalatine Fossa, PTP - Pterygoid
Process of Sphenoid Bone

Fig 4: Deep dissection of the left posterior maxilla in a cadaveric head

demonstrating the pterygopalatine fossa (red triangle) and the inferior orbital fissure
(blue rectangle); M 1 - First Molar, MSPW - Posterior Wall of Maxillary Sinus, MT -
Maxillary Tuberosity, PTP - Pterygoid Process of Sphenoid Bone, TBz -, Zygomatic
Process of Temporal Bone (partially resected), ZB -

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he Posterior Alveolar Process: Horizontal Dimensions
The horizontal dimension of the posterior alveolar process is
usually much larger compared to the anterior alveolar process, mainly
due to the wide orofacial diameter of the three - rooted molars.
However, marked bone resorption and bone remodeling are observed
following tooth loss or removal of teeth in the posterior maxilla.
Katranji et al. (2007)14 quantitatively assessed the width of the
posterior alveolar process in 28 cadaveric heads. In dentate sites, the
width of the alveolar crest was clearly more narrow at the premolars
(6.7 ± 2.08 mm) compared to the molars (10.2 ± 1.30 mm) while
these same parameters when recorded 3 mm below the crest
measured 7.9 ± 2.18 mm and 11.4 ± 2.49 mm, respectively. In
edentulous sites, the width of the alveolar crest in the premolar and
molar regions were significantly less measuring 5.1 ± 2.20 mm at the
premolars and 7.9 ± 2.26 mm at the molars while the same
distance parameters when recorded 3 mm below the crestwere
5.2 ± 1.96 mm at the premolars and 8.3 ± 2.57 mm at the molars. The
width of the edentulous sites was reduced by 22.5–34.2 % compared
to the width of the dentate sites. The average thickness of the buccal
bone plate of the premolars was 1.6 ± 0.48 mm and of the molars 2.2
± 0.84 mm at dentate sites, while the same parameters showed
values of 1.4 ± 0.61 mm for the premolars and 1.7 ± 0.51 mm for the
molars in the edentulous specimens. The corresponding values for
the lingual cortex thickness at dentate sites were 2.0 ± 0.33 mm at
the premolars and 2.4 ± 0.24 mm at the molars, while the
measurements at edentulous sites were 1.6 ± 0.64mm at the
premolars and 2.1 ± 0.66 mm at the molars.

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 Summary of mean measurements reported for bone width (mm) of
the posterior alveolar process: (Katranji et.al 2007)

Ono et al. (2008)15 assessed the cortical bone thickness using

CBCT in 43 patients (mean age 24.0 ± 8.2 years) who had
undergone orthodontic mini-implant placement. The thickness of the
cortex was measured mesial and distal to the first molar from 1 to 15
mm below the crest at 1 mm intervals. At the mesial location, the
mean cortical thickness ranged between 1.09 and 1.62 mm and at
the distal location between 1.14 and 2.12 mm. Comparing mesial and
distal locations, the latter demonstrated significantly thicker cortical
bone at several heights. Also, the cortical bone in males was
significantly thicker than in females at several heights.

Katsoulis et al. (2012)16 evaluated the relative bone width in 52

edentulous patients (mean age 62 ± 9 years) using CT and an
implant-planning software. The width of the complete ridge in first
premolar, second premolar, and molar sites were 12.7 ± 2.0 mm, 13.3
± 2.2 mm, and 15.4 ± 2.6 mm respectively, and the thickness of the
bone at those sites were 6.2 ± 1.6 mm, 6.9 ± 1.9 mm, and 9.0 ± 2.3
mm respectively. The calculated width of the bone relative to the
complete ridge was 48.8 % in first premolar sites, 51.9 % in second
premolar sites, and 58.4 % in first molar sites. The mean width of the
buccal mucosa at premolar and first molar sites ranged from 1.6 to
2.0 mm, whereas the palatal mucosa was considerably larger ranging
from 4.5 to 4.7 mm.

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 De Souza et al. (2013)17 assessed the bone width of 252
edentulous sites in the posterior maxilla of 122 patients (mean age
57.5 years, range 21–92 years) using CBCT. Horizontal
measurements were taken 2 mm below the margin of the alveolar
crest. The mean width measured at first and second premolar and
first and second molar sites were 6.3 mm, 7.4 mm, 9.2 mm, and 9.5
mm, respectively. Gender and age were not found to significantly
influence the width, but the morphology of the maxillary sinus floor
had a significant effect. A flat configuration of the sinus floor was
associated with an increase of mean bone width, whereas an oblique
configuration exhibited increased mean bone heights.

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he Posterior Alveolar Process: Vertical Dimensions
The height of the posterior alveolar process has mainly been
assessed in edentulous subjects during the planning of implant
placement in the premolar and molar areas.
Summary of mean measurements reported for bone height (mm)
of the posterior alveolar process.

Several studies have addressed the vertical dimension of the

posterior maxilla.

Ulm et al. (1993)18 evaluated the profile and bone volume of 78

maxillae in predefined areas. In the premolar-molar region, the bone
volume was found to be diminished upto 80 % following tooth
extraction. The main factors causing such bone deficit were the
remodeling of the alveolar crest and a continuous expansion of the
maxillary sinus into the posterior alveolar process (pneumatization).
The latter appeared to be the most decisive factor regarding loss of
bone volume in the posterior maxilla. Since even in apparently wide
and high crests, a thin bone plate of only 1 mm may remain below the
floor of the maxillary sinus.
Güler et al. (2005)19 measured the height of the posterior
alveolar process in 173 panoramic radiographs of edentulous
patients. The measurements were taken as the vertical distance from
the inferior border of the maxillary sinus to the alveolar crest on the
zygomatic vertical line. The mean distances in males were 7.8 ± 3.88

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mm (range 0.3–18.1 mm) and in females 8.2 ± 3.39 mm (range 1.8–
17.6 mm). The difference was not statistically significant.
Farina et al. (2011)20 assessed the alveolar ridge dimensions of
the posterior maxillary sextants in a split-mouth study in 32 patients
(mean age 55.9 ±7.8 years) using spiral CT, with one side of the
posterior maxilla fully edentulous and the contra lateral side dentate
(first premolar to second molar). The reduction of the bone width
measured 1 mm below the crest of edentulous sextants ranged from
2.8 mm (first premolar) to 5.3 mm (first molar) compared to the contra
lateral dentate sextants. Whereas the reduction of the bone height
ranged from 1.5 mm (first premolar) to 4.6 mm (second premolar).
Sinus pneumatization accounted for up to 46 % of reduced bone
height.
Kopecka et al. (2012)21 analyzed the “subsinus” bone height
unilaterally in panoramic radiographs of 583 edentulous patients
(mean age 55.4 ± 10.3 years). The mean bone height in first
premolars was 10.6 ± 3.8 mm, in second premolars 5.9 ± 2.5 mm, in
first molars 3.3 ± 2.2 mm, and in second molars 4.5 ± 2.4 mm. In 73.1
% of first molar sites, the subsinus bone height was <5 mm.
A similar study was performed by de Souza et al. (2013)17 in 122
patients (mean age 57.5 years, range 21–92 years) using CBCT for
measurement of bone height in 252 edentulous sites. The mean
height measured at first and second premolar and first and second
molar sites was 13.3 mm, 7.7 mm, 5.0 mm and 5.1 mm, respectively.
While the height in first premolar sites was never <5 mm, 54.1 % of
first molar sites and 44.6 % of second molar sites demonstrated a
reduced bone height <5 mm.

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Fig 5: Representative ridge heights depicted in a sagittal CBCT bisecting posterior
alveolar process of left maxilla in a 35-year-old male

Fig 6: Buccolingual CBCT in the area of the left maxillary second molar (note
excellent ridge width but limited ridge height)

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Fig 7: Buccolingual CBCT in the area of the left maxillary second premolar (note
excellent ridge width but limited ridge height)

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axillary Tuberosity
The maxillary tuberosity is the most posterior part of the alveolar
process. When the upper third molar remains retained or impacted, it
may occupy part of the tuberosity.
Cheung et al. (1998)12 evaluated 30 dry skulls of Chinese origin
with regard to the height and width of the tuberosity. The mean height
of the tuberosity was 4.89 ± 1.87 mm (range 2.8– 8.0 mm), and the
mean width distal to the second molar was 21.1 ± 2.16 mm (range
15.7–26.2 mm). The mean distance from the lowest point of the
tuberosity to the highest point of the pterygomaxillary junction
measured was 12.07 ± 1.99 mm (range 8.9–19.0 mm).
Apinhasmit et al. (2005)22 assessed the height and width of the
tuberosity in 55 dry skulls of Thai origin. The mean height of the
tuberosity was 7.45 ± 2.78 mm (range 1.2–14.0 mm), and the
mean width distal to the second molar was
20.38 ± 2.82 mm (range 12.4–27.1 mm). A relatively rare
complication considered in exodontia is the fracture of the maxillary
tuberosity that occurs in about 0.08–0.15 %. (Chrcanovic and
Freire- Maia 2011)23.
However, sequelae in conjunction with a fractured tuberosity may
be severe. A case report in a 22-year-old male described the fracture
of the completealveolar process including all three erupted molars
and the tuberosity during an attempt of extracting the first molar
(Altug et al. 2009)24.
A similar case report was published by Polat et al (2007)25. A
private practitioner, he attempted to extract the right maxillary first
molar in a 28-year-old male and produced a fracture of the tuberosity

21
including all three molars. Another case report of a 52-year-old male
patient described a severe subconjunctival and buccal hemorrhage
following maxillary third molar extractionwith fracture of the tuberosity
(Thirumurugan et al. 2013)26.
The etiological and predisposing factors were analyzed by
Chrcanovic and Freire-Maia (2011)23, publishing a literature review
concerning maxillary tuberosity fractures during extraction of upper
molars. Among 14 factors listed, only 1 was anatomy-related i.e. a
large maxillary sinus with thin walls and sinus extension into the
maxillary tuberosity. In contrast, most of the predisposing factors
were tooth or root related including fusion of teeth, ankylosis,
hypercementosis, elongated roots projecting into the sinus, and large,
divergent, or curved roots. The maxillary tuberosity has also been
described as a possible donor site for bone grafts to be used in
conjunction with implant placement (ten Bruggenkate et al. 1992;
Tolstunov 2009)27,28. While the amount of bone to be harvested from
the maxillary tuberosity is limited, access and visibility are good and
morbidity is low compared with other intra or extra oral donor sites of
autogenous bone grafts.

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 Fig 8 -Occlusal view of the right maxillarytuberosity in a dry skull. GPF - Greater
Palatine Foramen, LPF - Lesser Palatine foramen, M 2 - Second Molar, PTP -
Pterygoid Process of Sphenoid Bone, PTP lp - Lateral Plate of PTP

Fig 9 - Lateral view of the right side of a dry skull showing reported mean
dimensions related to the maxillary tuberosity. (1) Height of tuberosity, distance
from highest point of pterygomaxillary fissure to lowest point of maxillary tuberosity.
(2) PMF - Pterygomaxillary fissure

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he Posterior Superior Alveolar Nerve and Artery
As their names imply, the posterior superior alveolar nerve (PSAN)
and artery (PSAA) supply the posterior part of the maxilla including its
diverse anatomical structures. The PSAN is an important structure for
delivering local anesthesia to that region, whereas the PSAA might
be at risk of inadvertent intra- arterial injection of the local anesthetic.

Fig 10 - Interior view of the left maxillary sinus following removal of the wall
between the left nasal cavity and maxillary sinus in a dissected cadaveric
head(Lozanoff 2015). AN - Anastomosis between ASAA and PSAA, ASAA -
Anterior Superior Alveolar Artery, ASAN - Anterior Superior Alveolar Nerve, ION -
Infraorbital Nerve, MSAN - Middle Superior Alveolar Nerve, PSAA - Posterior
Superior Alveolar Artery.

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osterior Superior Alveolar Nerve
The path and relation of the superior alveolar nerves were studied
in 19 hemi sectioned cadaveric heads by Heasman (1984)29. PSAN
were found in all 19 specimens entering the infratemporal surface of
the maxilla at various levels (range 10–43 mm) above the most
inferior point of the maxillary tuberosity, either as three branches
(5/19), two branches (13/19), or a single branch (1/19). One of the
branches of the PSAN usually accompanied the PSAA. In nine
dissections, individual branches descended directly from the PSAN to
premolar and molar teeth, whereas in the remaining 10 specimens a
complex nerve plexus was observed.
In 15 dissections a PSAN could be traced antero-superiorly to form
a direct communication with the ASAN (the latter descending infero-
medially below the infraorbital foramen toward the piriform aperture).
Moretto et al. (2005)30 studied 30 hemisectioned of cadaveric
heads. In 70% two branches of the PSAN were present, in 20 %
three branches, and in 10 % one branch. Murakami et al. (1994)31
assessed 37 adult cadaveric heads regarding the PSAN after
staining by whole-mount silver impregnation. The PSAN originated
from the base of the infraorbital nerve in the pterygopalatine fossa
either as a single trunk (83.8 %) or as a thick nerve and multiple
branches (16.2 %). After running downward and forward and piercing
the infratemporal surface of the maxilla, the PSAN either passed
through canaliculus in the posterolateral wall of the maxillary sinus
(62.2 %) or it ran beneath the mucous membrane of the sinus (37.8
%). In the latter cases the PSAN always closely accompanied a
branch of the PSAA. The main trunk of the PSAN was never found to
pass outside the buccal cortex of the maxilla.

25
osterior Superior Alveolar Artery
The PSAA typically branches from the maxillary artery just as it
passes into the pterygopalatine fossa. In a study evaluating 20
hemisectioned maxillae, the PSAA and the infraorbital artery had a
common trunk in 60 % of the specimens whereas in 40 % of the
cases, the PSAA emerged directly from the maxillary artery (Kqiku
et al. 2013)32. The caliber (mean external diameter) of the PSAA after
exiting from the maxillary artery was reported to be 1.6 ± 0.21 mm
(range 1.3–2.0 mm) and the length of the PSAA measured on
average 8.2 ± 3.62 mm (range 4–16 mm) in 18 dissected
hemimaxillae (Solar et al. 1999; Traxler et al. 1999)33,34. The same
authors reported between one and four intraosseous and one and
two extraosseous branches from the PSAA. In those studies, the
PSAA and the infraorbital artery formed a common trunk in 33 % of
the cases.

Fig 11: Dissection of the posterior superior alveolar artery on the left side of a
cadaveric head with the zygomatic arch removed. IOA - Infraorbital Artery, MA -
Maxillary Artery, MSpw - Posterior Wall of Maxillary Sinus, PSAA - Posterior Superior
Alveolar Artery

26
 The PSAA enters the Posterior superior alveolar foramina on the
maxillary tuberosity and gives off dental and alveolar branches. The
dental branches of this artery supply the pulp tissue of the posterior
maxillary teeth, and the alveolar branches supply the periodontium,
whereas superficial branches contribute to the maxillary gingiva.
Dental and alveolar branches also supply the maxillary sinus
(Flanagan 2005; Ella et al.2008)35,36. The PSAA can be encountered
while aspirating during infiltration anesthesia of the maxillary second
or third molar because it runs near the tuberosity (Flanagan 2005)35.
Others have divided the PSAA broadly into an intraosseous branch,
supplying the molars and the maxillary sinus, and an extraosseous
branch, supplying the attached gingiva and mucosa of the buccal
aspect of the posterior maxilla (Hur et al. 2009)37.

Fig 12: Illustration showing the extra- and intraosseous anastomoses between the
infraorbital artery and the posterior superior alveolar artery. ANe - Extraosseous
Anastomosis, Ani - Intraosseous Anastomosis, ASAA - Anterior Superior Alveolar
Artery, IOA - Infraorbital Artery, MA - Maxillary Artery, PSAA - Posterior Superior
Alveolar Artery

The intraosseous artery may run through a bony groove or canal

along the lateral wall of the maxillary sinus. The PSAA usually has a

27
vascular anastomosis (VA) with the ASAA or the IOA. Extra osseous
anastomoses are formed by the mucosal branches of the PSAA that
connect with the mucosal branches of the ASAA or with inferior
branches of the IOA. These anastomosis run superficially tothe bone
surface of the maxillary sinus. Intraosseous anastomosis, also called
the alveolar antral artery (Rosano et al. 2009)38 are formed by the
alveolar branches of the PSAA and the ASAA and may run
completely embedded in bone or below the Schneiderian membrane
(Ella et al. 2008)36. Usually, 3- dimensional radiography depicts the
bone channels of these intraosseous vascular anastomoses.
Ligation of an unusually wide (3 mm) intraosseous anastomosis
was documented by Testori et al. (2010)39. The authors
recommended ligation of such large vessels to avoid intra and
postoperative bleeding complications in sinus floor elevation
procedures. In cadaver studies, the intraosseous anastomosis is
typically observed while the extraosseous anastomosis are less
frequently found.

Fig 13: Sagittal CBCT image showing multiple anastomotic bone channels in the
posterior left maxilla in a 42-year- old patient. M 2 - Second molar, MT - Maxillary

28
 tuberosity, VC - Vascular canals (bone channels).
Fig 14: Coronal CBCT image showing submembranous location of
intraosseousbone channel. CSin - Canalis sinuosus, IOC - Infraorbital canal, dbM
distobuccal root of fi rst molar, pM palatal root of first molar, SR sinus recessus with
swelling of Schneiderian membrane,VCvascularcanals
In general, the anastomoses of the PSAA and the branches of the
infraorbital artery form a double arterial arcade in the posterior maxilla
(Solar et al. 1999; Traxler et al. 1999; Kqiku et al. 2013)33, 34, 32.
Sato et al (2010)40 investigated the course of the PSAA with CBCT
and image reconstruction in 34 cadaveric hemimaxillae. The PSAA
ran in the posterolateral wall of the maxillary sinus either in a canal-
like structure (14.7 %), in a ditch-shaped tunnel structure (67.6 %), or
in a fragmented structure (17.6 %).

Yoshida et al. (2010)41 using the identical study sample of Sato et

al. (2010)40 described the supply pattern of the PSAA between the
alveolar foramen and the premolar region and categorized it into
three groups:
The PSAA ascended toward the infraorbital foramen (17.6%of
specimens),
The PSAA descended to an area above the lowest border of the
maxillary sinus (53 %),
The PSAA descended to the region below the floor of the
maxillary sinus (23.5 %).
In 5.9 % the pattern of the PSAA could not be categorized.
Mardinger et al. (2007)42 assessed the intraosseous VA in 104
patients with CT (208 sides). The bony canal formed a concave arch
with the most inferior site in the first molar area. In 6.7 % of the sides,
the canal had a diameter of 2–3 mm. The canal diameter was
significantly related to age, and the authors concluded that the older

29
the patient, the wider the canal. No correlation was found with
gender, presence of teeth, or side. Jung et al. (2011)43 determined
the position of the vascular canal in the lateral maxillary sinus wall at
207 sites with CBCT. A predominantly intraosseous location was
found in first premolar (69.2 %) and second molar sites (46.6 %).
Whereas an “intra sinus” location was more common in second
premolar (45.7 %) and first molar sites (89.1 %).
Overall, the “intrasinus” location was the most frequent (63.8 %)
followed by the intraosseous location (28.5 %). A superficial and
lateral location was infrequent (7.7 %).

Fig 15: Composite of three sagittal CBCT images showing the course of the
intraosseous bone channel (vascular anastomosis) in the left maxilla of a 53-year-
old male. CSin - Canalis sinuosus, M1 - first molar, M2 - Second molar, M3 - Third
molar, PM 1 - First premolar, PM 2 - Second premolar, VC – Vascular canal.

A detailed study of the course of the PSAA was performed by Hur

et al. (2009)37 in 42 Korean cadaveric hemi faces utilizing dissections
of 32 specimens that were injected with colored Latex, while the
remaining 10 specimens were subjected to routine histological
analysis including decalcification, sectioning, and microscopy. Before
entering the foramen (or foramina) above the maxillary tuberosity, the

30
PSAA divided into an extra- and intraosseous branch. The
intraosseous branch was found to forman anastomosis with ASAA in
all specimens and the course in the lateral wall of the maxillary
sinus was either straight (78.1 %) or U-shaped (21.9%).

Nicolielo et al. (2014)44 assessed CBCT scans of 100 patients

and divided superior alveolar canals (SAC) into anterior (ASAC,
originating from the infraorbital canal) and posterior (PSAC) canals.
ASAC were observed in 100 % of the cases, and PSAC in 73 %. The
mean diameter of ASAC was 0.9 ± 0.27 mm (range 0.4–1.8 mm) and
of PSAC 0.83 ± 0.27 mm (range 0.3–1.9 mm). The distances from the
ASAC to the alveolar crest ranged between 9.1 and 44.6 mm and
from the PSAC to the alveolar crest between 2.4 and 32.3 mm.

Fig 16: Schematic illustration of coronal CBCT images showing typical positions of
the vascularcanal within the lateral wall of the maxillary sinus. (a) Vascular canal
located between the Schneiderian membrane and the bony wall. (b) Vascular canal
completely embedded within the bony wall. (c) Vascular canal located lateral to the
bony wall.

31
requency of Vascular Anastomosis
Many cadaver and clinical studies have assessed the presence of
a VA between the ASAA and the PSAA and reflect a wide range of
frequency and pattern. The frequencies reported for VA detection
range between 90 and 100 % for the intraosseous VA, between 33.3
and 100 % for the extraosseous VA, and between 10.5 and 99.4 %
for an unspecified VA. Güncü et al. (2011)45 reported that the VA
was detected in 61.3 % of females, but only in 29.6 % of males. In
contrast, Kim et al. (2011)46 reported significantly more VA in males
(64 %) as compared to females (40 %). Ilgüy et al. (2013)47 observed
a VA significantly more frequently in dentate (99.4 %) compared to
edentulous (75.9 %) patients.

Fig 17: The periapical radiograph of the right maxillary second molar shows
periapical radiolucency (arrows) but also a prominent curved dark line (arrowheads)
projected over the maxillary sinus in a 52-year-old male.

32
Fig 18: The sagittal CBCT image demonstrates the course of a broad intraosseous
vascular anastomosis in the lateral wall of the right maxillary sinus. M 2 - Second
molar, PM 2 - Second premolar, VC - Vascular canal.

Fig 19: The coronal CBCT image at the level of the mesiobuccal root of the second
molar shows a large vascular canal (intraosseous anastomosis) in the lateral wall of
the right maxillary sinus. IC inferior concha, IM inferior meatus,

33
Fig 20: The coronal CBCT section exhibits the location of the vascular canal within
the lateral wall of the left maxillary sinus. IC inferior concha, IOC - Inferior Orbital
Canal, SuP - Sulcus Palatinus, VC - Vascular Canal, ZB - Zygomatic Bone.

34
ze of the Vascular Anastomosis
The mean diameter reported in the literature averaged between
0.8 and 1.52 mm with a maximum value of 3.8 mm. Most researchers
considered a VA diameter ≥2 mm a risk for intra operative
hemorrhage. In a radiographic study of 121 patients with CT, the
mean diameter of the VA was 1.3 ± 0.5 mm with a significant
difference comparing males (1.4 ± 0.4 mm) and females (1.2 ± 0.4
mm). No disparity was observed correlating the size of the VA with
age and side (Güncü et al. 2011 ).45

35
ocation of the Vascular Anastomosis
Conflicting data have been reported regarding the location of the
VA with respect to the lateral wall of the maxillary sinus. While two
studies (Güncü et al. 2011; Ilgüy et al. 2013 )45,47 predominantly
found an intraosseous course of the VA (68.2 %, 71.1 %), a third
study (Jung et al. 2011)43 reported that the VA was most commonly
situated along the inner aspect of the lateral wall (63.8 %). Various
studies have measured the distance from the VA to the alveolar crest
with large variations of the reported mean values (9.6–31.7 mm). The
likely reason for these discrepancies is that the distances were either
assessed at different sites (tooth positions), of intra- or extraosseous
VA, or in dentate, partially dentate or edentulous posterior maxillae.
Another landmark from where to measure the distance to the VA is
the floor of the maxillary sinus. The reported mean values for that
distance ranged between 5.9 and 10.3 mm.

36
yramidal Process
The pyramidal process of the palatine bone is located between the
maxillary tuberosity and the pterygoid process of the sphenoid bone.
Anatomically, it appears as it is fused to the anterior surface of the
pterygoid process. Only very few studies have studied the pyramidal
process.
Lee et al. (2001)48 assessed the dimension and shape of the
pyramidal process in 54 dry Korean edentulous skulls. The mean
height of the pyramidal process was 13.1 ± 2.8 mm (range 8.3–21.4
mm), the mean anteroposterior distance was 6.5 ± 1.1 mm (range
3.3–9.7 mm), and the mean mediolateral distance was 9.5 ± 1.7 mm
(range 4.2–11.8 mm). The most common shape of the pyramidal
process was the right-angled triangle from the lateral as well as from
the posterior aspect.Pterygoid Process
The pterygoid process is the most inferior part of the sphenoid
bone. The process consists of two bone plates (medial and lateral)
that are fused anteriorly. The development of surgical techniques
using the pterygoid process as a point of bone anchorage for oral
implants has generated considerable interest in this anatomical
feature. Implant placement into the pterygoid region of the posterior
maxilla was first reported by Tulasne (1992)5.

37
inical Relevance of the Posterior Maxilla
Frequent surgical interventions in the posterior maxilla include
removal of teeth or root remnants, apical surgery, cyst therapy, and
placement of dental implants. Thorough knowledge of the anatomy
and adequate preoperative planning is paramount to avoid surgical
complications related to the anatomy of the posterior maxilla. Correct
preoperative assessment of the bone width and height (the latter is
often limited) is a major diagnostic consideration prior to implant
therapy in the posterior maxilla. Particularly, implant placement into
the tuberosity, zygoma, or pterygoid process requires a thorough
understanding of the anatomy corroborated and augmented with 3D
planning of the surgical intervention. Knowledge of tooth positions
and bone anatomy of the posterior maxilla is also critically important
when performing orthognathic surgery, inserting orthodontic
anchorages and treating maxillofacial trauma. Performing “high” block
anesthesia in the region of the maxillary tuberosity carries the risk of
inadvertent intravascular injection. Intra-arterial (PSAA) or
intravenous (pterygoid plexus) administration of local anesthetics
and/or vasoconstrictors may cause side effects, e.g., ophthalmologic
complications and skin blanching in the posterior maxilla (von Arx et
al. 2014)49.
A thorough knowledge of anatomy of posterior maxilla can open a
wide range of treatment options for oral rehabilitation, thus leading to
increased function and enhance esthetic using procedures like
maxillary sinus lift, tilted implants, short implants, zygomatic implants
and pterygoid implants.

38
 IMPLANT REHABILITATION FOR ATROPHIC
MAXILLA

The high predictability of endoosseous dental implants has led to

routine use and expectation for success (Papaspyridakos et.al
2013; Branemark et.al 1969)50,51. However the ultimate success for
any patient or any particular implants relies on several factors, the
most important of which is the availability of bone. The loss of teeth
whether caused by disease or trauma, can result in severe deficiency
of alveolar bone.
The posterior maxilla represents a difficult and challenging intra
oral area for rehabilitation with osseointegrated implants (Adell R
et.al 1981)52. For many reasons such as anatomy and presence of
maxillary sinus, insufficient bone volume, poor bone quality, and
difficulties in accessing the area. Other anatomical factors such as
large fatty marrow spaces and the rare presence of cortical bone
covering the alveolous, have also made the posterior maxilla area
less than ideally suited for implant placement (Jaffin et.al 1991)53.
Biomechanical factors i.e. intense chewing forces generated during
mastication add to the difficulty in this area, as occlusal forces are
higher in premolar and molar regions than in anterior maxilla.
The poor bone quality characteristic of this region, coupled with
limited vertical bone height related to damage caused by periodontitis
and sinus pneumatization creates difficulties in providing a significant
number of implants of sufficient length to predictably support an
implant prosthesis. This presents challenge to the surgeon for
implant placement in harmony with the planned prosthesis.

39
 Before the utilization of bone augmentation procedure, patients
with missing teeth and deficient bone in the posterior maxilla could
only be rehabilitated with removable prosthesis, short implants or
cantilever restoration (i.e. supported by adjacent teeth or implants).
However there long-term success was questionable and even the
function was not fully restored.
To overcome these deficiencies, several surgical procedures such
as sinus lift, bone augmentation, tilted implants, short implants and
zygomatic implants were tried.
The treatment option for the implant rehabilitation of atrophic
maxilla can be broadly classified into two categories:

Augmentation of bony defects

Modified implant design for specific condition
Augmentation of bony defects
The augmentation of bony defects is done either in conjunction
with implant placement or during surgical intervention prior to implant
placement (staged approach). The staged approach is primarily the
treatment of choice in situation with large bone defects, where the
primary stability of implants in the prosthetically desired position is
questionable. The bone augmentation procedures used in implant
dentistry includes graft reconstruction, GBR, maxillary sinus floor
elevation and alveolar distraction osteogenesis.
Graft Reconstruction:
The reconstruction of the resorbed ridges using bone grafts is
considered as the gold standard procedure to which all other
rehabilitation techniques were compared. Various types of grafts are
available for ridge augmentation such as:

40
 Autograft
Allograft
Xenograft
Alloplasts
Growth [Dym Harry,Huange David et.al (2012)54, Precheur

HV (2007)55]

Autografts are the bone grafts transferred from one site to another
site within the same individual. It can be cortical or cancellous or
combination of both. They are obtained from the mandible, maxilla,
tibia, illac crest, and cranium. They are of 2 types, block grafts (inlays,
onlays, veneers, or saddle), particulate grafts and membranes. The
advantages of autogenous bone grafts are there is no immunogenic
graft rejection and it provides the transfer of osteocompetant cells. It
has certain disadvantages such as additional surgical procedure is
required morbidity occurs at donor site and it delays the treatment.
(Precheur HV 2007)55.
Allografts (allogenic, homologous, homografts) are the bone grafts
taken from different individual of the same species. It predominantly
acts as space occupying osteoconductive lattice or framework.
Osteoinductive capability is minimal because of low concentration of
bone growth proteins due to the rigorous process involved in removal
of potential antigenicity and pathogenicity. There are 2 types of
allografts: Dematerialized freezed dried bone allografts (DFDBA) and
Mineralized freeze-dried bone allografts (FDBA). Advantages of
allograft is that, it closely matches the recipient in constitutional

41
elements and architecture. It has certain disadvantages such as it is
antigenic and it has potential for transmission of diseases (Precheur
HV 2007).55
Xenograft (heterograft’s, xenogenic grafts) are the materials taken
from different species. Types of xenograft are bovine bone and coral
derivatives. Compared to allograft, xenograft shows less resorption of
graft substrate and form less new bone during the first few month. It
reduces the operative time and avoids the morbidity at donor site.
Disadvantages of xenografts are antigenicity and infectious disease
transmission. Compared with allograft xenograft forms less new
bone during first month (Precheur HV 2007)55.
Alloplast or synthetic grafts are derived from inert synthetic
materials. Types of Alloplast are hydroxyapatite, calcium phosphate,
β tricalcium phosphate, calcium sulphate, bioactive glasses, and
polymethylmethacrylate. There is no cellular or protein material within
this graft. It has disadvantage of increased resorption time and
decreased new bone formation when compared with allografts or
xenograft (Precheur HV 2007)55.
Growth factors are produced using recombinant DNA technology.
These are platelet rich plasma (PRP), platelet derived growth factor
(PDGF), transforming growth factor β (TGF-β) and bone morphogenic
proteins (BMP). Advantages of growth factors are that they can be
added to all the above graft materials, there is no risk of disease
transmission and it reduces the healing time and enhances bone
formation. Disadvantages of growth factors are they cause localized
swelling and there is an increased in cost compared with other bone
grafting alternatives (Precheur HV 2007)55.

42
 For most indications, autogenous bone continues to be the ‘gold
standard’ for graft material. In addition to the risks and complications
of the graft procedure itself, it also involves a donor site with
associated surgical morbidity, additional operating time and extra
costs. Systematic review articles (1) (Aghollo TL 2007, Esposito M
2006)56,57 have emphasized that guidelines for clinical practice are
difficult to define because of the heterogeneity among clinical trials.
However, one should be aware of the fact that the use of iliac crest
bone grafts, for example, in combination with immediate or delayed
implant placement, has a failure rate of 10–30% (Collins TA 1995,
Keller EE 1995, Lekholm U et.al 1985, Sjostrom M et.al 2007,
Widmark G et. al 1988)58-62.
Through review of literatures (Matteo et.al 2009)63, it is evident
that survival rates of implants placed in reconstructed jaws are, lower
than implants placed in native bone. The overall survival rate of
implants in reconstructed maxilla after follow-up periods of 6–240
months was 79.5 %. If used alone or with particulate bones, if not
used with barrier membranes, provide insufficient rigidity to withstand
overlying soft tissue tension or the compression by provisional
removable dentures, leading to complete resorption (Matteo et al.
2009).63

43
uided Bone Regeneration (GBR):
Glossary of oral and maxillofacial implants (GOMI) (Laney WR
2007)64 defines GBR for alveolar ridge augmentation as ‘‘principle of
GBR using barrier membranes, either restorable, to exclude certain
cell types such as rapidly proliferating epithelium and connective
tissue, thus promoting the growth of slower-growing cells capable of
forming bone.” GBR is often combined with bone grafting procedures.
The first commercial membrane used for GBR was made from poly
tetrafluoroethylene (PTFE) and is considered as the gold standard for
GBR treatments. Since conventional ePTFE membranes do not
maintain adequate space unless supported by graft materials, PTFE
was reinforced with fluorinated ethylene propylene (ePTFE) for
rigidity and by titanium in situations like large defects or in supra
crestal areas to increase the stability of the membrane. But, ePTFE
membranes have high surface roughness, facilitating the bacterial
adhesion. So, primary closure over the membrane is mandatory to
avoid exposure. In addition, the removal of ePTFE membranes
requires a second surgical procedure. To avoid these disadvantages,
a high density polytetrafluoroethylene (dPTFE), which does not
require primary closure, was introduced by Barry Bartee. In addition,
the comparatively smooth surface of dPTFE membranes facilitates
the removal of the membrane without any additional surgical
procedure (Hammerle CHF et.al 2000)65.
The requirement of second surgical procedure for the removal of
PTFE membranes led to the introduction of bioresorbable
membranes. The advantages of bio-resorbable membranes over non-
resorbable membranes are, improved soft tissue healing,
incorporation of the membranes by the host tissues (depending on

44
material properties), and quick resorption in case of exposure,
eliminating bacterial contamination. The resorbable membranes can
be categorized into two groups, they are aliphatic polyesters
(polyglycolide and/or polylactide or copolymers) and collagen. At
present, a wide range of resorbable membrane materials are
available including collagen, freeze-dried fascia-lata, freeze-dried
dura mater allografts, polyglactin-910, polylactic acid, polyglycolic
acid, polyorthoester, polyurethane, polyhydroxybutyrate etc. However,
the relative amount of bone formation using resorbable membranes
was less favorable than ePTFE.
Bioresorbable membranes are not capable of maintaining
adequate space unless the defect morphology is minimal and
favorable. Because they lose their mechanical strength soon after
implantation into the tissues and need to be supported. Even though,
bioresorbable membranes provide more bone regeneration, ePTFE
membranes should be the material of choice for GBR, provided if soft
tissue dehiscence are avoided.
In case of vertical defects, Simion et al. reported that vertical bone
regeneration was possible to an extent of 4 mm in height with 42 % of
implant- bone contact. In another study, twelve months following
membrane placement, an average gain of 5 mm of vertical bone
height was measured, reaching up to a maximum of 7 mm. Recent
studies show that 3–20 mm of vertical bone gain is possible by using
autogenous bone grafts or bone substitute materials in conjugation
with titanium reinforced ePTFE membranes (Hammerle CHF et.al
2000)65.
Corinaldesi et al. (2007)66 compared the use of only autologous
bone (Control group) to a combination of autologous bone and BPBM

45
for alveolar ridge augmentation (Test group). For the sites augmented
only with particulate autologous bone, the amount of newly formed
bone was 62.38%±13.02%, whereas connective tissue constituted
37.62%±13.02% of the entire area. For the sites augmented with a
mixture of autologous bone and BPBM (test group),the amount of
new bone was 52.88% ± 11.47%, the soft tissue was 29.96% ±
12.58% and the remaining 17.16%±2.72% was filled with BPBM
particles.

Lizio et al. (2014)67 have made an assessment of the regenerated

bone by means of 3D measurements, evaluating the lacking bone
volume (LBV) and the planned bone volume (PBV). The mean LBV
was 0.45 cm3 that was 30% of the mean PBV (1.49cm3).
Furthermore, it was evaluated how LBV was positively correlated with
the area of mesh exposure.
Gutta et al. (2009)68 in a randomized controlled study in dogs,
analyzed the different pore sized meshes, and compared with
controls without the mesh. They showed how macroporous
membranes facilitated greater bone regeneration compared with
microporous and resorbable membranes. Furthermore, macroporous
mesh also prevented significant soft tissue in growth compared with
other types of meshes.
In principle, bone regeneration using GBR is performed either in
conjunction with implant placement (combined approach) or prior to
implant placement (staged approach). The staged approach is the
treatment of choice in situations with large bone defects, because the
primary stability of implants in a prosthetically desired position is not
possible. Presently available data shows that GBR is a predictable
and successful option for horizontal bone defects under standard

46
conditions. Studies reported with 5-year data provides survival
rates of

79.4 % for 37 implants with

dehiscence/fenestration defects treated with ePTFE
membranes (Hammerle CHF et.al 2000)65.

47
axillary sinus floor elevation:
Maxillary Sinus Floor Elevation procedures are indicated during
free end situations in maxilla, where insufficient bone height is
available for implant placement. Although Tatum (1970)69 was first
credited with augmentation of the maxillary sinus for implant
placement, Boyne’s (1980)70 landmark paper described the sinus
augmentation using autogenous bone marrow graft with long- term
follow-up (Smiler DG, Johnson WP et.al 1992)71. From those initial
investigations, many techniques have be-come available to the
implant surgeon.
Del Fabbro et al72 performed a systematic review of 39 selected
studies in which 2046 patients underwent sinus grafting and received
6913 implants. After an accompaniment of 12 up to 75 months, the
reported survival rate was 92.5% (range, 61.2% to 100%). Results
were also divided according to type of grafting materials.
Overall, the survival rate of implants was 87.7% with autogenous
bone, 94.9% when autogenous bone was mixed with other grafting
materials and 95.9% with nonautogenous grafting materials. Results
were also reported according to type of implant surface. Overall, the
survival rate was 85.6% for implants with smooth/machined surfaces
and 95.9% for implants with rough surfaces.
Van den Bergh et al. (2000)73 conducted a pilot study involving
the use of morphogenetic protein-7 (BMP-7) with a collagen
transporter in four sinus elevations, and autologous bone in another 5
elevations. The results obtained with the morphogenetic protein after
6 months were very diverse, and in only one case was sufficient bone
formed to allow implant placement. In contrast, the 5 sinuses filled

48
with autologous bone presented no problems for implant
rehabilitation. On the other hand, variations have also been described
in the maxillary sinus elevation technique.
Geurs et al. (2000)74 conducted a retrospective radiological
analysis of the cases presented at the 1996 Consensus Conference
to determine the effect of the graft material and tobacco smoking
upon graft height after a period of three years. In all cases a reduction
in graft height was documented, the magnitude of reduction being
greater when allografts were used. In comparison, the best results
were obtained on combining autologous bone and alloplastic
material. Smoking was found to exert a negative influence on graft
survival.
Nasar S et.al (2016)75 A systematic review of sinus floor
elevation found nongrafted maxillary sinus floor elevation seems to
be characterized by new bone formation as well as high implant
survival rate which was comparable to bone graft-assisted maxillary
sinus floor augmentation. It also quotes that the main rationale for
bone grafting is to improve implant stability and act as a space
maintainer. The key factor affecting the primary stability of dental
implants is RBH and its quality could be improved independent of the
presence of grafting materials through peri-implant bone
condensation. Sinus elevation surgical techniques necessitate long
healing period and there is risk of morbidity at donor site (Wood et.al
1988)76.
Despite numerous publications, the effectiveness of sinus-grafting
procedures remains controversial. Most of the literature describing
these techniques lacks defined implant success and failure criteria or
has not described the initial bone height and standardized

49
radiographic follow-up (Wallace SS et.al 2003)77. In a systematic
review of the lateral window technique, an estimated annual failure
rate of 3.5%, translating into a 3-year implant survival of 90.1%, was
found (Petruson BE et.al 2008)78. The best results (98.3% implant
survival after 3 years) were obtained with moderately rough surface
implants. According to the authors, the systematic reviews had
several shortcomings. First, the absence of appropriate randomized
controlled trials, making it necessary to include papers with lower
levels of evidence (e.g. prospective and retrospective cohort studies).
Second, out of 48 reviewed studies, 65% did not report on dropouts.
Third, it is known that the residual bone height significantly influences
implant survival; However, many of the included studies failed to
report the original residual bone height at the site of implant
placement or graft failures. Finally, the studies included were
conducted mainly in an institutional environment, such as universities
or speciality clinics, and the long-term outcomes observed may not
necessarily be generalized to the routine private practice.

Reviews of the trans-alveolar technique (Jensen SS 2009)79

reported very similar results, with an estimated survival rate of 92.8%
after 3 years of function. However, again, only 16% of the studies
reported on dropouts. It was evident that the failure rate increased
with reduced residual bone height and reduced implant length. A
multicenter retrospective study (Rosen PS 1999)80 reported a survival
rate of 96% when the residual bone height was 5 mm or more,
compared with 85.7% when the residual bone height was 4 mm or
less.

50
straction osteogenesis (DO)
It is the process of bone generation between two
bone segments in response to tensile stress (Bradley
S et.al 2003)81. The technique was first described by
Codivilla in 1905 and was developed by Dr Gavriel
A. IIlizarov in 1950s. He provided the basic
principles for DO which consists of three distinctive
phases such as,
Latency phase—initial post-surgical healing
period of osteotomy site
Distraction phase—gradual and incremental
bone separation at the rate of 1 mm/day
Consolidation phase—bone regeneration at
distracted site.
Mario J et al (2002)82 conducted a retrospective study, to review
preliminary results using distraction osteogenesis for the correction of
craniofacial deformities and to determine its role in treating anatomic
deformities and functional deficits relative to conventional
craniofacial surgery. Twenty-four consecutive patients were treated
with distraction osteogenesis during a 34-month period. Outcomes
were compared with preexisting anatomic deformities and functional
deficits using records of clinical assessments, photo documentation,
diagnostic imaging and treatment planning aids. Distraction achieved

51
vs planned distraction based on clinical and radiographic
assessment, clinical status of functional deficits before and after
treatment and objective rating of aesthetic improvement Preliminary
results demonstrated good to excellent outcome in correcting facial
skeletal deformity in 80% of patients. Functional outcomes included
resolution or significant improvement of upper airway obstruction in
13 of 14 patients and correction of corneal exposure for all 5 patients
with preexisting exorbitism. Correction of malocclusion was less
reliable. Problems related to the distraction devices, including failure
of the advancement mechanism and fixation, were the most prevalent
complications. Distraction osteogenesis represents an exciting new
development in craniofacial surgery with several potential benefits,
including less invasive surgery, the ability for earlier intervention, and
the potential for correction of more severe deformities with improved
posttreatment stability. The exact role of distraction osteogenesis
relative to conventional techniques requires ongoing assessment.
McCarthy et al (1992)83 Reported the first clinical application in
western literature of mandibular lengthening by gradual distraction in
patients with hemefacial microsomia and Nagers syndrome. Since
the there has been explosion of reports in the litratureon distraction
osteogenesis in the craniofacial skeleton.
Kojimoto et al. (1988)84 implanted an ortho fix attibiofibular
junction in rabbit and found that removing periosteum could obviously
affect callus formation, suggesting that periosteum is important for
DO even more important than corticotomy. Another study also
supported this finding, G. A. Ilizarov (1989)85.
The main indication for alveolar distraction in implant rehabilitation
is vertical augmentation of the ridge with a minimum of 6–7 mm

52
remainingbone height above the vital anatomic structures and at least
a 4 mm vertical defect when measured from adjacent bony walls
(Bradley S et.al 2003)86. The length of edentulous zone should
include three or more missing teeth.
In extremely atrophic areas, an onlay bone graft was performed
initially, and vertically distracted after 4 months of healing period. In
moderate horizontal atrophy situations, the distraction is performed
first followed by an onlay bone graft. If secondary grafting is not
necessary in case of mild atrophy, implants are usually placed at the
time of distractor removal, minimizing the resorption.

53
odified implant designs for specific conditions
Mini implants:
Mini-implants were first introduced in the literature as the
‘‘Miniplant’’ by Barber and Seckinger, in 1994 with an external
connection. This study was followed by Sendax (1996)87 who
considered the ultra-small single piece implant. The primary intention
was to support an interim prosthesis, as it was expected these
implants would be easily removed. However, it was noted that
removal of these implants from the bone was difficult as they
appeared to have osseointegrated. Histologic studies later confirmed
that bone appeared to be integrated to the surface of the ultra-small
implant at the light microscopic level, and the bone appeared to be
mature and healthy.
Available implants vary in diameter from 1.8 mm to 7 mm. The
mini- implant is a dental implant that is fabricated with a reduced
diameter (less than 3 mm) and a shorter length but with the same
biocompatible material as compared with standard dental implants.
Mini implants present a reduced diameter (less than 3 mm) while
narrow/conventional diameter implants typically have a diameter
greater than 3 mm. Therefore, the use of mini-implants to retain over
dentures enables the use of less complex surgical techniques since
the reduced diameter of the implant permits its placement in areas
with low bone thickness.
These implants are associated with high survival rates, favorable
marginal bone loss and increased satisfaction and quality of life of
patients. The quantity and quality of bone tissue available in the jaw
typically define the characteristics (diameter and length) and the
number of implants.

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 Bertil (2000)88 has recommended the use of mini-implants
(preferably threeimplants) in clinical situations with vertical height of
5–8 mm and width of 4–5 mm to support a posterior maxillary fixed
prosthesis.

Todd Ellis Shatkin et al. (2012)89: Conducted a retrospective

analysis of 5640 mini dental implants placed into 1260 patients
over a 12-year period. The mean length of follow-up was 3.5 years.
The implants placed supported removable (2319) and fixed
prostheses (3321) with placement in the maxilla (3134) and mandible
(2506). The overall implant survival was 92.1%. Failures of implants
(445) were attributed to mobility of the implant; the mean time to
failure for these implants was 14.4 months. The small size of these
implants has led to the development of techniques that enable
placement and use in a short amount of time for both the doctor
and patient. The high rates of success show that mini dental implants
are suitable for use in supporting fixed and removable prosthetics.
Bulard RA et al. (2005)90 A previous study by the primary author
of 2514 mini dental implants placed in the mandible and maxilla
reported an average overall implant survival rate of 94.1%.3 In a
multi-clinic evaluation of mini dental implant use in denture
stabilization, Bulard and Vance reported similar results with
approximately 90% success rates.

Gowri Sivaramakrishnan et al. (2017)91 Conducted systematic

review and meta-analysis to compare conventional implant over
dentures to mini- implant- retained over dentures as regards to
patient satisfaction. Electronic databases were searched for eligible
studies data required were extracted. Four studies were included for

55
the review and two for meta-analysis. Two studies in 177 patients
comparing quality of life with mini or standard diameter implants
showed a pooled result of −4.76 [−6.48, −3.04] favoring the use of
mini-implants. The results for other outcomes were incomputable due
to inadequate studies. GRADE approach was used for quality oflife,
and the strength of evidence was observed to be “low”. Mini-implant-
supported over dentures had better patient satisfaction levels
compared to standard diameter implant over denture. There is
definite lack of evidence to support the use of mini-implants for over
dentures.
However, mini-implants should be considered for retaining over
denture prosthesis as an alternative treatment when standard implant
placement is not possible. Mini implants may be considered for the
rehabilitation of patients who express dissatisfaction with
conventional dentures and have limitations regarding the placement
of standard implants. They are indicated for replacement of the teeth
in a narrow ridge. Multiple implants can be used for removable full or
partial denture stabilization and are offered at a lower cost. These
can be acceptable for patients with limited economic capabilities.
Mini implants in the edentulous or partially edentulous arch are
indicated when the facial-lingual width of the bone is insufficient for
the placement of a traditional width implant. Mini implants are also
used in the anterior maxilla because of decreased palato-labial
bone width and/or insufficient inter dental space. In the atrophic
posterior mandible, insufficient buccolingual bone width is the
common indication for mini-implant placement (Marcello –
Machado RM 2018).92

56
 Mini implants should be avoided for patients who are medically
unfit for the treatment. Prospective patients must be thoroughly
evaluated for all known risk factors and conditions related to oral
surgical procedures and subsequent healing before any clinical
treatment. Contraindications include but are not limited to the
following:
Vascular conditions
Uncontrolled diabetes
Clotting disorders
Anticoagulant therapy
Metabolic bone disease
Chemotherapy or radiation therapy
Chronic periodontal inflammation
Insufficient soft tissue coverage
Metabolic or systemic disorders associated with wound and/or
bone healing
Use of pharmaceuticals that inhibit or alter natural bone
remodeling
Disorders inhibiting patient ability to maintain adequate daily
oral hygiene
Uncontrolled parafunctional habits
Insufficient bone height and/or width
Insufficient inter arch space (not always placed in the narrow
alveolar ridge)
In edentulous arches, more than two implants are usually needed
due to narrow the diameter, the unpredictability of survival, and the

57
lack of scientific understanding. Treatment of children is not
recommended until growth is finished and epiphyseal closure has
been completed.
The primary disadvantages of mini-implants for definitive
prosthodontic treatment are as follows:
The need for multiple implants because of the unpredictability
and lack of current scientific guidelines and understanding
The limited scientific evidence about long-term survival
The potential for fracture of the implant during placement
Lack of parallelism between implants is less forgiving because
of the one- piece design
The reduction in resistance to occlusal loading similar to
narrow diameter implants
Other disadvantages attributable to flapless surgery (when used)
such as lack of bone visibility, inability to irrigate the bone and
contraindications in situations requiring alveoloplasty to gain
prosthetic space.
Despite these disadvantages, the need for mini-implants will
continue to grow especially among edentulous patients because of
the following:
An increase in the need for complete dentures
The increased cost of standard implants
Access-to-care issues, especially among economically
disadvantaged patients and patients indicated for maxillofacial
prostheses
Medically compromised patients who may not be candidates
for traditional surgical procedures or ridge augmentation

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 procedures
Increased interest in implant dentistry among general dentists.
Therefore, the current evidence must be reviewed and synthesized
with the available clinical data on the survival of mini-implants for
definitive prosthodontic treatment.
Though mini-implants were first introduced over 15 years ago, no
studies compared the mini-implants with standard dental implants for
rehabilitation of complete edentulism. But the evidence for short-term
survival of mini-implants used for partial edentulous situations is
encouraging with a first year interval survival rate of 94.7 %.
However, the follow-up period of several implants was reported to
be 12 months. Limited evidence for the medium-term survival and no
evidence for the long-term survival of mini- implants for definitive
prosthodontic treatment are available in the literature.
Short Implants:
Short implants showed increased failure rate in comparison to
longer implants. With the improvements in the surface topography of
implants, which increase the bone implant contact and use of
adapted surgical protocols similar survival rates as that of regular
implants have been reported even with short implants. Various
methods to increase the functional surface area and decrease the
stress on the prosthesis have greatly contributed to the increased
success rate of short implants.
When stress is applied to the natural tooth, it is distributed in to the
underlying bone along the entire root length due to the presence of
periodontal ligaments as the tooth tends to pivot around the center of
the root. However, in case of implants, where periodontal ligament is

59
absent, the greatest magnitude of stress concentration is seen at the
crest which tapers apically up to 5 mm from the crest.
Stress concentration in the apical region is much less (Lum LB
1991)93. Most endosteal dental implants are fabricated from alloyed or
pure titanium with a modulus of elasticity (stiffness) approximately 5
times greater than dense cortical bone. A basic mechanical principle
states that when two materials of different moduli of elasticity are
placed together with no intervening material and one is loaded, the
stress concentration can be observed where the two materials first
come into contact (Von Recum A 1986)94. These stress contours
form a v-shaped or u-shaped pattern, with greater magnitude near
the point of first contact, which corresponds to the crest of the bone
(Shigley JE 1989)95. The phenomenon of higher crestal stresses next
to the implant is confirmed in photoelastic and two- dimensional or
three-dimensional finite element analysis (FEA) studies when an
implant is placed within a bone simulant and loaded (Bidez MW
1992, Sevimay Met.al2005)96,97.
Increase in implant length will increase the total surface area of the
implant and improve the primary stability by increasing the bone
implant contact (BIC). But the area that transfers the compressive
and tensile loads to bone i.e. functional surface area (FSA) is
confined to the crestal 5-7 mm. Increasing the length of the implant
will not change this where as a short implant with a wider
diameter provides both, improved primary stability and increased FSA
(Mish 1999)98.
There is no consensus in the literature on the definition of a short
implant. Various authors have used different lengths of implants as

60
short implants. Earlier studies considered 10 mm as standard length
for implants and anything less than that as short implants. Renouard
and Nisand defined short implants as an implant with a designed
intra bony length of 8 mm or less (Renouard F& Nishad 2006).99
6th European consensus conference of European Association of
Dental Implantologists in 2011 approved the classification of implants
given by Olate et al. which states, implants are usually referred to
as short if their length measures <8 mm, 9-13 mm in length as a
medium and long implants are usually understood to be over 13 mm
in length (Olate S et.al 2012)100.
The main advantage of using short implants is that it simplifies the
implant surgery by avoiding the more invasive procedures like bone
grafting, sinus lifting, nerve repositioning, etc., and thus decreases
morbidity and reduces the healing period.
Advanced imaging modalities may not be required which will
reduce the radiation exposure. Patient acceptance will be more as it
avoids the need for complicated surgeries, reduces the duration of
treatment period and cost.

Jonas Lorenz et.al (2019)101 Conducted a retrospective study to

evaluate weather a reduced implant length has any impact on implant
success and peri- implant hard and soft tissue health in implants
placed in posterior maxilla to avoid sinus augmentation procedure.
Fourteen patients received a total of 30 implants of 7-mm length in
the posterior maxilla. Implants with a mean loading period of 5years
were followed up clinically and radiologically, with a focus on the peri-
implant soft tissue parameters probing pocket depth (PPD), bleeding
on probing (BOP) and the stability of the marginal peri-implant bone

61
level. Results showed no loss of implants and no technical failures. A
mean PPD of 2.5mm, a mean BOP of 13.3%, and a mean marginal
bone loss (MBL) of 0.5mm indicate healthy peri- implant hard and soft
tissue conditions without signs of peri-implantitis. The present results
indicate the suitability of implants of 7-mm length to replace missing
teeth in the posterior maxilla. An unfavorable implant-crown ratio or
reduced bone-implant contact length seems to have no negative
influence on midterm implant success or on peri-implant hard and
soft tissue health.
In a systematic review, Lemos et al. compared short implants with
a length of 8mm or less to standard implants (larger than 8mm)
placed in posterior regions of the maxilla and mandible. The authors
reviewed 13 studies with a total of 1269 patients who had received a
total of 2631 dental implants. Short implants showed marginal bone
loss, prosthetic failures, and complication rates similar to those of
standard implants. Therefore, short implants have been considered a
reliable treatment for posterior jaws, especially in patients who
require complementary surgical procedures (Lemos CA et al.
2016).102
Though the literature reports predominantly satisfying results,
further performance of prospective multicenter studies with high
scientific evidence seems to be important to overcome the continued
concerns about increased technical and biological susceptibility.
Earlier clinical trials have shown conflicting reports regarding the
treatment outcome and long-term survival of short implants. However,
recent clinical trials have shown that success rate of short implants is
comparable with that of regular implants (Kotsovilis S et al. 2009,
Romeo E et al. 2010, Misch CE et al. 2006)103,104,105. This difference

62
was due to the various methods they adopted to overcome the above
mentioned shortcomings of the short implants. This includes
modification of implant characteristics and biomechanical
considerations for stress reduction.
Reduction of the implant surface area is one of the presumed
reasons for the lower survival rate of short implants which will lead to
less bone to implant contact after osseointegration. The functional
forces after loading will be transferred to the crestal bone through this
reduced surface of force distribution, which will lead to crestal bone
loss. Compromised crown to implant the ratio is thought to be another
problem, which will affect the success of the treatment. The poor
quality of bone in the posterior region, especially in the maxilla, where
short implants are mostly used is another contributing factor.
Inclined / Tilted Implants:
Implants were first introduced in the early 1990’s. Implants were
originally tilted in a bodily fashion to bypass certain anatomical
structures that otherwise hindered clinicians from placing them in
areas such as the maxillary sinus, inferior alveolar nerve canal and
the mental foramen (Tahmasebi S & Nicopolous C 2015)106.
In addition to bypassing the anatomical constraints, the tilting of
posterior implants in a distal manner results in an increase in the
length of the prosthetic table thereby allowing better load distribution
and reducing the cantilever length. (Tahmasebi S & Nicopolous C
2015)106.
Tilted implants feature 12°, 24° or 36° correction angles which
allow for implant placement into existing native bone without time

63
consuming and painful bone grafting augmentation procedures.
(Tahmasebi S & Nicopolous C 2015)106.
While using tilted implants along with the angulated abutments the
fixture platform emerges in an optimal esthetic angle and relatively
parallel to other implants in the arch thereby allowing the fabrication of
screw retained full arch restorations. Subsequently the use of
cements and costly angled abutments is eliminated (Cavalli N et al.
2012)107.
Tilted implants were useful in the treatment of edentulous jaws
avoiding the bone augmentation procedures and the involvement of
anatomical structures during surgery. However, tilting of distal
implants in full-arch rehabilitation allows to reduce cantilever length
and to augment the antero-posterior distance between the most
anterior implant emergence and the most posterior ones with several
prosthetic advantages (Candell E et al. 2012)108. Surgical
complications during implant placement in posterior region such as
bone resorption, poor bone quality, jaw shape, location of mental
foramen or loop of alveolar nerve, presence of sinus, mandibular
nerve and canal associated with maxilla and mandible can be taken
care of (Krekmanov L et al. 2000)109.
Rationale of tilted implants
To achieve primary implant stability (35 to 45 Ncm inser tion
torque) (Taruna m et al. 2014)110.
Indicated with a minimum bone width of 5mm and minimum
bone height of 10mm from canine to canine in maxilla and 8mm in
mandible.
If angulation is 30º or more, the tilted implants can be splinted.

64
 For tilted posterior implants, the distal screw access holes should
be located at the occlusal face of the first molar, the second premolar
or the first premolar.
Improved masticatory functions in terms of chewing efficiency
and bite force (Taruna m et al. 2014).110
Advantages of Tilting Implants:
Stability in minimum bone volume: Longer implants can be used in
minimum bone volume with advantage of increasing bone-to- implant
contact and reducing the need for vertical bone augmentation.
Results are better.
Need for bone grafting is eliminated.
Can be performed in patients with systemic diseases which
are contraindicated for bone grafting.
The angulations allow avoids impingement of anatomical
structures
Biomechanical advantage in using tilted distal implants
rather than distal cantilever units.
Reduce the length of cantilevers without performing bone
grafting or sinus lifting.
Alternative to maxillary sinus floor augmentation procedures.
Distally tilted implants induced better loading transmission.
Difference between tilted and non-tilted implants.

65
66
mplant Design
This tapered body tilted implant is available in 12°, 24° and 36°
degree built in angle ranging in 4,5, 6 mm diameter and 8.5mm to
18mm in length. It is currently available in the external hex, Trihex
and internal octagon connections. In extreme cases for even higher
angle correction, the Co-Axis implant can be combined with a 17° or
even the 30° angled abutment.
The angled direction indicator inserted into the osteotomy site and
the axis is checked regarding the access hole position for screw
retention as well as for parallelism with other implant fixtures.
Based on tooth and cephalometric analysis, the angulated implant
was designed as follows
5mm restorative interface.
12º angulation from long axis.
Reduced pitch of thread which allows 0.5mm apical movement
per placement rotation. This ensures that placement depth is
controlled by less than 0.5 mm.
Implant length will range from 10 mm-18 mm.
Taper ranges from 8.2º (10 mm implant) to 3.6º (18mm
implant).
This allows for a total angulation discrepancy from available
buccal maxillary cortex to screw access ranges from 30º (10 mm)
to 25.6º (18 mm). Placement is affected by means of an angular
correct fixture mount marked to assist with the correct
orientation.
Bellini et al. 111 investigated the stress patterns at the bone-
implant interface of tilted implants using three-dimensional finite

67
element analysis and found that the numerical values of compressive
stress were lower in the tilted implant configurations. He also found
that tilting of the implants reduces the cantilever length by increasing
the inter-implant distance. This may have produced a better load
distribution, thereby reducing the stress level of the splinted
implants. As a result, a biomechanical advantage is gained by using
the tilted implants.
Menini et al112 has systematically reviewed 1,623 implants placed
in the maxilla of 324 patients. Of these, 778 implants were tilted. The
overall weighted cumulative success rate was reported as 98.62 %.
They have suggested the use of tilted implants for full-arch
immediate loading rehabilitations of the maxilla with a favorable
short-term prognosis.
Disadvantages of tilted implants.
Technique sensitive procedure.
Surgeon need to be very skillful.
Computer guided surgical stent required for implant to be
placed in desired angulation.
Not even slight change in angulation can be done.
Long term studies are not available (Asawa N et al.
2015)113.

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ygomatic Implants
Efforts have been made to pursue alternatives to grafting
procedures. The pterygomaxillary suture has been identified as an
alternative site for implant placement (Fernandez Valeron J, et al.
1997)114. Others have suggested the use of tilted and/or short
implants to avoid the need for sinus lift procedures (Aparicio C
2010)115. During the last two decades, the zygoma implant has
proven to be an effective option in the management of the atrophic
edentulous maxilla, as well as for maxillectomy defects (Higuchi KW
et al. 2012)116. The Branemark zygoma implant was introduced for
the prosthetic rehabilitation of patients with extensive defects of the
maxilla caused by tumor resections, trauma and congenital defects
(Branemark PI 2004)117. The bone of the zygomatic arch was used
for anchorage of a long implant, which, together with conventional
implants, could be used as an anchor for episthesis, prosthesis
and/or obturators. The technique has enabled sufficient rehabilitation
of these patients, providing restored function and improved esthetics
and has given many patients back a normal social life.
After their initial clinical use in patients with neoplastic disease, the
indication of zygomatic implants was expanded to completely
edentulous patients with severe maxillary atrophy. Since then, the
main indication for zygomatic implants posterior maxillary support in
patients who are completely edentulous with significant sinus
pneumatization and severe posterior alveolar ridge resorption has
remained unchanged. For the most common indication, the
zygomatic implants are combined with two to four anterior maxillary
axial implants. Contraindications to the use of zygomatic implants
include acute sinus infection, maxillary or zygoma pathology and

69
patients who are unable to undergo implant surgery because of
underlying uncontrolled or malignant systemic disease. Relative
contraindications include chronic infectious sinusitis, the use of
bisphosphonates and smoking more than 20 cigarettes a day. Any
pathology of the maxillary sinus should preferably be treated before
placement of the zygomatic implant.
Once the clinical examination is complete, radiographic
examination allows for further appropriate treatment planning of the
zygomatic implant (Once the clinical examination is complete,
radiographic examination allows for further appropriate treatment
planning of the zygomatic implant (Gr€ondahl HG 2012)118.
Computed tomography is crucial for evaluation of the zygomatic
implant site and the sinus status, as well as for the implant path. The
amount of bone in the zygomatic arch and in the residual alveolar
crest has to be explored. The angulation, expected emergence site
and the relationship of the implant body to the maxillary sinus and the
lateral wall are also considered. With the original technique, the path
of the zygomatic implant was inside the maxillary sinus. The
emergence of the head of the implant in the alveolar crest (typically in
the palatal aspect of the second premolar region) is dependent on the
spatial relationship of the zygomatic bone, the maxillary sinus and the
alveolar crest. As discussed later, a new technique that includes the
possibility of extra-sinus passage of the implant has been
introduced, with promising results. Computed tomography is crucial
for evaluation of the zygomatic implant site and the sinus status, as
well as for the implant path. The amount of bone in the zygomatic
arch and in the residual alveolar crest has to be explored. The
angulation, expected emergence site and the relationship of the

70
implant body to the maxillary sinus and the lateral wall are also
considered. With the original technique, the path of the zygomatic
implant was inside the maxillary sinus. The emergence of the head of
the implant in the alveolar crest (typically in the palatal aspect of the
second premolar region) is dependent on the spatial relationship of
the zygomatic bone, the maxillary sinus and the alveolar crest. As
discussed later, a new technique that includes the possibility of extra-
sinus passage of the implant has been introduced, with promising
results.

According to Bedrossian et al. (Bedrossian E. 2010)119 the maxilla

can be divided into three zones:
the premaxilla; zone
the premolar area; and zone
the molar area.
The clinician should determine the availability of bone in all three
zones. Cone beam computed tomography can be used to determine
the amount of bone in these zones as well as in the zygomatic arch,
in both horizontal and vertical dimensions. Moreover, any pathology in
these areas, as well as in the maxillary sinuses, needs to be verified
pre-operatively. In the presence of adequate bone in zones 1 and 2
the clinician can consider the use of four to six conventional implants,
tilting the most distal one on each side to achieve good load
distribution. As such, one can bypass the need for bone grafting. The
anterior extent or position of the sinuses, as well as the slope of the
anterior sinus walls, determine both the most posterior position of the
distal implant as well as its angulation. This unless the pterygoid
region is used, ultimately impacts the most distal extent of the
prosthesis.

71
The general guidelines for zygomatic implants (Lesley D et al.
2012)120are as follows.
Adequate bone in zone 1 for two to four axial implants and
bilateral lack of bone in zones 2 and 3. Typically, two to four
conventional implants are distributed in the anterior maxilla
plus one zygomatic implant on each premolar/molar side.
Adequate bone in zone 1 and lack of bone in zones 2 and 3 on
only one side. One single zygomatic implant is placed and
conventional implants are placed on the anterior maxilla and
on the side opposite the zygomatic implant.
Inadequate bone in zone 1 and adequate pristine bone in
zones 2 and 3. An anterior zygomatic implant, together with
posterior conventional implants, can solve the problem.
Lack of bone in all three zones of the maxilla. Four zygomatic
implants can be used for the rehabilitation.
Inadequate bone in zones 1, 2 or 3 in a partially edentulous
patient. The placement of three implants to support a partial
prosthesis is recommended. Use of a zygomatic implant in
partially edentulous patients requires more clinical validation
before widespread use can be advocated.
A rescue solution for patients in whom either conventional
implants and/or the maxillary bone augmentation procedure
have failed.
A rescue solution for patients in whom either conventional
implants and/or the maxillary bone augmentation procedure
have failed.

72
 Treatment recommendations based on the presence of bone in the
different zones of the maxilla (Bedrossian E. et al. 2010)119

The original Branemark customized zygoma fixture was designed

to be inserted from the palatal aspect of the resorbed maxilla in the
region of the second premolar, through the maxillary sinus into the
compact bone of the zygoma. Initially, it had the characteristics of a
conventional implant but with increased length and diameter.
It was a self-tapping titanium implant with a machined surface and
available in lengths of 30–52.5 mm (Aparicio C, et al. 1993)121. The
threaded apical part had a diameter of 4 mm and the crestal part had
a diameter of mm. The implant head was provided with an inner
thread for connection of standard abutments. Later on, the implant
head was angulated to 45° (Branemark Pi et al. 2004)117. In today’s
fixture the surface has evolved to a moderately rough oxidized
threaded surface and the head includes an implant driver screw that
remains inside the implant, offering an inner thread for the connection
of special ‘zygomatic’ abutments. Currently, zygomatic implants are
commercially available from at least three different companies that
offer implants with an oxidized rough surface, a smooth mid-implant

73
body, a wider neck at the alveolar crest and a 55° angulation of the
implant head.
According to the original protocol, surgery was carried out under
general anesthesia with nasal intubation. A sealing throat pack and a
gastric tube were used in each patient. Afterwards, local anesthetic
was infiltrated with injections of lidocaine with epinephrine (1:50.000
to block the superior alveolar nerves (posterior, middle and anterior)
and the palatal nerves (posterior and nasopalatal).
The epinephrine helped to create a regional hemostasis. Hospital
based surgery was strongly recommended for those patients.
Recently, the protocol has been simplified with the use of local
anesthesia and oral or intravenous sedation (Aparicio C et al.
2008)122. This procedure is recommended if the surgeon is
experienced and the procedure is expected to last for <1.5 h. The
local anesthetic procedure includes the simultaneous use of four
different local anesthetic approaches, as follows:

Normal infiltration anesthesia (1:50.000

epinephrine) in the buccal sulcus from the central
incisor to the third molar tooth using lidocaine with
1:50.000 epinephrine (about 3.6 ml) and block of the
posterior superior alveolar nerve about 1 cm palatal to
the bone crest.
Infra-orbital nerve block by an oral approach using
lidocaine (1:50.000 epinephrine) or felypressin with
about1.8 ml of prilocaine.

74
 Block of the sphenopalatine ganglion through the
greater palatine foramen using lidocaine (1:50.000
epinephrine) or felypressin with about 1.8 ml of
prilocaine.
Infiltration anesthesia around the zygoma area
through the skin using about 3.6 ml of lidocaine
(1:50.000 epinephrine).
After an initial period during which a vestibular Lefort II type
incision is used, the current protocol attempts to expose the area via
a mid- crestal incision and vertical releasing incisions along the
posterior part of the infra-zygomatic crest and anterior to the surgical
site. The vertical ridge/ anterior border of the zygomatic arch is
always identified.
A second landmark is the lateral orbital border, as interference with
the orbital must be avoided. Subsequently, a mucoperiosteal flap is
raised, exposing the central/posterior part of the zygomatic
complex, the lateral wall of themaxillary sinus and the alveolar
crest. A retractor is positioned for visibility and to protect the soft
tissues. An indicator is used to determine the drilling direction and the
starting point at the crest, usually the second premolar/first molar
region. A bone window around 10 mm wide, is created at the lateral
aspect of the maxillary sinus following the desired path of the
zygomatic implant from the sinus floor to the top of the sinus cavity.
The sinus membrane is carefully dissected, freed from the sinus walls
and placed inthe sinus cavity. A series of drills is used to penetrate
the alveolar process and the zygomatic bone. The estimated length of

75
the zygomatic implant is selected using a depth gauge. The self-
tapping zygomatic implant is placed with the aid of a motor or
manually using an implant mount. Care should be taken not to
enlarge the palatal hole during insertion, which is especially important
in patients with thin alveolar/basal bone. If needed, bone particles
harvested locally can be packed around the implant in an effort to
diminish an eventual gap between the implant surface and the
palatal bone. A cover screw is placed on the implant and the
mucoperiosteal flap is closed. Abutment connection is usually made
after a healing period of 6 months, using standard or
straight/angulated multiunit Branemark abutments.
In patients with pronounced buccal concavities on the lateral
aspect of the maxillary sinus, the use of the original technique with an
intra-sinus path results in excessive palatal emergence of the implant
head. This commonly results in a bulky dental bridge at the palatal
aspect, which sometimes leads to discomfort and problems with oral
hygiene and speech (Al- Nawas B et al. 2004, Becktor JP 2005,
Boyes Varley JG 2003)123,124,125. In order to use an anatomically and
more prosthetically driven approach, the original technique has been
modified by allowing an extra-sinus path for zygomatic implants
(Aparicio C et al. 2010, Malo P et al. 2008, Peñarrocha M et al
2007)115,126,127. The authors have been working with a concept called
the zygomatic anatomy-guided approach (ZAGA) (Aparicio C et al.
2011)128. A modification of the original zygomatic implant technique
that focuses on interindividual anatomic differences. The preparation
of the implant site is now guided by the anatomy of the area, and no
initial window or slot is opened at the lateral wall of the maxillary
sinus. Thus, depending on the relationship between the zygomatic

76
buttress and the intra-oral starting point of the zygomatic implant, the
path of the implant body will vary from being totally intra sinus to
being totally extra-sinus. In other words, the new approach
mentioned for the placement of the zygomatic implant is neither
‘internal’ nor ‘external’ to the sinus wall but instead promotes the
placement of the zygomatic implant according to the anatomy of the
patient.
Postoperative cone beam computed tomography images and
clinical intra- surgery photographs of 200 sites corresponding to 100
of the 177 patients treated, between April 2005 and December 2010,
with zygomatic implants using the referred anatomy-driven prosthetic
approach (i.e. the zygomatic anatomy guided approach) were
reviewed by an independent investigator with regard to the anatomy
and the pathway of the zygomatic implant body. Of special interest
was the morphology of the lateral sinus wall, the residual alveolar
crest and the zygomatic buttress. As a result, five basic skeletal forms
of the zygomatic buttress– alveolar crest complex and subsequent
implant pathways were identified. Accordingly, a classification system
comprising five groups, namely ZAGA 0–IV was proposed. It is
believed that the proposed system is useful for classifying zygomatic
implant patients for therapy planning and for scientific follow-up
purposes. Placement of the long implant following the ZAGA
principles optimizes support provided by the bone, even at the level
of the maxillary wall, which is critical in a patient suffering from
extreme bone atrophy. The implant itself seals the wall osteotomy,
which minimizes the risk of sinus contamination. Moreover, the
clinician will be able to use the available crestal bone, allowing also

77
for bone integration at the implant body and neck level in most
ZAGA types.
The zygomatic implant has an increased tendency to bend under
horizontal loads (Darle C et al. 2000)129. This is related to two
factors: the greatly increased length of these implants (30–52.5 mm)
and the fact that insome circumstances there is limited or no bone
support in the maxillary alveolar crest. Consequently, these implants
have to be rigidly connected to stable conventional implants in the
anterior maxilla. Based on clinical experience and biomechanical
theoretical calculations, a full-arch restoration of the maxilla,
supported by two zygomatic implants (one on each side), should be
assisted by at least two stable conventional implants in the anterior
maxilla (Brunski John B et al. 2012).130The prosthetic procedure
follows conventional protocols. As the emergence of the zygomatic
implant is often 10–15 mm medial to the ridge, the bridge should be
designed to enable proper oral hygiene in the area. Originally, a two-
stage procedure was recommended for the zygoma technique
(Branemark PI et al. 2004).117 However, over time, the original
protocol has been replaced with immediate loading (Bedrossian E et
al. 2006,Chow J et al. 2006).131,132 Several clinical reports have
shown good outcomesfollowing immediate/early loading of zygomatic
implants in thetotallyedentulous maxilla (Ostman PO et al. 2005,4
Tarnow DP et al.1997)133,134. For instance, Ostman et al. was able to
establish a treatment concept for immediate / early loading of dental
implants
(Ostman Po et al. 2008)135 and in a zygoma study (Ostman Po et
al. 2005)133 reported the lossof only one (0.8%) of 123 implants in 20

78
patients after 1 year. Bedrossianet al. reported no losses of 28
zygomatic and 55 conventional implants in14 patients after more
than 12 months.
In another study, Davo et al.(Davo C 2007)136 lost none of 36
directly loaded zygomatic implants, but lost three of 68 conventional
implants, after a follow up period of 6–29months. Although the
available studies are short term, the findings showthat
immediate/early loading is a viable treatment modality also
whenzygomatic implants are included in the treatment. Moreover, it is
reasonable to believe that any negative effect from immediate/early
loading per se should be seen soon after commencing loading and
not after a prolonged period of time.
The provisional prosthesis is extremely important for patients
treated with zygomatic implants. The goals for such prostheses are to
provide acceptable esthetics as well as masticatory and speech
function during the healing process, and also to explore the
occlusal and esthetic position of the teeth and soft tissue substitutes
(Davo C et al. 2007, Duarte LR 2007)136,137. The routine option for
both provisional and finalprostheses is to develop a screw-retained
structure that can easily be removed in the event of complications.
For this purpose, the surgeon must analyze the type of resorption
in relation to the opposite dentition and provide an implant head
with an adequate abutment type in length and angulation. The
angulation of the abutment will be critical, not only forpositioning the
screw emergence on the palatal/occlusal surfaces but also for
determining the final thickness of the prosthesis. As stated in our
previous work, the construction of the prosthesis starts at surgery.
In fact, during implant placement the surgeon must provide the

79
correct implant inclination in relation to the antagonist dentition. At
present, the head of the zygomatic implant can be positioned more
accurately by observing the screw locking the implant mount to the
implant. The screw position duplicates the future abutment screw
position exactly.
The use of multiple zygomatic implants (e.g. two to three in each
side) to support a prosthesis was suggested by Bothur et al.
(2003)138. Despite numerous publications with positive long-term
outcomes, there are no randomized controlled trials comparing their
clinical effectiveness with alternative means for rehabilitating patients
with atrophic edentulous maxillae (Esposito M et al. 2005)139.
Moreover, there are few published prospective long-term studies
that endorse this technique. Currently, there are no well-defined,
specific criteria that help the clinician to evaluate the success of a
zygomatic-supported rehabilitation.
Zygomatic implants serve to be a very novel procedure for
atrophic maxilla. However, the complexity of procedure, experience
required, use of general anesthesia, makes it a procedure which will
take time to be used routinely. A procedure, comparatively easier and
less complex as compared to zygomatic implants led to introduction
of pterygoid implants.

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terygoid implants:
The use of pterygoid implants was described by
Tulsane JF in 1992 and was subsequently used by many other
researchers. One of the most important reasons and advantages for

the use of pterygoid implants is the elimination of the need for sinus
lift surgeries or bone grafts, thereby decreasing the associated
morbility as well the treatment time, as it has been proved that the
osseointegration of such implants can occur in only 2 to 3 months.
Unlike maxillary tuberosity implants, pterygoid implants anchor in
cortical bone, allowing a better primary stabilization which is known to
be a critical factor for long-term success. Bicortical stabilization of the
implants reduces implant micromotion during osseointegration and

enhances the implant survival rate (Fuh et al. 2010,7 Pancko et al.

2010).8,9 From a prosthetic viewpoint, it can minimize the time unto

rehabilitation, bypass the need for a distal cantilever as well as allow

for immediate prosthetic loading, if indicated (Bidra AS et al. 2011)6.

Maxilla is different in its function, physiology, and bone density

from the mandible. These differences, along with its varied anatomy,
challenge the implant placement in harmony with planned prosthetic
restoration. However, a thorough knowledge of various augmentation
procedures, materials and proper patient selection will result effective
long- term solutions in the management of the atrophied maxilla. By
analyzing these augmentation procedures it can be concluded that,

81
 The atrophic posterior maxilla should be evaluated and classified
not only in terms of residual bone height and width, but also vertical
and horizontal inter-maxillary relationships to optimize implant
placement from a functional and esthetic point of view.
Despite the limitations discussed, reconstruction of atrophic maxilla
with bone grafts is an acceptable treatment modality to restore with
implant- supported prostheses, taking into account of its higher
morbidity rate.
For posterior atrophic areas, where esthetics is not a prime
concern, contemporary treatment options such as zygoma implant,
pterygoid implant, tilted implant, mini-implants can be the treatment of
choice taking into account that they may result in a prosthetic and
functional compromise.
However, the use of mini-implants should not be considered in
severely atrophied edentulous maxillae and should be limited to mild-
moderate atrophic situations.
Pterygoid implants have high success rates, similar bone loss
levels to those of conventional implants, minimal complications and
good acceptance by patients; therefore, they constitute a reliable
alternative for treating patients with atrophic posterior maxilla.
Taking into account the favorability of pterygoid implants in
atrophic posterior maxilla, implants placed in pterygomaxillary region
will be reviewed in detail.

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 Anatomical Consideration of Pterygoid Plate for
Placement of Implant

The loss of superior posterior teeth and the consequent alteration

of the occlusion can lead to occlusal instability, deficiencies in the
masticatory function and local bone loss, among other results
(Araugo M et al. 2010)1. When treating long-term edentulous
patients, the surgeon may face a situation in which pneumatization of
the maxillary sinus, resorption of the alveolar bone and insufficient
osseous density occur together. The placement of implants in the
posterior maxilla can become a challenge due to, among other
factors, the poor osseous quantity and quality of the maxillary
tuberosity (Tulasane JF et al. 1989)2, and it has been
demonstrated that implants have a higher propensity to fail under
conditions of low-density bone (Fischer K et al. 2009)3.
To avoid sinus lift surgeries or bone grafts, Tulasne first described
the pterygoid implants in 1989 as an alternative to conventional
dental implants. Unlike maxillary tuberosity implants, pterygoid
implants anchor in cortical bone, allowing for a better primary
stabilization, which is known to be a critical factor for long-term
success. The pterygoid implants also present some inconveniences:
the learning is convoluted compared to conventional dental implants,
access for surgeons and oral rehabilitators is complex and serious
injuries can occur in sectioning the maxillary artery or invading the
pterygomaxillary fossa (Tulasane JF et al. 1989)3. For the placement
of these implants, it is essential to have a thorough knowledge of the
anatomy involved because nearby vital structures can be injured
during surgery.

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 The aim of this chapter is to improve the knowledge of the
morphological characteristics of the pterygomaxillary region by
anatomical three-dimensional analysis to improve pterygoid implants
surgical planning and thus improve long- term success rates. Volume,
height, width and bone density of the pterygomaxillary joint were
measured to assess whether age, sex or dental status significantly
affected these variables.
The pterygoid process is the most inferior part of the sphenoid
bone. The process consists of two bone plates (medial and lateral)
that are fused anteriorly. The development of surgical techniques
using the pterygoid process as a point of bone anchorage for oral
implants has generated considerable interest in this anatomical
feature. Implant placement into the pterygoid region of the posterior
maxilla was first reported by Tulasne 19892.

Fig: 20 -Occlusal view of the posterior maxilla showing the pyramidalprocesses of

the palatine bone and contiguous bony structures. GPF - Greater Palatine
Foramen,LPF - Lesser Palatine Foramen, MT - Maxillary Tuberosity, M 2 -
Second Molar,OP - os Palatinum, PPP – Pyramidal Process of Palatine Bone,PTP
- Pterygoid Process of Sphenoid Bone
The pterygoid implant technique includes placement of a long
implant (up to 22 mm) through the tuberosity, pyramidal process into

84
the pterygoid plate with a distal angulation of between 35° and 55°
(Candel et al. 2012)108.

Rodriguez et al. (2014)140 studied the anatomy of the

pterygomaxillary area for implant placement in 100 patients (mean
age 52 years) using CBCT. The mean inclination of the
pterygomaxillary buttress relative to the Frankfurt plane was 72.5 ±
4.9° in the sagittal plane and 81.3 ± 2.8° in the horizontal plane,
respectively. The mean height of the pterygomaxillary buttress as
measured from the tuberosity of the alveolar bone to the most apical
point of the pterygoid apophysis was 22.5 ± 4.8 mm.
One of the most important reasons and advantages for the use of
pterygoid implants is the elimination of the need to perform sinus lift
surgeries or bone grafts, therefore decreasing the morbility and
shortening the treatment time, as it has been proved that the
osseointegration of pterygoid implants can occur in only 2 to 3
months (Tulasane JF 1992; Balshi et al. 1999)5,141. Unlike maxillary
tuberosity implants, pterygoid implants anchor in cortical bone,
allowing a better primary stabilization which is known to be a critical
factor for long-term success (Fuh LJ et al. 2010)8. From a prosthetic
point of view it can minimize the time to rehabilitation and bypasses
the need of a distal cantilever and also makes it possible to
perform, if the patient meets the indication criteria, an immediate
prosthetic load (Bidra AS et al. 2011)6.

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 Fig 21: Occlusal view of the right posterior maxilla showing the pyramidalprocess
of the palatine bone. GPF - Greater Palatine Foramen, LPF - Three Lesser Palatine
Foramina, MT - Maxillary Tuberosity, M 2 - Second Molar, PPP - Pyramidal Process
of Palatine Bone, PTP - Pterygoid Process of Sphenoid Bone.
Special attention should be paid to the internal maxillary
artery, which crosses between 10 and 23.5 mm above the
pterygomaxillary suture according to authors (Candel E et al. 2012;
Apinhasmit W et al. 2004)108,22. According to Candel et al. (2012)108,
any bleeding observed in the preparation of the pterygoid implant bed
comes from the irrigation of the pterygoid muscles and will be
controlled once the implant is inserted. When placing a pterygoid
implant, it is essential to pay attention to its proximity to the greater
palatine canal and nerve (Tulasane JF)5. There are other authors
who believe that none important anatomical structure can be injured
during the placement of these implants (Balshi TJ et al. 2013,
Graves SL et al. 1994)142,7.
Research shows that three critical factors affect osseous density
locally:
Gender (female subjects had statistically less density)
Age (density decreased as age progressed) and

86
 Dental status (edentulous patients presented an inferior
density)
In a study performed by Lee et al. (2001)48, the height of the
pterygopalatine suture has been reported to be 13.1 mm. Studies
have suggested that implants measuring 13.0 to 18.0 mm could be
appropriated to ensure an engagement in the cortical bone of the
pterygoid process (Balshi SF 2005; Rodriguez X et al. 2014).143,140
The width of the pterygomaxillary joint has been previously studied
in articles related to surgical techniques such as Le Fort I
osteotomies (Dadwal H et al. 2015145; Chin Y et al. 2017)146.
Regarding bone densities, Rodríguez et al. 2016147 reported an
average of 307.4 GSD (SD 155.9 GSD) in the maxillary tuberosity
and 632.0 GSD (SD 209.7 GSD) in the pterygoid area. Measurements
are slightly higher for both maxillary and pterygoid region (370.3
GSD, SD 71.4 GSD; and 692.4 GSD, SD 85.5 GSD; respectively)
which could be due to mean age. The bone density in the pterygoid
area was 139.2% higher than in the tuberosity area, proving that it is
an area of better choice for the anchorage of the implant head
(Rodriguez X et al. 2016)147. Ithas been proven that implants in type
I and II bone had a higher survival rate and could support sand with a
higher occlusal load for which type IV bone was unsuitable (Linetsky
I et al. 2017)148, which supports the use of pterygoid implants for the
rehabilitation of the posterior maxillae.
Dentate patients have proven to have a greater muscular strength
which develops into a mayor osseous density. A minor
electromyographic activity of the masticatory muscles is related to the
deterioration of the dental status (Gaszynska E et al. 2017; Takagi D

87
et al. 2017)149,150. Also, the middle section of the pterygomaxillary
column had a greater density along with age; the older the subject
was, the greater the density of the bone (Pearson’s correlation =
0.46, p = 0.01). This is also believed to be a result of muscular
strength (Sato H 2015)151.
The osseous density of this middle section of the pterygoid
process is important because it is one of the main sites of anchorage
of the pterygoid implants. These implants are anchored in the
pterygoid plate of the sphenoid bone, moving backwards and upwards
through the maxillary tuberosity and palatine bone (Graves SL 1994;
Bidra AS et al. 2011; Venturelli A et al. 1996)7,6,152.
It was observed that an implant placed in the pterygomaxillary area
with an angulation on 45 degrees would increase a mean of 8–9 mm
the bone to implant contact (Graves SL et al. 1994)7. As for the
angulation of the pterygoid implants with respect to the Frankfort
plane, there is no consensus. Different authors defend their
placement with an approximate angle of 45° (Graves SL et al. 1994;
Bidra AS et al. 2011; Curi M et al. 2015)7,6,153 while in more recent
studies their placement is defended at an angle of 70° (Dadwal H et
al. 2015; Chin Y et al. 2017; Curi M et al. 2015)145,146,153.

In a study developed by Rodríguez et al. 2012144, where 454

implants were placed in 392 patients, the mean angulation was 70.4°
± 7.2°. Anatomical studies support this technique: the average
inclination of the bone pillar composed of the pterygoid process and
the tuberosity of the maxilla is between 67.3° and 75.1° in relation to
the Frankfort plane (Yamaura T et al. 1998)154.

88
 This traditional angulation of the pterygoid implants has different
disadvantages, the main one being that the transmission of the
occlusal forces does not occur in an axial direction, and may
compromise the long-term result of the prosthetic rehabilitation
(Rodriguez X et al. 2012)144. An inclination of 45° decreases its load
capacity by up to 50% with respect to the same implant placed at
90° (Venturelli A et al. 1996)152. Therefore, a 20 mm pterygoid
implant with an angle of 45° would have the same occlusal loading
capacity as a 10 mm implant placed at 90° 36.
In 1992, Tulasne described a success rate of 80% (1992),
nonetheless during the past years several studies have reported a
much higher success rate, reporting from 90.7% to 99% of success
(Balshi TJ et al. 1999; Candel E et al. 2012; Valeron JF et al.
2007)141,105. These implants are proven to compensate for the
posterior maxilla’s poor osseous quality by anchoring themselves to
the pterygoid process’s cortical bone (Tulasane JF et al. 1989; 1992;
Wang F et al. 2017).2,5,156.

Loss of the dental implants is related to low-primary stability, which

is at the same time related to bone density (Goiato M et al. 2014)157.
It has also been shown that increasing dental implant length plays a
fundamental role in increasing dental implant primary stability
(Bataineh A et al. 2017)158.
The survival rate of pterygoid implant is high (97.86% in a 36-
month follow-up period), according to the systematic review by Goiato
et al. For the placement of these implants, it is imperative to have a
thorough knowledge of the anatomy involved because nearby vital
structures can be injured during surgery. Special attention should be

89
paid to the internal maxillary artery (Tulasane JF et al. 1992; Candel
E et al. 2012; Apinhasmit W et al. 2004; Suzuki M et al.
2016)5,108,22,159.
Pterygomaxillary region morphology has a wide range of variation
between individuals, and every time a pterygoid implant is planned to
be placed in this area, a personalized pre-surgical radiological
assessment should be performed. Various factors such as:
Dental status (edentulous patients presented an inferior
density)
Age (density decreased as age progressed) and
Gender (female subjects had statistically less density)
have an impact on bone density in the pterygomaxillary region.
Nevertheless, it has been shown that the bone density of the
pterygoid process is always greater than the bone density of the
maxillary tuberosity and therefore, it should be the choice for implant
anchoring in atrophic maxillae.

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 HISTORY

Implant dentistry has growing leaps and bounds in recent years

after the successful introduction of osseointegration concept by
Prof. P.I Branemark in the early 1960s. Rehabilitation of the maxillary
anterior region has been far easier than the maxillary posterior region
due to various factors. (Albrektsson T et al. 1986).160 The posterior
maxillary region is characterized by:

Inadequate residual bone height due to maxillary

sinus expansion and/or alveolar bone resorption and poor
bone density (Type III or IV) according to Lekholm and Zarb
classification system. (Cucchi A et al. 2017, Procacci P et al. 2014,
De Santis D et al. 2012)161,162,163

Considering these challenges posed by the anatomy, few

techniques have been in use such as sinus lift procedures, guided
bone regeneration grafting with bone autogenous and allogenous
grafts and later tilted implants (All-on-4), zygomatic implants were
introduced. (Balaji VR 2017)4. However, these procedures have
complications such as sinus membrane perforation, rejection of graft,
graft displacement into sinus cavities, and screw loosening of tilted
implants.To prevent such problems posterior-most area of maxillary
tuberosity; distal to maxillary sinus can be utilized for implant
placement. (Balaji VR 2017)4
Implants placed in the compact bone of the pterygomaxillary
region shows ossteogration and provides retention and stability
(Tulasane JF 1989).2 This area is pterygoid or pterygomaxillary

91
region. It was introduced by Tulasne 19925. Tulasne 19892 credited
Paul Tessier for proposing an idea of placing implants in the
pterygoid region. Due to their long path, length of pterygoid implants
ranges from 15 mm to 20 mm. (Tulasane JF 1989, 1992)2,5 Pterygoid
implants take bicortical anchorage, due to which the axial loading is
improved and posterior cantilever is eliminated. (Ali SA 2014)164
Throughout literature, several terms are being used to define
pterygoid implants. The terms “pterygoid implants,” “tuberosity
implants,” and “pterygomaxillary implants” are interchangeable.
“Pterygoid implants” have been defined as “implant placement
through the maxillary tuberosity into the pterygoid plate” by the
glossary of oral and maxillofacial implants. The maxillary tuberosity is
defined as “the most distal aspect of the maxillary alveolar process.”
(Laney WR et al. 2007, Park YJ et al. 2010, Reiser GM et al.
1998)165,166,167
Pterygoid implants are anchored in the junction of three
different bone structures: The pyramidal process of the palatal bone,
the pterygoid process of the sphenoid bone and the maxillary
tuberosity. Placement of dental implants in the pterygo-maxillary
region provides posterior bone support for the prosthesis, without
sinus floor augmentation and can achieve better distribution of
masticatory forces in comparison to conventional maxillary implants.
Hence providing promising technique for treatment of atrophic
maxilla.

Balshi et al. 1995168 reported three clinical series of pterygoid

implants.They made a preliminary study in which 51 pterygoid
implants with machined surface were placed in 41 patients, with a

92
follow-up period of 1month to 63 months. The success rate was
86.3%.
Balshi et al. 1999141 they increased the sample to 356 implants,
obtaining a cumulative success rate of 88.2%, after a mean loading
period of 56 month. Of note, most implants (41) failed at stage II
surgery before loading, and only one implant failed after loading.
Vila-Biosca et al. 1999169 compared pterygoid implants with the
sinus lift technique. The authors explained the main indications,
advantages and inconveniences of both procedures. They considered
the pterygoid implant technique to be less invasive, with a usually
shorter intervention time and interval to patient rehabilitation.

Nocini et al. 2000170 presented a clinical case in which they

described the placement of pterygomaxillary implants using modified
osteotomes. A handle tilt angle of 20 degrees allowed better
osteotome adaptation to the anatomy of the oral cavity, reducing the
risk of damaging the lips or cheek mucosa and facilitating the work of
the dental surgeon. The authors considered the main advantage of
these osteotomes with respect to drills to be the lesser risk of
damaging the palatal artery though this affirmation has not been
clinically demonstrated.
Mateos et al. 2002171 also conducted a review of the literature on
pterygoid implants. On the other hand, they developed a protocol with
a detailed description of the technique and prosthetic procedure.

Vrielinck et al. 2003172: placed 14 pterygomaxillary implants and

had a success rate of 71%, after an average follow-up of 6 months to
24 months. The failures occurred because the implants did not follow

93
the direction of the prepared implant bed and were therefore out of
place.
Balshi et al 2005143 placed 164 pterygoid implants with titanium
oxide surfaces. After 54 month of follow-up, the success rate was
statistically significantly higher than in previous studies (96.3%). The
authors related this additional 8.1% percentage points gain in implant
survival to the change of implant surface from machined to titanium
oxide.
Pi et al. 2006173 published the results of 177 pterygomaxillary
implants in 136 patients, with a follow-up of 1-10 years. The success
rate was 97.2%. Four implants were removed in the second phase
and one was removed due to fracture after three years of loading.

Ridell A et al. 2007174 Conducted a study to retrospectively

evaluate the survival rate and marginal bone conditions at fixtures
placed in the tuber region of the maxilla in 21 patients previously
treated with at least 1 implant in the tuber region of maxilla. A total of
23 standard Brånemark System fixtures in the tuber regions and 71
implants in adjacent areas were placed to support fixed dental
bridges. Healing period of 6-8 months were given before abutment
connection and following prosthetic treatment. The patients were
radiographed after 1-12 years to evaluate marginal bone levels and
the relation between the apex of the fixture in the tuberosity area and
the posterior border of the maxilla. The mean marginal bone level at
tuber implants was situated on average 1.6 mm from the abutment-
fixture junction, whilst the other implants showed an average bone
level of 1.9 mm. The results were similar when comparing partially
and totally edentulous patients. The results showed good clinical
outcome and it was concluded that this technique can be used as an

94
alternative to more extensive surgery and especially to the sinus lift
procedure.
Balshi et al. 2013142 carried out retrospective comparison of
pterygomaxillary implant lengths to determine if there is a statistically
significant difference in the survival rates between different sized
implants placed in the pterygomaxillary region. All Brånemark System
4.0 mm diameter implants delivered into the pterygomaxillary region
were separated into 7 to 13 mm and 15 to 18 mm groups by
retrospective patient chart review. Cumulative survival rates (CSR)
were calculated. Of all implants delivered, 930 of the 992
osseointegrated for a CSR of 93.75%. Fifty-nine of the 67 implants in
the 7 to 13 mm grouping and 871 of the 925 implants in the 15 to 18
mm grouping osseointegrated for CSRs of 88.06% and 94.16%,
respectively. The results were statistically significant (P, 0.05). The
results suggest that increased implant length in the pterygomaxillary
region may result in higher osseointegration rates. The implant apex
better engages the cortical bone between the medial and lateral
pterygoid plates and therefore increases primary and secondary
stability.
Curi et al. 2015175 Conducted a retrospective study of pterygoid
implants in atrophic posterior maxilla to evaluate success rate of
pterygoid implants and prosthesis in the atrophic posterior maxilla.
Study was performed on patients with atrophic posterior maxilla
rehabilitated with pterygoid implants between 1999 & 2010 and
followed for 36 months after implant loading. Implant and prosthesis
success were considered separately following predictors were
recorded: sex, age, implant placement angulation, number & size of
implant, prosthetic rehabilitation, bone loss, date of prosthesis

95
delivery & date of last follow up. A total of 238 titanium implants were
placed in 56 patients. The 3 year pterygoid implant survival rate was
99%, prosthesis survival rate was 97.7%. The mean bone loss
around pterygoid implants after 3 years of loading was 1.21 mm
hence concluded, placement of implants in pterygoid region is
available alternative for atrophic posterior maxilla rehabilitation.
X. Rodriguez E et al 2015176 carried out cross sectional study of
202 CBCT examinations to define the 3 dimensional angulation of
pterygomaxillary corridor in which pterygoid implants should be
ideally placed & to study the bone density in tuberosity area and
pterygoid plate. 202 CBCT of atrophic posterior maxillae were
evaluated implant placement was guided by individual anatomy of
each patient. The mean implant angulation was 74.19±3.13˚ in the
anterioposterior axis & 81.09± 2.65˚ in the buccopalatal axis relative
to Frankfort plane. Density in tuberosity area ( 285.8- 329.1 DV unit)
& in pterygoid plate area (602.9- 661.2 DV units with 95% confidence
interval. The density in pterygoid area was 139.2% greater than in
tuberosity zone. Statistically significant difference were found
between tuberosity & pterygoid plates in terms of bone density.
Hence, it was concluded that implant of at least 15 mm long should
be usedin order to take advantage of quantity & quality of bone in this
region.
Alessandro Cucchi et al. 2017161 Presented a minimally invasive
approach based on pterygoid and short implants for rehabilitation of
an extremely atrophic maxilla. This surgical approach, based on the
combination of short implants in the premaxillary regions and
pterygoid implants in the pterygomaxillary regions, represents a way

96
to shorten treatment timing, minimize the risk of surgical
complications, and reduce patient discomfort and costs.

Leon Ardekian et al. 2018177 Presented a clinical report on a

series of 20 patients to evaluate the survival rate of the pterygoid
implants in a short to moderate time period. The reported survival
rates of pterygoid implants reported in this study are in the range
reported in the literature to date. They concluded that Pterygoid
implants have a high success rate, minor and infrequent
complications and similar bone loss in comparison to conventional
implants. Pterygoid implants are considered as a good alternative for
extensive augmentation procedure in patients with atrophic maxilla.

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 PTERYGOID IMPLANTS.

The insertion of pterygoid implants may be an important alternative

to bone grafting, guided bone regeneration, nerve lateralization, short
implants, or height deficient atrophic posterior jaw. Additionally, it
allows for bicortical stabilization of the implants which reduces
implant micromotion during osseointegration and enhances the
implant success rate (Pancko F et al. 2010)178.
The pterygoid implant is an axial implant placed through the
maxillary tuberosity with fixation apically in the pterygoid process of
the sphenoid bone and the pyramidal process of the palatine bone.
Pterygoid implants were first proposed by Linkow in 1975 and the
method was first described by JF Tulasne in 1992.
These implants are relatively long and specifically manufactured
with the characteristics of the pterygoid region in mind. The implant
was introduced to solve the problem of implants restoration in the
posterior maxilla due to the presence of the maxillary sinus and as a
result of limited quantity and poor quality of available bone in this
region (Candel E 2012)108. Support for pterygoid implant is derived
from the tuberosity of the maxillary bone, the pyramidal process of
the palatine bone, and the pterygoid process of the sphenoid bone
(Bidra AS 2011)6. The length of pterygoid implant ensures that the
implant can cross the mucosa (which is often thick in this region)
and engage the implant apex in the cortical bone of the
pterygopalatine suture.

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 Fig. 22: Structure of Pterygoid Implant
Pterygoid implant passes through the maxillary tuberosity and the
pyramidal process of palatine bone to engage the pterygoid process
of the sphenoid bone (Bidra AS et al. 2011; Graves SL 1994)6,7, its
length ranges from 16 to 20 mm, they have a pointed, self-tapping
apex to ensure strong anchorage when inserted. Apical engagement
into the dense cortical bone also plays a crucial role in initial implant
stability and the ability to immediate load said implant. However,
penetrating these cortical plates requires the proper implant length
(Adell R et al. 1992)52. Thus, proper understanding of the anatomical
region and identification of the dense cortical bone structures in each
patient will allow the operator to choose an implant length that will
achieve stability in the pterygomaxillary region.
Balshi et al. in 2013 found that implants in the 15 to 18 mm group
had a CSR six percentage points higher (94.16%) than and
statistically significant to the 7 to 13 mm group (88.06%). These
results suggest that longer implants, which are better able to fully
engage the cortical plates found in the pterygomaxillary region, may
play a role in increased survival rates of implants in this region.

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 The anatomy of the pterygomaxillary region favors a longer
implant. The pyramidal process of the palatine and lateral pterygoid
plate of the sphenoid are located behind and slightly medial to the
maxillary tuberosity (Tulasane JF 1992)5. To achieve the desired
stability, an implant must transverse the tuberosity for the apex to
engage the cortical plates. Implants that are placed solely in the
tuberosity usually require a wider diameter implant for more support
because there is a high presence of cancellous bone in that region
(Rieser GM et al. 1998)167. Yet, only engaging the tuberosity is not a
recommended treatment plan for achieving stability in the posterior
region.
Penetration through the cortical pterygoid plates with the implant
apex should also be considered as a proper method to achieve high
osseointegration rates. In a 1984 study, Brånemark et al. noted that
implants that encroach upon the nasal or sinus floor cause no
undesirable side effects during healing and maintain their anchorage
during load. The investigators of this report believe that similar
conclusions can be made for the pterygomaxillary region. The apex of
a Brånemark implant is narrower in diameter than the rest of the
body. As the apex is driven 1 to 2 mm through the dense plates and
exposed the implant surface area increases in the limited dense bone
that exists. Thus, the increased bone to titanium interface should
produce higher primary and secondary stabilization.
The implant neck has a wide thread profile which provides
compression in the region of the tuberosity, where the bone is often of
low density (Figure 22). Pterygoid implants have a conical shape with
compressive threads. The implants are of 3.5 or 4.5 mm diameter
with a length of 16, 18, 20 mm respectively (Figure 23).

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 Fig 23: Pterygoid Implants of different length and diameter

Morphological difference
There has been morphological difference in Pterygoid implant.
Depending on the angle of placement and length of the posterior
implant, four apical anatomic bone engagements are possible and can
be classified as follows: (Riesser GM et al. 1998)167
Tuberosity
If the anatomy of the tuberosity is favorable, a long implant can be
placed so that it is confined to this structure. Care must be taken to
avoid perforating the posterior wall of the maxillary sinus, the location
of which is determined radiographically.

The bone within the tuberosity is typically of poor quality.

Therefore, if the dimensions of this structure are favorable, implants
of wide diameter should be used. The wide-diameter implant fills a
greater volume of the tuberosity and may provide an osteotome-like

101
effect by condensing and compacting the internal bone of this
structure between the implant and the cortical plates of bone.
Tuberosity/pterygoid process
The dimensions of the tuberosity may not be sufficient for the
placement of an implant. In such cases, the angle of the posterior wall
of the sinus is determined radiographically.

If the angle is not severe, and if the tuberosity provides ample

dimension crestally, an implant of sufficient length can be placed so
that it initiates in the tuberosity and terminates apically in the
pterygoid process of the sphenoid bone.
Tuberosity/pyramidal process
In patients demonstrating exaggerated angulation of the posterior
sinus wall, an implant of sufficient length may be placed so that it
initiates in the tuberosity and terminates apically in the pyramidal
plate of the palatine bone.

Tuberosity/pyramidal process/pterygoid process

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 In some cases the angle of the posterior wall of the sinus may
permit a twist drill angulation that places the apex of the implant at
the junction of the pyramidal process of the palatine bone and the
pterygoid process of the sphenoid bone. The implant placed would
then engage all three bone segments that constitute this region. The
location of the posterior implant is dictated by the dimensions and
quality of the tuberosity. The mesiodistal angulation of the implant is
dictated by the angle of the posterior wall of the sinus and its
proximity to the posterior wall of the tuberosity.

The buccopalatal angulation of the implant is dictated by the

bone segments to be engaged. When indicated and when sufficient
bone structure is available, the surgeon may place the apical portion
of the implant in the pterygoid process of the sphenoid bone and/or
the pyramidal process of the palatine bone
Summary of differences between pterygoid and tuberosity implants
(A.S. Bidra 2011)6

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 Krekmanov et al. and Aparicio et al. evaluated alternatives for
implant insertion in severely atrophic maxillas. The authors suggested
that a mesiodistal inclination of the implant associated or not with a
buccopalatal direction, respects the maxillary sinus and are a
treatment option for reabsorbed posterior upper jaws. More recently,
in a report1 comprising 196 tilted implants in 64atrophic posterior
mandible edentulous, an absence of osseointegration resulted in

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failure of only two implants, and the neurovascular structures were
intact.
Bahat reported that 7% of the 72 implants inserted with a modified
technique in the tuberosity area failed after a follow-up period of 21.4
month, while Ridell et al. did not observe failures of any of the 22
implants placed in the same area after an accompaniment of 8 years.
Peñarrocha et al. evaluated 68 pterygoid implants over 1 year of
loading and found a success rate of 97.05% and a peri- implant bone
loss of 0.71 mm. After that period, the patients were satisfied with the
functional and esthetical aspects of the oral rehabilitation.
On the other hand, Balshi et al. found a cumulative survival rate of
90.8% of 1.608 implants placed into the pterygomaxillary region.
These authors compared two-stage freehand, single-stage freehand
and single-stage guided protocols. They observed that single-stage
protocol exhibited higher cumulative survival rate (96.45%) than two-
stage protocol (85.94%) and guided surgery (93.38%). Therefore,
immediate loading of those implants is beneficial to treatment.
The pterygoid implant was first introduced to be placed in the bone
pillar,that is formed by the three structures: pyramidal process of the
palatine bone, pterygoid process of the sphenoid bone and maxillary
tuberosity (Lee SP et al. 2001)48. While the first two are formed by
dense cortical bone, the maxillary tuberosity is based on poorer bone
quality. The surgeon should be aware that the maxillary artery and its
branches passess through the posterior and medial regions of the
maxillary tuberosity (Ridell A et al. 2009)178. In case of full-arch
implant supported restorations, the use of pterygomaxillary implants
gives support and retention for the restorations and eliminate the

105
cantilever’s length that may be necessary when just anterior implants
are placed (Balshi TJ 1999)141.
When implants are inserted into the tuber area, normally it is
necessary to tilt the implant, which is unfavorable to the
biomechanical point of view, increasing the peri-implant bone
resorption and reducing implant success rates. On the other hand,
previous studies showed appropriate results with tilted implants
vs straight ones. Maybe it occurs because the tilted implants can be
longer than axial ones (Ridell et al. 2009).178
The use of splinted implants has been indicated to reduce the
stress on tilted implants (Pancko F et al. 2010)179. This
recommendation has been originated from studies that demonstrated
that splinted implants showed better stress distribution when
compared to non-splinted prosthesis. On the other hand, Lan et al.
2010180 observed, through finite element study, that tilted implants
with splinted crowns exhibited greater stress concentration, specially
in implants with distal tilting. Nevertheless, additional follow-up and
long-term evaluations are necessary.
Placement of implants into the pterygomaxillary region opens new
views in rehabilitating atrophic posterior maxilla. Due to the
disadvantages such as tear of sinus membrane during sinus lift
procedure, seepage of bone grafts into the sinus, loss of bone grafts
due to resorption during bone augmentation procedures, high
morbidity seen in zygomatic implants, screw loosening or breakages
in tilted implants, a single but effective method of replacing posterior
maxilla is placement of implants in pterygomaxillary region (pterygoid
implant).

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107
 PATIENT SELECTION

Candidates for use of pterygoid implants are those patients with

non- restorable or missing dentition (specifically second molar to first
premolar at least) with inadequate height for standard implant
placement. Because the implant is not oriented perpendicular to
occlusal plane, it must be used in multiunit treatment plane (fixed
partial denture or full arch restoration) splinted to anterior implants to
dissipate off excess occlusal forces that would otherwise unfavorably
concentrated on mesial cantilever.
Pretreatment Evaluation
A comprehensive evaluation is indicated for any patient who is
being considered for dental implant therapy. The evaluation should
assess all aspects of the patient's current health status including:
General examination
Local examination.
General examination:
Chief complaint
Patient's past medical history
Medications
Medical treatments
Parafunctional habits, such as clenching or grinding teeth
Substance use or abuse, including tobacco, alcohol and
drugs
Evaluation of the patient's motivations, level of understanding,
compliance and

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 Overall behavior
Chief complaint: It is essential to listen to a patient's chief
concerns. The patient will ultimately decide whether the implant is
successful based on his or her personal criteria. The overall comfort
and function of the implant restoration are often the most important
factors, but satisfaction with the appearance will also influence the
patient's perception of success. Patient satisfaction will be influenced
by the impact of treatment on their perceived quality of life. Patients
will evaluate for themselves whether the implant treatment helped
them to eat better, look better, or feel better.
Medical History: A thorough medical history is required for any
patient in need of dental treatment, regardless of whether implants
are part of the plan. This history should be documented in writing by
the patient's completion of a standard health history form and
verbally through an interview with the treating clinician. The patient's
health history should be reviewed for any condition that might put the
patient at risk for adverse reactions or complications. Patients must
be in reasonably good health to undergo surgical therapy for the
placement of dental implants. Any disorder that may impair the normal
wound-healing process, especially as it relates to bone metabolism,
should be carefully considered as a possible risk factor or
contraindication to implant therapy. A thorough physical examination
is warranted if any questions arise about the patient's health status.
Appropriate laboratory tests (e.g. coagulation tests for a patient
receiving anticoagulant therapy) should be requested to evaluate
further any conditions that may affect the patient's ability to undergo
the planned surgical and restorative procedures safely and effectively.
If any questions remain about the patient's health status, a medical

109
clearance for surgery should be obtained from the patient's treating
physician.
Dental History: A review of a patient's past dental experiences
can be a valuable part of the overall evaluation. Does the patient
report a history of recurrent or frequent abscesses, which may
indicate a susceptibility to infections or diabetes? Does the patient
have many restorations? How compliant has the patient been with
previous dental recommendations? What are the patient's current
oral hygiene practices?
The individual's previous experiences with surgery and prosthetics
should be discussed. If a patient reports numerous problems and
difficulties with past dental care, including a history of dissatisfaction
with past treatment, the patient may have similar difficulties with
implant therapy. It is essential to identify past problems and to
elucidate any contributing factors. The clinician must also assess the
patient's dental knowledge and understanding of the proposed
treatment, as well as the patient's attitude and motivation toward
implants.
Intraoral Examination: The oral examination is performed to
assess the current health and condition of existing teeth, as well as to
evaluate the condition of the oral hard and soft tissues. It is
imperative that no pathologic conditions are present in any of the
hard or soft tissues in the maxillofacial region. All oral lesions,

especially infections, should be diagnosed and appropriately

treated before implant therapy. Additional criteria to consider include
the patient's habits, level of oral hygiene, overall dental and

110
periodontal health, occlusion, jaw relationship, temporomandibular
joint condition and ability to open wide.

Local Examination (Protocol for pterygoid implant placement)

Diagnostic level Preclinical record:
Clinical assessment summary/relevant medical history:
Pretreatment Photographs:
Extraoral: Frontal, lateral, oblique
Intraoral: Frontal, right, left, upper, and lower occlusal view
Radiographs: OPG, CBCT, RVG.

Indication of pterygoid implants:

Pterygoid implants are suited to all age groups and systemic
conditions unless there is a frank surgical contraindication. Patients
with diabetes Type 2 (HbA1c <7 %) are suitable for pterygoid implant.
Anatomical consideration for pterygoid implant placement
The pterygoid implant placement technique requires thorough
knowledge of each patients anatomy and their individual needs. Thus
dental implant placement must respect the pterygomaxillary anatomy
of each patient. The pterygoid implant must enter at the level of
maxillary tuberosity and travel length wise through the palatine bone
until it is inserted in the pterygoid apophysis (Tulasane JF et al.
1989)2. Some authors state that pterygoid implantnplaced on the
anterioposterior axis with a 45 degree angulation relative to Frankfort
horizontal plane (Graves SL 1994, Venturelli A et al. 1996, Bidra
AS et al. 2011)7,152,6. Another study found that the implant angulation

111
was around 70 degree relative to Frankfort plane (Rodriguez X et al.
2012)144.
The tuberosity of maxilla is composed of Type III and Type IV
cancellous bone. The pyramidal process of palatine and pterygoid
process of the sphenoid are mainly composed of dense cortical bone.
The pterygoid fossa is bordered by median and lateral pterygoid
plates (Graves SL et al. 1994)7. The pterygopalatine fossa (PPF) is
considered as a key area in the deep space, which needs to
evaluate carefully during head and neck imaging. The PPF is
confined by the junction of three bones (maxilla, palatine and
sphenoid). The pterygopalatine ganglion, the maxillary division (V2)
of the trigeminal nerve and its branches, the Vidian (pterygoid)
nerve, the distal branches of the maxillary artery and a few
emissary veins are the contents of the PPF. (Tashi S et al. 2016,
Tanoue S et al. 2013)181,182 The thickest buttress of bone is medial to
the alveolar ridge. The ideal placement for the implant is through
the pterygoid process into the pterygoid fossa (Graves SL 1994)7.
The thickest area of supporting bone is located in the middle part of
the pterygoid process between plates. This 3–4 mm medial to the
alveolar ridge, the implant should angle slightly medially to bisect
dense point of bone in the pterygoid region.
The hamular process on the medial pterygoid plate is palpable in
the oropharynx. Implants are placed laterally to this landmark
(Graves SL 1994)7. The pterygoid implants, when used in full arch
rehabilitation, eliminate distal cantilevers, an extension of posterior
occlusion, and the finest distribution of functional loads

112
(Anandakrishna GN et al. 2012, Bidra AS et al. 2011, Curi MM et
al. 2015, Candel E et al. 2012)183,6,153,108.

Posterior maxillary support for a fixed prosthesis can be achieved

by placing implants into the cortical bone of the pterygomaxillary
region. Multiple factors need to be taken in to account to achieve
initial stabilization, rapid osseointegration and long-term support for
the restored dentition. Previous research has proven the importance
of factors such as implant surface and the protocol used for delivery.
Apical engagement into the dense cortical bone also plays a crucial
role in initial implant stability and the ability to immediate loads aid
implant.
However, penetrating these cortical plates requires the proper
implant length. Thus, proper understanding of the anatomical region
and identification of the dense cortical bone structures in each patient
will allow the operator to choose an implant length that will achieve
stability in the pterygomaxillary region. Literature suggests that longer
implants, which are better able to fully engage the cortical plates
found in the pterygomaxillary region, may play a role in increased
survival rates of implants in this region.
The pyramidal process of the palatine and lateral pterygoid plate of
the sphenoid are located behind and slightly medial to the maxillary
tuberosity. To achieve the desired stability, an implant must
transverse the tuberosity for the apex to engage the cortical plates.
Implants that are placed solely in the tuberosity usually require a
wider diameter implant for more support because there is a high
presence of cancellous bone in that region. Yet, only engaging the
tuberosity is not a recommended treatment plan for achieving stability
in the posterior region. Penetration through the cortical pterygoid

113
plates with the implant apex should also be considered asa proper
method to achieve high osseointegration rates. In a 1984 study,
Brånemark et al. noted that implants that encroach upon the nasal or
sinus floor cause no undesirable side effects during healing and
maintain their anchorage during load. The investigators of this report
believe that similar conclusions can be made for the pterygomaxillary
region. The apex of a Brånemark implant is narrower in diameter than
the rest of the body. As the apex is driven 1 to 2 mm through the
dense plates and exposed, the implant surface area increases in the
limited dense bone that exists.
Thus, the increased bone to titanium interface should produce
higher primary and secondary stabilization.With regard to
biomechanical forces, all the pterygomaxillary implants placed
splinted with other implants. This splinting effect causes a distribution
of the functional loads between all implants in the prosthesis. Loading
the pterygomaxillary implant alone would provide a biomechanically
unfavorable advantage due to the angulations of implant placement in
relationship to the occlusal plane. Surgical safety issues in this region
also need to be addressed as they are often misconceived.
Accordingto Graves et al. here are no anatomically significant
structures found in the pterygomaxillary region. The maxillary nerve
and terminal branches of the internal maxillary artery travel through
the sphenopalatine fossa, located approximately 10 to 15 mm
superior and lateral to the intended implant apex location. Thus, no
vital structures are threatened when implants are placed inferior to
the sphenopalatine fossa.
Radiographic evaluation:

114
 To obtain excellent results in rehabilitations with pterygoid implants
meticulous attention must be paid to details. Prior to implant insertion,
intraoral and panoramic radiographies should be considered. But,
since those techniques just provide information in a 2-dimensional
view, the localization maxillary sinuses, in addition to the angulation
of the alveolar crest and the bone volume are of primary importance
during implant treatment planning in the posterior jaw area.
Therefore, the use of CT in all sliced images is suggested to indicate
the most convenient dimensions of the implant and its optimal
position and inclination Spiral/helical CT scanners provide images
with higher quality, with tridimensional view, associated with lower
radiation exposure, than conventional computerized tomography.
Nevertheless, the CT scan is kind of expensive and requires large
equipment. The radiation dose isrelatively high. In general, the
conventional CT liberates a higher dose of radiation than another
option of image scan, the cone-beam computed tomography (CBCT),
which offers realistically tridimensional sliced images. Therefore, this
method is useful during implant treatment planning for partial
edentulous patient.
Though surgical planning for pterygoid implant may be adequately
accomplished via panoramic radiographs, cone beam computed
tomography (CBCT) is becoming standard for screening and
treatment planning in most contemporary oral surgery practices and
is ideal, especially in case of severe maxillary atrophy. The degree of
pneumatization of maxillary sinus determines anterio-posterior
insertion and angulation of implant. CBCT also allows for
measurement of height and width of tuberosity and the pterygoid

115
plates, visualization of the position of lateral plates in relation to
hamular process, as well as suggestion of bone density in the area.
The CT occlusal view of maxilla is used to determine the optimal
angle of implant placement to obtain a fixed implant for possible
immediate function.

Fig 23: Three dimensional steriolithographic model from the

CBCT via computer aided design

The preoperative examination consisted in most patients of a

panoramic radiograph, and if necessary intra-oral periapical
radiographs to exclude pathology. In a few patients conventional
tomography was obtained to evaluate the bone volume.
Presurgical steriolithographic model
Printing of three dimensional steriolithographic model from the
CBCT via computer aided design/ computer assisted manufacturing
is often helpful for visualization and allows the surgen to plan and
practice via model surgery prior to the actual live patient surgery.
Rarely inadequate height of tuberosity below and behind the sinus is
contraindication to pterygoid implant placement. This results in
excessive flattening of implant angle, making the implant unable to

116
engage the height of pyramidal pterygoidal pillar and resulting in less
favorable restorative angle.
To take clinical advantage of pterygoid implants surgical guides
and stereolith models are necessary, fabrication of which is done by
conversion of patients CT scan images (Dicom) to STL format. Virtual
planning of implant placement and clinical angle measurement should
be done. Surgicalmetal template is fabricated with markings of point
of entry and drilling angulation as per the planned sites. The use of a
surgical guide avoids perforations into adjacent anatomical sites
(palatal or buccal). Models help to identify the patient-specific
anatomy, point of entries, exit andmesiodistal, and buccopalatal
angulations.
CAD-CAM: Due to the special architectural features of the
pterygo-maxillary area, placement of dental implants in this area is
technically more difficult in comparison to other regions of the maxilla.
Computer Aided Design - Computer Aided Manufacturing (CAD-
CAM) is of great value in planning and placing pterygoid implants, as
well as other implants that bypass the maxillary sinus. The surgical
guide enables the clinician to determine the exact direction of drilling
and the correct length of pterygoid implants.

117
ARP (pterygoid anatomic radiographic prediction)
Luis et al. 1916184 proposed the classification of diagnostic
prediction PARP for implantology in the pterygomaxillary region.
Through the PARP, the choice of implant is individualized for each
patient, acting as a guide to make implantology accessible in the
pterygomaxillary region to the greatest number of specialists. From
the degree of sinus invasion obtained after a three-dimensional (3D)
computerized tomography (CT), the PARP establishes the prediction
of the difficulty implied by implantology in this anatomical region, as
well as the appropriate choice of the type of implant and length with
which to approach it.
The PARP classification allows working only in the
pterygomaxillary region with retromolar implants (Luis et al. 2016)184.
PARP 1. It is the simplest scenario when there is no sinus invasion
and we have a bone in all its route. In these cases, the length of the
implant depends on the bone density.
PARP 2. The patient presents with a sinus invasion but still has
>10 mm of the remaining bone. In case of having good bone density,
it would be more appropriate to place a conventionally
conceptualized retromolar implant.
PARP 3. This is a case of medium-high difficulty, with sinus
invasion leaving a bone surface between 5 mm and 9 mm of
remaining bone. In these cases, due to the scarce remnant of
alveolar bone and the air of the sinus invasion, the pterygoid anchor
will always be used in the apophasis of the same name, with a
suitable density.

118
 PARP 4. In the majority of cases of a large sinus invasion, leaving
only a remaining bone smaller than 5 mm, the possibility of using
long pterygoid implants or opting for other surgical approaches will
be evaluated.

Space for restoration

The discussion about the space requirements for placing an
implant is very important. The mesiodistal space required is related to
the type and number of teeth that will be replace (Jivraj S et al.
2010)185. According to Misch 2005186, the selection of implant size is
influenced by the mesiodistal distance available for implant
placement. These authors indicated a guideline for this selection:
A distance of at least 1.5 mm must be respected between the
implant and the adjacent teeth;
A distance of at least 3.0 mm between the implant and an adjacent
implant for the replacement of a molar tooth, a implant with a wider
diameter is indicated.
If the implant-supported proshtesis is positioned with a large
distance from the adjacent tooth, critical contours and cantilever

119
forces are generated on the implant. Since the mesiodistal dimension
of molar teeth is greater when compared to other teeth, a distance of
at least 2.5 mm between the implant and the adjacent implant has to
be respected to assure restoration proper contours (Jivraj S et al.
2006)187.
According to Gastaldo et al. 2004188, a distance of 3 mm between
the bone crest adjacent implants and the proximal contact point is
essential and the implant should be placed 3-5 mm away from the
tooth in order to guarantee a healthy interproximal papilla. Simşek et
al. evaluated, through finite element analysis (FEA), different
distances between implants that retained three-unit partial prosthesis
and their effects on bone stress distribution in the posterior lower jaw.
Axial, horizontal and oblique forces were applied and tensile and
compressive bone stresses were evaluated. Theauthors observed
that a space of 1.0 cm was the greatest distance between the
inserted two implants. Both the mesiodistal and the buccolingual
dimensions from the crestal level to the apical part of the implant site
should be evaluated (Smidt A et al. 2007)189. At least, a 6 mm of
bone.
Buccolingual extension is necessary to insert a 4 mm-wide dental
implant. For diameters higher than 5 mm, a 7 mm extension is
required (Jivraj S et al. 2006)187.
Additionally, the intermaxillary space is an important source.
Adistance of 10 mm between the residual ridge and the antagonistic
archmust be respected when substituting posterior teeth (Cooper LF
et al. 2012)190. A multidisciplinary approach is considered when
planning a dental implant treatment and involves orthodontics,

120
surgery and restorative, so that the function and aesthetics of those
patients are improved (Jivraj S et.al 2007; Smidt A 2007; Chan HL
et.al 2011)191,189,192.
Generally, over-eruption of opposite teeth occurs after a long
period of tooth absence, which affects the restorative space.
Therefore, several treatment options to create a sufficient space for
restoration are available such as enameloplasty, minimal restorative
therapy, orthodontic ntrusion, tooth realignment, endodontic treatment
and full crown preparation, segmental osteotomy for dentoalveolar
extrusion and extraction (Basa S et al. 2008; Lee HE et al. 2007;
Smidt A 2007).193, 194,189

Fig 24: Left – Pterygoid area in sagittal view; Right – comparison of the density in
the Pterygoid area (upper) and Tuberocity area (lower).

Occlusal considerations
The excess of loading in posterior jaws associated with the
functional activity of the mandible in a buccolingual direction and with
cusp inclination can create lateral forces onto implants. Thus, during
implant treatment planning, a broad evaluation of the loading is

121
essential, since a bending moment at the peri- implant bone can
result in prosthesis components damages and/ or crestal bone loss.

Various factors can overload an implant. Rangert et al.195

identified two principal factors that justify this excess of loading:
geometric and occlusal load reasons. The first one is related with the
implant number and position and with the prosthesis configuration.
The second factor includes lateral occlusal force components and
parafunctional habits, which increase the loading onto implant
surfaces. If forces are higher than normal, the implant can be
overloaded. Ogawa et al.196 affirmed that a decrease in number of
supporting implants is to promote an increase in implant loading. The
bending moments were higher when prosthesis were supported by
three implants than four or five implants. Additionally, concerning the
implant position, the smallest implant distribution increased the
bending moments.
The prevention of occlusal overload should be the focus of any
treatment planning. In case of no alternative, the prosthesis should be
protected from injuries with an inter-occlusal device. Some guidelines
were reported aiming to respect physiologic limits for occlusal
loading, optimized passive fit, reduction of cantilevers, adequate
selection of the dimensions and number of implants, presence of a
correct preload in the abutment screw and a proper buccal-lingual
dimension and cusp inclination of the crown.
Furthermore, the principles of implant occlusion are mostly based
on the traditional principles of conventional restoration. Anterior
guidance should be presented and during lateral excursion, a
posterior disocclusion is indicated for working and non-working sides.

122
 Group function disocclusion is indicated when the canine is
compromised. Payer et al.197 evaluated the outcome of edentulous
posterior mandible treated with implant-retained immediate
provisional prosthesis. According to these authors, immediately
loaded implants exhibited similar results when compared to
conventionally loaded implants. During a follow-up period of 5 years,
the survival rate was95%. Similarly, Degidi et al.198 performed a
randomized clinical trial that aimed to evaluate the effect of
immediately loaded and immediately restored implants for edentulous
posterior lower jaws. The authors found that both procedures are
predictable. No differences in marginal bone loss or survival rate
were observed.
Nonetheless, concerning the conditions of early loaded implants in
the posterior upper and lower jaws, Kim et al.199 observed that,
although early loading is a predictable procedure, it is important to be
careful with maxillary implants.

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 SURGICAL PROTOCOL FOR PTERYGOID
IMPLANT PLACEMENT

The junction of the palatine bone and pterygoid plates forms a

narrow column of dense bone, referred to as the pterygoid pillar, into
which the apical portion of an implant can be fixed. If the tuberosity is
of favorable dimension- height, width and length-an implant may be
successfully placed within this structure and a more distal placement
of the implant apex avoided. However, if the dimension and/or quality
of the tuberosity is insufficient, a more medially angled and posteriorly
placed implant is determined by the angle of the posterior wall of the
maxillary sinus (Graves SL 1994).7The implant must be placed
parallel to the posterior sinus wall to prevent penetration of the sinus.

Fig 25: PtP -Pterygoid Pillar

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 Fig 26: Placement of implants parallel to posterior to sinus wall
The anatomic fundamentals of the use of implants in the
pterygomaxillary region have been previously reported by (Bahat O et
al. 1992)200. The aim of this technique is to embed the apical portion
of the implant into dense bone, which is formed by the joining of
anatomic structures:
anterior border of the pterygoid process of the sphenoid and
posterior border of the maxillary tuberosity.
The middle area between the two structures of the pyramidal
process is formed by the horizontal portion of the palatine bone. This
pyramidal processes of great interest, as it is a structure of compact
bone several millimeters thick, providing bone volume for implant
placement, while theother two anatomic structures are thinner (Fig
27).

125
Fig 27: Diagram of surgical anatomic area.

126
re- operative evaluation
In addition to the usual radiographic study (panoramic radiograph,
topographies’, skull side view, andso forth), preoperative
computerized axial tomography is needed to help establish the
exact location, quality and quantity of the bone available in the
described anatomic region (Bahat O. 1992)200.
This preoperative study should also include:

assessment of the occlusion

study of potential prosthetic space
fabrication of templates for radiographic and
surgical positioning
It is important to determine the patient's degree of mouth opening,
since the operation is performed with local anesthesia in the most-
distal portion of the maxilla, and the lack of patient cooperation and/or
mouth opening could present a great handicap, making the use of
these techniques impossible. Even though an extensive preoperative
workup is done, it is very difficult during surgery to exactly reproduce
the implant situation as simulated and planned during preoperative
studies (Tulasen JF 1992)5, because bone access is achieved
following an oblique direction antero-posteriorly and inferior-
superiorly (Fig 28). Therefore, access to the bone resembles the
hypo ten use of an imaginary triangle, that (to simplify calculations)
we consider as a triangle rectangle (Fig 29).

127
Fig 28: Direction of implant placement

Fig 29 a: Basic trigometry

128
ow to determine the length of implant?
Translated into basic trigonometry, this means that
�� = �� / cos ��
If “c” the distance from the access point of the maxilla to the
posterior edge of the maxillary tuberosity, can be determined in the
preoperative study, then variations in cos b will determine “a” or the
length of the implant. The purpose is to discourage distal drilling of
the pterygoid process and thus avoid the risk of hemorrhage
(Tulasane JF 1992)5.
For examples the distance from the posterior access point of
maxilla to the posterior edge of maxillary tuberosity is 10 mm (c = 10
mm) and the angle of approach is 45 degree (B = 45). Value of cos
45 = 0.70. Therefore, according to formula a = 10/ 0.70 = 14.28.
Implant of 14 mm length is required in this situation.

Fig 29 b: Variation in length of implant according to angle of approach

Using this technique, the exact angle, direction and length of the
implant to be placed will be determined intra-surgically using drills as
little as possible duringaccess to the bone, resulting in an important
conservation of bone.

129
urgical Procedure.
Local anesthesia and incision
Adequate local anesthesia is obtained through (2%Lignocaine
hydrochloride with adrenaline 1: 200000) blockade at the greater
palatine artery and nerve and local infiltration in buccal vestibule as
well as posterolateral to the tuberosity. Under local anesthesia, a
paracrestal incision is performed, slightly displaced towards the
palate (2-3 mm palatally to alveolar crest), that goes mesiodistally
from the posterior edge of the maxillary tuberosity to a few millimeters
distal to the last existing tooth. In this way, the distal gingival papilla of
the tooth will be preserved when releasing incisions are made
towards the buccal vestibule. A mucoperiosteal flap is elevated
towards the vestibule and kept in place with the help of a retractor,
so that vision is not affected in any way during surgery.
Anacrylic resin surgical template is used to locate the access point
to the maxilla as determined in the preoperative analysis. At that
point, a small perforation of the cortical bone of the maxilla is made
with a round bur. The guide hole is placed approximately in the
second molar area of tuberosity with no 4 or 6 round bur.

Fig 30: Round burs no 2,4 and 6

130
 Fig 31: 2 mm twist drill

To establish angulation, a long shaft 2 mm twist drill on an

extension is used. The pterygoid hamulus is palpated and the drill is
directed 5 mm laterally to this landmark. The angle is approximately
45 degree to the occlusal plane (Graves SL 1994; Bidra AS 2011).7,6
This process is the primary guide used to determine the thickest part
of pterygoid pillar of bone.
Excessive palatal inclination should be avoided, i.e. more than 40
degree. This could result in transection of greater palatine artery, vein
and nerve within the canal, potentially causing excessive bleeding
(Uchida Y et al. 2017; Suzuki M et al. 2016).201,159
If the correct path is followed, twist drill will encounter dense
cortical bone of pterygomaxillary suture area at the depth of 10 to
14mm. The drill will slow down noticeably and then speed up again
after it passes through pterygoid cortical bone, entering the pterygoid
fossa. The drill is removed, and the probe is placed in the hole to
attempt to feel for the sinus cavity. If the large perforation has
occurreda new site must be located at least 3mm posterior to original
one. Cylindric osteotomes (Site Formers SF0/SF1/SF2/SF3/SF4/SF5,

131
Osteo-Ti, Vale, Guernsy, England) (Fig 32),which are calibrated in
millimeters in a set of six instruments of increasing diameter, are used
for further bone preparation. Number 0 has a 0.5 mm diameter, no. 1
a 1 mm diameter, no. 2 a 2 mm and no.3 a 3 mm diameter (nos. 4
and 5 are not used). First, the no. 0 instrument, the onl y one with
a sharp end; is introduced through the cortical access, made with
the round bur.

Fig 32: Cylindric osteotomes of increasing diameter used for Bone preparation

With the appropriate angle and direction (based on preoperative

radiographic analysis), it is moved slowly through the porous bone of
the maxillary tuberosity. The impulsion and rotational movement will
be continued until dense bone, the Pterygomaxillary-pyramidal
junction, is reached. At this point, an intraoral and intra surgical
radiograph is obtained or laser visiography is used to access the
angle and location, so that alterations can be made if necessary.
Because the osteotomes are graduated in millimeters, the exact
length of space existing between the access point and the apical
embedding point of the implant will be known (Figs 33a and 33b).

132
 It is not difficult to know when the dense bone of the
pterygomaxillary- pyramidal region has been reached, as the
osteotome will advance easily through the porous bone of the maxilla,
while it is difficult for it to penetrate and progress in the dense bone.

Fig 33 a: Intra-surgical approach showing the osteotome no 0

Fig 33 b: Intraoral radiograph, location and length are determined.

Once it is known that the direction is correct, use of the no. 1

osteotome is indicated. Its round head is slowly introduced into the
hole made previously with the no. 0 instrument. With impulsive and
rotary movements, it will advance slowly and carefully, so as not to
alter the direction of the initially obtained path, as well as to allow

133
dilation and microfracture of the cancellous portion of the porous
bone. This procedure is continued until the entire length of the no. 0
osteotome is reached; osteotomes no. 2 and 3 are then used in an
identical manner.
After finishing with these instruments, a 3-mm wide tunnel in the
bone will have been created from the access point at the cortical
ridge of the maxilla as far as the pterygomaxillary-pyramidal region
(Figs 33a and 33b). Because no drills have been used, there has
been no bone loss; on the contrary, it has been compacted at the
tunnel walls, which will envelope the turns of the implant's threads. All
osteotomes are used under continuous irrigation. The length of the
osseous tunnel is known exactly in millimeters and through
preoperative radiographic and tomographic studies, the measurement
in millimeters of the apical embedding area in the mesiodistal
direction (pterygomaxillary-pyramidal region) is also known.

Fig 34 a: Diagram of Osteotome no 3

134
 Fig 34 b: Clinical photograph showing use of osteotome no 3

For example, let it be assumed that a measure of 5 mm is attained.

To the known length of the tunnel (X), a number of millimeters (Y) will
have to be added to ensure that the apical portion of the implant is
embedded in compact bone and it coincides with the length of the
implant of the system being used. If X is 14 mm, it would be
necessary to increase 4 mm (Y = 4 mm) to ensure good apical
embedding and to enable the use of an 18 mm implant.
Once this new working length (X + Y) is determined, long-shaft
drills (SDIB-133, Nobel Biocare, Göteborg, Sweden) are used; the
drills are mounted on a handpiece to facilitate the correct
workingangle, marked at a working length (X+ Y) and operated at
low speed with copious irrigation. They are used in sequence,
working not all along the osseous tunnel, but only in the last few
millimeters (Y mm) of the pterygomaxillary-pyramidal region (Figs
35a and 35b).

135
 Fig35a: Diagram of round drill at working length of X + Y

Fig 35 b: Diagram of 3mm diameter drill at working length X +Y

Care should be taken not to under prepare the dense pterygoid

pillar because the implant could “bottom out” if the osteotomy hole is
too small. That is, if implant reaches the dense bone, it may be
unable to continue to self-tap into the pillar halting forward motion and
with sustained rotation strip the previously tapped less dense bone
of the tuberosity that surrounds it. After the implant site has been
completely prepared, a depth probe with an enlarged tip is used to
explore the site and to determine the length of implant to be used.
The implant should pass completely through pterygoid process to
establish bi-cortical stabilization.

136
 An implant is selected that will extend roughly 2mm past the
pterygoid process. This is generally self tapping implant 15 mm or
longer. It is easily placed with the long fixture mount or with use of
long shaft straight hand torque ‘onion’ driver. The implant should be
seated so that half of the head is buried in the cortex of tuberosity. A
goal of 30-40 Ncm of torque should be expected. A cover-screw or
straight abutment is then placed. Where angulation exceeds 60
degree an angled abutment is used. An alternative method for
placement is more vertical with only a 15-20-degree angulation
forward relying on the posterior sinus wall and the pterygoid places.
With this approach insertion torque exceeds 50 Ncm and immediate
function is assured.
The operation is completed with careful counter sinking of the
cortical maxilla and the placement of a self-tapping implant, type
Mark II (Nobel Biocare SDCA). The result is the placement of an
implant with part of its apical portion embedded in dense bone and its
coronal portion in the cortical maxilla. It is important to achieve good
initial stability of the implant.
Soft tissue plasty or tuberosity reduction is often performed at
wound closure to reduce extraneous thick tissue. (Rodriguez X et al.
2016)147. This allows for better access for restorative treatment
and correction of an inverse alveolar plane.

137
uturing
The incision is closed with 3-0 resorbable suture on a no 6
cutting needle in continuous fashion. The restorative dentist may at
this time make impression for a provisional fixed denture prosthesis.
The prosthesis should be designed without excursive contacts to
promote osseointegration during the healing period of 6 months
(Raspall G et al. 1992)202.
The patient is placed on antibiotics for 1 week. Augmentin is the
antibiotic of choice due to potential involvement of sinuses, though
amoxicillin or penicillin may be used. In case of penicillin allergy
clindamycin or cephalosporin may be used. At re-entry in 6-month
implant is reverse torque tested to 10 Ncm to ensure
osseointegration.
When osseointegration is achieved, implants in this area will
support forces well, (Graves SL et al. 1994)7 which, because of
their angle, will be nonaxial forces. None of the implants placed to
date have failed under function. (Tulasane JF 1992)5 Failures are
normally detected during the second surgical stage and would be the
result of lack of osseointegration (Bahat O 1992)200.
The significance of this surgical procedure is that, the use of drills is reduced to
minimum and thus it leads to conservation of bone. Drills do not enter the retro-
pterygoid area, so that surgical risks are reduced, mainly those related to
hemorrhage, basically of internal maxillary artery (Tulasane JF 1992)5.

138
Fig 36 a: Pre- operative panoramic radiographs.

Fig 36 b: Post-operative panoramic radiograph.

139
 PROSTHETIC LOADING

In the past, according to the original concept for the placement of

Brånemark System implants in atrophied completely edentulous
arches, the implants were placed in a fairly upright position. With
such implant position it was often necessary to fabricate a bilateral
cantilever that was up to 20 mm in length so as to provide the
patient with good chewing capacity in molar regions, increasing the
risk of implant failure (Rangart B et al.1989; White SN et al. 1994;
Sertgoz A et al. 1996)195,203,204.
Different procedures have been proposed to overcome these
anatomic limitations. The least invasive is the use of short implants
(Renouard F et.al 2005)205; however, when bone height is insufficient
even for short implants, reconstructive alternatives, such as
autogenous bone grafting (Keller EE et al. 1987)206 and sinus lift
augmentation (Tatum h et al. 1986)207 may be indicated.
Nevertheless, each of these techniques presents disadvantages,
such as morbidity in graft donor sites, postoperative discomfort,
questionable predictability, and surgical complexity (Al—Nawas B et
al. 2004; Chung DM et al. 2007; Esposito M et al. 2008; Aparicio
C et al. 2001)123,208,209,210. To overcome these issues implants placed

140
in the pterygomaxillary region has been proposed as a conservative
solution for the treatment of the atrophic edentulous maxillae
(Aparicio C et al. 2003; Fortin Y et al. 2002; Malo P et al. 2003;
Calandriello R et al. 2005)211,212,213,214.
Pterygoid implants are beneficial in restoring the entire maxillary
arch with a prosthesis that is biomechanically stable and free of
cantilevered pontics. Implants placed in pterygomaxillary area assist
in stabilizing bone anchored prosthesis in completely edentulous
patients. Multiple studies have noted that pterygoid dental implants
have a high learning curve and are technically challenging due to
difficult surgical access and close proximity to vital anatomic structurs
(Bidra AS et al. 2011; Tulasane JF et al. 1992; Balshi TJ et al.
1999)6,7,141. Vascularity such as pterygoid venous plexus and
descending palatine artery are in propinquity to the pterygomaxillary
fissure.
The concept of immediately loading implants has been well
documented in the literature (Babbush CA et al.1986; Schnitman
PA et al. 1997, Becker W et al. 1997)215,216,217. The maxillary arch
poses difficulties for immediate loading that are not found for the
mandible. These difficulties include a predominance of type III and IV
bone, shown to be responsible for an increased number of implant
failures (Jaffin RA et al. 1991; Friberg BS et al. 1991, Truhlar RS
et al. 1997)218,219,220 as well as the presence of the maxillary sinus,
which can limit the quantity of vertical bone necessary to place
implants. To provide patients with a successful, immediately loaded
prosthesis, these problems must be overcome. Use of the
pterygomaxillary has been shown to be a viable treatment modality
to support immediate implant placement and the immediately loaded

141
fixed prosthesis (Balshi SF et al. 2005; Tulasane JF et al. 1989;
Bedrossian E et al.2008)143,2,221.
The purpose of this treatment is to provide the patient with an
immediately loaded, functional maxillary fixed prosthesis without bone
grafting surgery in a single visit, showing that even the most severely
resorbed maxilla can be restored and functionally loaded when the
pterygomaxillary region are used for implant support.
The biomechanical rationale for using inclination of distal implants
is based on the reduction of cantilever length and as a consequence
give rise to better load distribution of the prosthesis support.
Additionally, tilting implants can optimize the anterior/posterior spread
of the implants along the alveolar crest increasing the polygonal area
to provide satisfactory molar support for a fullfixed prosthesis (FFP) of
12 masticatory units. Several clinical studies have reported high
survival rates for tilted implants.
However, questions remain relative to the amount of stress
generated at the bone surrounding tilted implants. The single tilted
implant in fact, submitted to a vertical load, demonstrate higher peri-
implant bone stress than the single vertical implant submitted to the
same vertical load. The stresses increases as the tilt of the single
implants increases.
However, when the implants are splinted in a rigid FFP, the use of
tilted distal implants, with reduced cantilever lengths, results in lower
mechanical stresses on the peri-implant bone with respect to the
vertical implants with longer cantilevers.
Moreover, a reduction of stress around anterior implants is
observed with the tilted distal implants compared to the vertical
implant FFP (Full Fixed prosthesis) design. Multi-unit prostheses may

142
demonstrate greater inaccuracies compared with single implant
restorations infact, but due to the absence of moment loading, the
multi-implant configuration appears to compensate for the higher
strain development.
These results have done so as that the last frontier in implant
dentistry is represented by reducing the number of implants
supporting a prosthetic rehabilitation as well as the time that elapses
between implant placement and prosthetic loading.
From this point of view the protocols in which four implants were
placed to support a full-arch prosthesis indicate that the placement of
larger numbers of implants may not be necessary for successful
implant treatment of edentulous arched. In 2003 Malò et al.
proposed a special guide designed from himself for the assisted
placement of the distal tilted implants. This guide was placed into to a
2 mm hole made at the midline of the mandible or the maxilla, and
its titaniumband was bent so that the occlusal centerline of the
opposite jaw was followed. In this way it was possible the implants to
be placed in the center of the opposite prosthesis and concurrently to
find the optimal position and inclination for the best implant anchorage
and prosthetic support.
The introduction of digital systems into the diagnostic routine and
their application using three-dimensional data sets of the bone
topography, have made it possible to reconcile the two central aspects
of planning an ideal prosthetic solution with the given anatomic
situation prior to implant surgery. There is no intrinsic limitation of this
technique if the initial bone height is severely reduced and the risk of
perforations of the sinus membrane or alveolar nerve and loop during

143
the drilling procedure are no likely to occur because of the accuracy
of the safety distance calculated during the computer planification.

Biomechanical consideration: The occlusal forces developed in

the molar region are very high (300 to 400 N) (Skalak R et.al
1985)222. To effectively counter these forces and to also achieve
optimum primary stabilization, the longest possible implants are
used. Special efforts are made to engage the upper cortical plate with
the apex of the implant (bicortical support). In case where bicortical
support is not achievable, more than one implant is placed from a
biomechanical point of view. Angulation of the implant minimizes
potentially injurious horizontal forces. The importance of the
inclination factor is illustrated in Fig 37, which shows that with an
angulation of 45degrees, 50% of the load is transmitted horizontally.

144
Fig 37: Load distribution (Newtons) between vertical and horizontal forces according
to different inclinations of implants (Vf - Vertical Force, Hf -Horizontal Force).

Prosthetic design may also play a role in the final success. All of
the distal implants are purposely left out of occlusion to reduce the
amount of force on these implants.
Prosthetic protocol for pterygoid implant placement:
For partial or full arch rehabilitation with posterior pterygoid
implants and anterior implants prosthetic protocol is as follows:

A two step open tray direct impression technique

is used with putty and light body material after
splinting of multiunit impression copings
Multiunit implant analogs are attached to the
impression copings
Gingival mask is poured around implant analog
Die stone is poured to form final cast

145
 Jig trail; jaw relation and bite registration are
recorded and sent to lab for CAD CAM
designing screw retained fixed prosthesis
Metal trial and bisque trial
Final prosthesis

Fig 38: Panoramic radiograph of patient after implant placement

Fig, 39: Images of prosthesis and patient at completion of treatment

An impression is executed with soft putty immediately after the

surgical procedure. After removing surgical copings abutment healing

146
caps are attached to prevent mucosa from collapsing. After 3 hours
acrylic resin fixed partial prosthesis are constructed. All crowns are
adjusted to eliminate contact with antagonist teeth in excursive
movements.
The definitive ceramic or metal ceramic fixed partial prosthesis is
manufactured and placed 4 to 6 months after the surgery with an
occlusion mimicking natural dentition.

147
 COMPLICATIONS

Many authors have reported success rates for pterygoid implants

ranging from 90.9% to 100% after follow-up periods ranging from 1 to
12 years (Graves SL 1994)6. However, some success rates of less
than 90% have been reported because of a lack of osseointegration
(Penarrocha M et al. 2009)223. Only a few studies have measured
crestal bone loss around pterygoid implants because it is difficult to
assess the crestal bone levels, given the posterior position of these
implants. Nevertheless, some authors have reported values of crestal
bone loss similar to those for maxillary implants, that is, less than 2.0
mm. Park and Cho 2010224 found mean crestal bone loss of 0.9 mm
after 6 years of functional loading, whereas Balshi et al. 2005143
reported mean bone loss of 1.2 mm after a follow-up of 5 years.
Multiple studies have noted that pterygoid dental implants have a
high learning curve and are technically challenging due to difficult
surgical access and close proximity to vital anatomic structures
(Balshi TJ et al. 1999)141. Vascularity such as the pterygoid venous
plexus (Kashani H et al. 2016)225 and descending palatine artery are
in propinquity to the pterygomaxillary fissure and pose a risk for
excessive hemorrhage should they be damaged during implant
placement (Bidra et al. 2011)6.
Complications can be categorized as:

Surgical complications,
Biologic complications,
Bone loss,

148
 Prosthetic/ Mechanical complications
Surgical complications
Surgical complications include bleeding, sinus perforation, and
restorative issue from thick local mucosa. However, these are rare
and usually minor and avoidable with proper technique (Tulasane JF
1989; Rodriguez X et al. 2012)2,144. However, surgical safety issues
in this region also need to be addressed as they are often
misconceived. According to Graves SL et al. (1994)7 there are no
anatomically significant structures found in pterygomaxillary region.
The maxillary nerve and the terminal branches of the internal
maxillary artery travel through the sphenopalatine fossa (Turvey T et
al. 1980)226, located approximately 10 to 15 mm superior and lateral
to the intended implant apex location. Thus, no vital structures are
threatened when implants are placed inferior to sphenopalatine fossa.
Any bleeding from implant sites from veins of the pterygoid muscle
or venous pterygomaxillary plexus can quickly be stopped once the
implants are placed. The internal maxillary artery crosses 10 mm
above the pterygopalatine suture as it enters the pterygopalatine
fossa. The distance from the internal maxillary artery to the
pterygomaxillary suture is approximately 25 mm. (Bahat O et al 1992;
Khayat P et al. 1994; Balshi SF et al. 2005; Penarrocha M et al.
2007; Ridell A et al.2009)227,228,143,127,11.

Lee et al. 2007194 measured the height distance, anteroposterior

distance and mediolateral distance of the pyramidal process from
pterygoid implants, observing the shape of lateral and medial
surfaces of the pterygoid process. A classification of these regions
provided anatomical features in relation to placement of implants in

149
the molar region of the maxilla and is useful in treatment planning of
totally edentulous patients.
Finally, Valeron and Valeron 2007155 suggested to prepare the
implant site with a combination of drills and straight osteotomes. The
entry point is created with a round bur followed by preparation of the
implant bed with the smallest straight osteotome. A pilot drill
establishes the direction of the implant axis, and site preparation
continues with consecutive osteotomes in combination with drills of
increasing diameter.
A possible major complication that may occur during the surgery
is massive bleeding from the maxillary artery or its branches, which
are situated 1 cm superiorly to the pterygomaxillary suture
(Penarrocha MI et al. 2009; Mateos L 2002)223,171. This
complication is rare and has not been mentioned in the literature.
Regardless of surgical technique used, care must be taken to avoid
damaging either the maxillary artery or its branches within the
pterygopalatine fossa. However, the distance from the inferior end of
pterygomaxillary suture to maxillary artery is 25 millimetres, which
make this area safe for working.
Valero’n and Valero’n 2007155 described a minor venous bleeding
caused by over insertion of the drill, a few millimetres into the venous
plexus in the retropterygoid area. The bleeding was stopped with
local haemostatic methods. Krekmanov L et al. 2000230, reported
difficulties when anchoring the implants into the pterygoid process.
An implant was lost during placement due to over drilling beyond the
pterygoid process. Vrielinck et al. 2003231 lost 4 of 6 implants due to
problems in placing them in the initially drilled implant bed. The

150
repeated attempts to drill in different directions, in order to improve
the designs of the implant bed, resulted in insufficient bone
anchorage, which jeopardized primary stability of pterygoid implant.
The biggest reason for failure to achieve primary stability is inability
to engage the cortical bone of pterygoid plates. This is due to either
an error in angulation or inadequate implant length. The 2 mm twist
bur should be the operators first indicator for proper placement –
increased resistance should be felt by approximately 14 mm. If this is
not the case, landmarks should be checked, the bur reoriented and
the site reosteomatized before proceeding to wider drill bits, which
may destroy bone needed for stabilization. It may be helpful to take
CT scan to verify position of the drill prior to sizing up. The long
probe is excellent for angle visualization and palpation of the cavity.
If an implant in pterygoid region fails to integrate, it tends to not lead
to significant bone loss. The bone of the tuberosity and pterygoid
region is not important for alveolar function, nor will it cause a gross
alveolar deformity intra orally if an implant is lost. Because of the
limited volume of the bone, another pterygoid implant is no generally
considered. Instead operator may use either a zygomatic implant or
traditional sinus elevation to achieve posterior occlusion. In some
cases, 2 pterygoid implants can be placed on same side.

151
 Fig 40: Pterygoid venous plexus has potential for haemorrhage complications if
damaged during placement of pterygoid based dental implants.
Biologic complications:
Rose´n and Gynther et al. 2007232 reported postoperative
biological complications. They observed local mucositis in 9 patients,
8 of which expressed problems maintaining optimal oral hygiene.
Three patients suffered postoperative sinusitis during the first year.
Prosthetic/ Mechanical complications:
Several authors reported prosthetic complications; however, these
were all considered minor and most could be solved without removing
the prostheses. Aparicio et al. 2001233 reported 28 mechanical
incidents in 16 prosthesis (55.2%): 18 and 5 of these incidents were
respectively abutment and gold screw re-tightening, 2 were abutment
screw fractures and 1 was a fracture of occlusal material. Hinze et al.
2010234 found that after 12 months the most common technical
complication was acrylic veneer material fracture in provisional
prostheses (10.8%), followed by loss of screw access hole
restorations (9.5%) and occlusal screw loosening (6%). For Agliardi
et al. 2009235 and Francetti et al. 2010236 the only prosthetic
complication was the fracture of the acrylic prostheses, which
occurred in 10 (16.4%) and 3 (19%) cases respectively; Testori et al.
2008237 only found screw loosening, which occurred in 7 (17.5%)
provisional prostheses, in 3 tilted and 4 axial implants. Calandriello
et al. 2005214 reported crack propagation and subsequent fracture of
the acrylic bridgein 1 case, which was only one in which implant
failures (1 tilted and 1 axial) were recorded. Malo et al. 2005238 only
recorded fractures of prostheses in 4 bruxing patients, of whom two
were patients who lost 1 implant each.

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Bone loss:
Bone loss in pterygoid implants was assessed by 8 authors. Hinze
et al. 2010234 and Penarrocha et al. 2010229 measured bone loss in
calibrated panoramic radiographs; other authors used intraoral
radiographs made with the paralleling technique (Balleri P et al.
2010, Agliardi EL et al. 2009)239,235. Penarrocha et al. 2010229
assessed bone loss in panoramic radiographs calibrated with
CliniView (Version 5.1, Tuusula, Finland) after the surgery and a year
after loading, giving an average marginal bone loss of 0.78 mm for 48
pterygoid implants. Rose´n and Gynther 2007232 published the
series with the longest follow-up: they reported an average bone loss
of 1.2 mm after 8 to 12 years; 10% of the implants presented bone
resorption larger than that acceptable according to the criteria of
Albrektsson et al. 1 mm during the first year after loading and 0.2 mm
each year thereafter. Several authors have compared bone loss
between tilted and axial implants. Aparicio et al. 2001233 measured
bone loss in intraoral radiographs using the prostheses placement
radiograph as baseline at the mesial and distal aspects of each
implant and then calculated a mean value to the closest half thread:
They reported average bone losses of 0.92 mm and 1.21 mm for
axial and tilted implants respectively after 5 years of follow-up, with
no statistically significant differences. Agliardi et al. 2009235 also
averaged mesial and distal values to provide a single value for each
implant but used peri-apical radiographs after implant placement as
baseline; the radiographs were scanned (Epson Perfection Pro,
Epson) and the marginal bone level assessed with an image analysis
software (UTHSCSA Image Tool version 3.00 for Windows,
University of Texas Health Science Center at San Antonio) by an

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independent blinded radiologist. They obtained an average bone loss
of 0.9 mm for axial implants and of 0.8 mm for tilted implants in the
one-year control visit, exhibiting no statistically significant
differences. Similarly in the study by Calandriello et al (2005)214
radiographs were digitized with a scan (Epson 1240, 800 dpi) and
bone loss was measured with an image analysis program (NIH Image
Version 4.0.2, Scion Corp, Frederick, Md) by an independent
radiologist; radiographics were repeated in cases of non-readable
examination. They reported changes in bone level of 0.82 - 0.86 mm
and 0.34 - 0.76 mm for axial and tilted implants respectively after 1
year, being the only series reporting statistically significant
differences. The authors suggested that the lower bone
resorption observed in tilted implants may be related to the position
of the implant neck relative to the bone crest; mesially the neck was
in supracrestal position, while distally it was subcrestal, resulting in a
favorable soft tissue seal.
Table: Quantitative data of the final 9 included studies that were
analysed.

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 Well organized, thorough treatment plan leads to successful
implant treatment and patient satisfaction, which are ultimate long-
term goals. Pterygoid implants are relatively safer to place however, a
thorough knowledge of anatomy and proper surgical technique allows
for minimizing the complications and enhancing the treatment
success.

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 HEALING

The ultimate long-term success of implants is largely relied upon

the interface between implants and their surrounding tissues, both
soft and hard tissues. Dental implants have two distinct interfaces
with oral tissues.
The hard tissue-implant interface is where the alveolar bone
contacts with implant surface. This integration provides stability and
rigidity that implant needs.
The soft tissue-implant interface is where the peri-implant mucosa
meets the implant creating a biological seal to prevent future disease
invasion. Due to the nature of the tissue components, soft tissues
surrounding the dental implants are called peri-implant mucosa
instead of gingiva.
To achieve and maintain long-term success of dental implants, it is
necessary to understand how these interfaces are and how they can
be maintained (Joseph Fiorellini et al. 2006).240

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ard Tissue Interface
The primary goal of implant installation is to achieve and maintain
a stable bone-to-implant connection (i.e. osseointegration)
(Branemark PI et al. 1969; Branemark PI et al. 2005)51,241.
Histologically, osseointegration is defined as the direct structural and
functional connection between ordered, living bone and the surface of
a load-bearing implant without intervening soft tissues (Branemark PI
et al. 2005).241
Clinically, osseointegration is the asymptomatic rigid fixation of an
alloplastic material (implant) in bone with the ability to withstand
occlusal forces (Albrektsson T et al. 2005; Zarb G et al. 1991).242,243
The hard tissue interface is afundamental requirement for and an
essential component of implant success.
Initial Bone Healing
The osseointegration process observed after implant insertion can
be compared to bone fracture healing. Implant site osteotomy
preparation (bone wounding) initiates a sequence of events,
including an inflammatory reaction, bone resorption, release of
growth factors, and attraction by chemotaxis of osteoprogenitor cells
to the site.

157
 Fig 40: A - Three-dimensional diagram of the tissue and titanium interrelationship
showing an overall view of the intact interfacial zone around the osseointegrated
implant. B - Physiologic evolution of the biology of the interface

Differentiation of osteoprogenitor cells into osteoblasts leads to

bone formation at the implant surface. Extracellular matrix proteins,
such as osteocalcin, modulate apatite crystal growth (Xio G et al.
1997)244. Specific conditions, optimal for bone formation, must be
maintained at the healing site to achieve osseointegration. Immobility
of the implant relative to the bone must be maintained for bone
formation at the surface. A mild inflammatory response enhances the
bone healing, but moderate inflammation or movement above a
certain threshold is detrimental (Albrektson et al. 1987)245. When
micro- movements at the interface exceed 150 μm, the movement will
impair differentiation of osteoblasts and fibrous scar tissue will form
between the bone and implant surface (Recum AF 1996)246.
Therefore, it is important to avoid excessive forces, such as occlusal
loading, during the early healing period. Bone tissue damage and
debris created by the osteotomy site preparation must be cleared up
by osteoclasts for normal bone healing. The multinuclear cells,

158
originating from the blood, can resorb bone at a pace of 50 to 100 μm
per day. There is a coupling between bone apposition and bone
resorption.

Fig 41: The basic multicellular unit is the basic remodeling process for bone
renewal. Osteoclasts are imported by the vascular supply, and the resorption
lacunae are soon filled by the lining osteoblasts.

Preosteoblasts, derived from primary mesenchymal cells, depend

on a favorable oxidation-reduction (redox) potential of the
environment. Thus, a proper vascular supply and oxygen tension are
needed. If oxygen tension is poor, the primary stem cells may
differentiate into fibroblasts, form scar tissue, and lead to implant
failure (nonintegration).
If bone is overheated or crushed during preparation, it will become
necrotic and may lead to non-mineralized (soft tissue) scar formation
or be sequestered. The critical temperature for bone cells that should
not be exceeded is 47°C at an exposure time of one minute
(Albrektsson T et al. 1987)245. Thus preparation of implant
osteotomy sites require profuse irrigation (cooling) along with gentle,
intermittent, moderate-speed drilling using sharp drills. Another
complicating factor, well recognized from open wound fractures, is
that microbial contamination jeopardizes the normal bone healing.
Accordingly, strict aseptic techniques should be maintained.

159
 New bone formation follows a specific sequence of events. Woven
bone is quickly formed in the gap between the implant and the bone;
it grows fast, up to 100 μm per day, and in all directions.
Characterized by a random orientation of its collagen fibrils, high
cellularity, and limited degree of mineralization, the biomechanical
capacity of woven bone is poor.

Fig 41: A - After initial healing, woven bone, as characterized by its irregular
pattern, is laid down. B - After weeks or months, progressively a lamellar bone is
laid down, with regular concentric lamellae. B, Bone; I, implant. (Courtesy Professor
T. Albrektsson, Gothenburg, Sweden.)

Thus any occlusal load should be well controlled or avoided in the

early phase of healing. After several months, woven bone is
progressively replaced by lamellar bone with organized, parallel
layers of collagen fibrils and dense mineralization. Contrary to the
fast-growing woven bone, lamellar bone formation occurs at a slow
pace (only a few microns per day). Ultimately, after 18months of
healing, a steady state is reached where lamellar bone is
continuously resorbed and replaced (Branemark PI 1987)247.

160
Fig 42: Once a steady state has been achieved at the bone-to-implant interface, an
intimate contact can be observed, with some marrow spaces seen in between at
the light microscopic level.

At the light microscopic level, an intimate bone-to-implant contact

has been extensively reported (Balshi TJ 2003)248. Once the bone-to-

implant interface has reached a steady state, it can maintain itself

over decades, as ascertained by human histology from

implants retrieved because of hardware fractures
(Barewal RM 2003)249.

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one Remodeling and Function
Clinically, both primary and secondary stability of an implant are
critical to success. Primary stability, achieved at the time of surgical
placement, depends on the implant geometry (macro design), as well
as the quality and quantity of bone available for implant anchorage at
a specific site. Secondary stability, achieved over time with healing,
depends on the implant surface (micro design), as well as the quality
and quantity of adjacent bone, which will determine the percentage of
contacts between the implant and bone (Fransson C et al. 2009)250.
For example, areas such as the anterior mandible have dense
cortical bone and provide rigid primary stabilization and good support
throughout the healing process. Conversely, areas such as the
posterior maxilla have thin cortical bone and large marrow spaces
provide less primary stability. For this reason, the posterior maxilla
has been associated with lower success rates compared to other
sites with greater bone density and support (Barewal RM 2003;
Jemt T 1991)249,251.
Once osseointegration is achieved, implants can resist and
function under the forces of occlusion for many years. Longitudinal
biomechanical assessments seem to indicate that during the first
weeks after placement of one-stage implants, decreased rigidity is
observed (Friberg B et al. 1999)252. This may be indicative of bone
resorption during the initial phase of healing. Subsequently, rigidity
increases and continues to increase for years. Thus, when a
prosthesis is installed immediately (in 1 day) or early (in 1 to 2
weeks), care must be taken to control against overload. It is important
to recognize that sites with limited primary stability or less bone-to-
implant contact (e.g., posterior maxilla) will likely go through a period

162
of even less bone support in the early stages of bone healing due to
the initial phase of bone resorption.
Implant/Soft Tissue Interface
Epithelial attachment
Connective tissue attachment
Biological width
Keratinized mucosa to maintain implant health
Epithelial Attachment
The peri-implant mucosa, similar to the natural gingiva, can be
divided into two parts: epithelium and connective tissue. Briefly, the
epithelial tissues around implants move more in apico-coronal
direction and as a result it is average 1 mm longer when compared to
natural teeth. The attachment of epithelial cells to implant surface
occurred directly via basal lamina (<200 nm) and hemidesmosomes
which was the same as natural teeth. The implant surface topography
has been shown to play a role in influencing how soft tissue attached
to dental implant. It is generally agreed that polished surfaces are
more compatible to fibroblasts than rough surfaces. Obtaining a peri-
implant mucosal seal to prevent bacterial invasion is suggested as a
pre-requirement for maintaining long- term success of dental
implants. When the seal is not achieved, it often leads to apical
migration of the epithelium, thus cause partially or completely
encapsulation of the endosseous implant. In natural teeth, the
junctional epithelium provides a seal at the base of the sulcus against
the penetration of chemical irritants and bacterial by-products. Once
disruption of the seal and/or destruction of the fibers apical to the
epithelium take place, the epithelium migrates apically, forming a

163
periodontal pocket. Due to the lack of cementum and fiber insertion
into the implant surface, the biologic seal was important in preventing
formation of a "peri-implant pocket" extending into the osseous
structures (Tsao and Wang et al.2003).253
Connective Tissue Attachment
The average length of connective tissue attachment around
implant ranges from 1.3 to 1.8 mm. Majority of the studies showed a
parallel-oriented fiber’s orientation instead of perpendicular as those
formed in natural teeth. In addition, the connective tissue around
implants had been shown to possess less vascularities, more
collagen and less fibroblasts when compared to natural teeth. The
connective tissue of the peri-implant mucosa can be further divided
into outer and inner zone. The outer zone located under the
junctional epithelium, is composed of collagen Types I and III and is
responsible for the transformation of collagen. The inner supra crestal
connective tissue zone is composed mainly of Type I collagen and is
responsible for mechanical resistance and stability of the peri-implant
mucosa (Tsao and Wang et al. 2003)253.
Difference between natural teeth and dental implant

164
 Fig 43: Biologic in natural tooth

Biological Width
A term frequently used to describe the dimensions of the soft
tissues that face the teeth is the biologic width of the soft tissue

165
attachment. The development of the biologic width concept was
based on studies and analyses by, among others, Gottlieb (1921)254,
Orban and Köhler (1924)255, and Sicher (1959)256, who documented
that the soft tissue attached to the teeth was comprises of two parts,
one fibrous tissue and one attachment of epithelium. In a publication
by Gargiulo et al. (1961)257 called “Dimensions and relations of the
dentogingival junction in humans”, sections from autopsy block
specimens that exhibited different degree of “passive tooth eruption”
(i.e. periodontal tissue breakdown) were examined. Histometric
assessments were made to describe the length of the sulcus (not part
of the attachment), the epithelial attachment (today called junctional
epithelium), and of the connective tissue attachment.

Fig 44: Drawing describing the “biologic width” of the soft tissue attachment at the
buccal surface of a tooth with healthy periodontium. The combined length of the
junctional epithelium (epithelial attachment) and the connective tissue attachment is
considered to represent the “biologic width” of the soft tissue attachment. Note the
gingival sulcus is NOT part of the attachment.

The biological width around dental implants acts as a protective

barrier against potential bacterial infection, food debris entrapment

166
into the implant/soft tissue interface. It had been shown in animal and
human studies that an adequate biological width/seal can only be
achieved if there is supra-crestal smooth titanium surface of at least 3
mm long in the apico-coronal direction. Approximately 2 mm of the
surface was occupied by the junctional epithelium, while the rest 1
mm is connective tissue. Biological width has been reported
composed of 2.0 mm of junctional epithelium and 1.3 to 1.8 mm
connective tissue for a two-part implant. Similar dimensions were also
observed around one-part implant before and after 12 months
loading. Recent evidence has suggested that reformation of biological
width may be the primary etiology contributing to early implant crestal
bone loss. Nevertheless, some authors have speculated that
biological width/seal increases approximately 1 mm after implant
loading, possibly due to crestal bone resorption.27 Extensive research
in animals and humans in diverse implant systems (Abrahamsson
et al. 1996, Ericsson et al. 1996)258,259, following abutment
reconnection (Abrahamsson et al. 1997)260, with loaded and
unloaded implants (Cochran et al. 1997)261, with different materials
and roughness (Abrahamsson et al. 1998)262 and with alterations in
the vertical dimensions of the soft tissues (Berglundh & Lindhe
1996)263 has shown that a stable biological seal can only be
achieved if there is a surface atleast 3mm long in the apico-
coronal direction supra-crestally. The junctional epithelium covers
about 2 mm of this surface, while the rest is utilized for the
connective tissue adhesion (Tsao and Wang et al. 2003)253.
The junctional and barrier epithelia are about 2 mm long and the
zones of supra-alveolar connective tissue are between 1 and 1.5 mm

167
high. Both epithelia are attached via hemi-desmosomes to the tooth/
implant surface (Gould et al. 1984)264. The main attachment fibers
(the principal fibers) invest in the root cementum of the tooth, but at
the implant site the equivalent fibers run in a direction parallel with the
implant and fail to attach to the metal body. The soft tissue
attachment to implants is properly established several weeks
following surgery.
a) Keratinized Mucosa to Maintain Implant Health
The need of keratinized mucosa around dental implants to
maintain implant mucosa health remains controversial, since healthy
peri-implant tissues can be observed regardless of the amount of
keratinized mucosa. It has been reported 90% of overall fixture
survival rate even only 67% of these cases had keratinized mucosa in
the facial aspect and 51% in the lingual surfaces. Hence, it had been
challenged that keratinized mucosa is not the pre-requisite for peri-
implant health and movable tissue surrounding dental implant does
not contribute to more implant failure. On the other hand, some
papers have reported increased implant failure rate in the areas of
insufficient peri-implant mucosa width. Although the conflicted results
existed, it is desirable to have keratinized mucosa around the implant
since keratinized tissue not only promotes resistance to mechanical
trauma but also facilitates personal home care and professional
maintenance procedure. Different procedures including connective
tissue grafts, free gingival grafts, and others have been described to
augment keratinized mucosa around dental implants successfully
(Tsao and Wang et al. 2003)253.
Vascular Supply

168
 The vascular supply to the gingiva comes from three different
sources, the large supra periosteal blood vessels, the vascular plexus
of the periodontal ligament and the arteries arising from the alveolar
crest. Berglundh (1994)265 observed that the vascular system of the
peri-implant mucosa of dogs originated solely from the large supra
periosteal blood vessels on the outside of the alveolar ridge. This
vessel gave off branches to the supra-alveolar mucosa and formed
the capillaries beneath the oral epithelium and the vascular plexus
located immediately lateral to the barrier epithelium. The connective
tissue contained only few blood vessels identified as terminal
branches of supra periosteal blood vessels (Tsao and Wang et al.
2003)253. Picture plate 6 describes the schematic representation of
vascular supply.
Periodontal tissues versus peri-implant tissues
The soft and hard tissues around osseointegrated implant show
some similarities with the periodontium. However, the following
differences are very important:
The absence of periodontal ligament in the peri-implant region.
The orientation of the soft tissues around implants, which are non-
attached and parallel to the implant surface, while the gingival tissues
around teeth are perpendicular and attached to the root cementum.
The response to pathological insults.
The coronal portion of implant and/or abutment is surrounded by a
thin layer of collagen fibres arranged circumferentially and with
minimal vascular structures. This less vascular soft tissue band may
affect the defense mechanisms around an implant as compared to
those seen in tissues around teeth with periodontal ligament. If

169
plaque accumulates on the implant surface, the sub epithelial
connective tissue is infiltrated by large numbers of inflammatory cells
and a layer of epithelial cells appear ulcerated and loosely adherent.
Also, the absence of periodontal ligament inthe peri-implant region
reduces the load bearing capacity of the implant owing to limited
movement of the implant and irreversibility of the peri-implant bone
microfractures as a result of occlusal overloading. Picture plate 6
schematically describes the distribution of collagen fibres in normal
periodontium and on implant surface.
Peri-implant tissues do not accommodate increased biomechanical
stresses, due to the fact that: implants move minimally in bone
compared with their natural tooth counterparts; With overload, micro
fracturing of the bone occurs, and this is irreversible, even with
control of the overload; and a reduced area of support exists in the
root- form implant compared with that of natural teeth.

170
 In contrast, the periodontal ligament hypertrophies with increased
function, allowing for greater movement in bone; with overload,
mineralized bone volume may be reduced around natural teeth, but in
the absence of inflammation, periodontal disease, the situation is
reversible once the overload is eliminated or reduced; and the
periodontal ligament is attached to a natural tooth with greater
surface area and allows for off-axis loading. It has also been shown
that the inflammation is more pronounced and the inflammatory
process goes deeper and faster around the dental implant than
around the adjacent natural tooth (Lindhe et al. 1992)266. It has been
suggested that implants have a less-effective natural tissue barrier
than natural teeth and are less resistant to infection (Berglundh et al.

171
1992; Lindhe et al. 1992)267,266. The predictability of a stable soft
tissue attachment has not been confirmed and the peri-mucosal seal
may be just a circular fiber arrangement (Meffert 1988)268.

172
 SUMMARY

Maxillary bone is different in its function, physiology, and bone

density from the mandible. These differences, along with its varied
anatomy, challenge the implant placement in harmony with planned
prosthetic restoration. However, a thorough knowledge of anatomy,
materials and proper patient selection will result effective long-term
solutions in the management of the atrophied maxilla
Extremely atrophic maxillae are the most challenging task for
restorative dentists. Pterygoid implant may be considered as
promising alternative to 3D maxillary reconstruction, sinus lifts, and
bone augmentation technique. They allow anchorage in the posterior
atrophied/resorbed maxilla, achieving proper stability, and high rates
of long-term success. In addition, posterior cantilevers can be
eliminated and axial loading is improved.
The location of the posterior implant is determined by the
dimensions and quality of the tuberosity. The mesio-distal angulation
of the implant is determined by the angle of the posterior wall of the
sinus and its proximity to the posterior wall of the tuberosity. The
buccopalatal angulation of the implant is determined by the bone
segments to be engaged. When indicated, and when sufficient bone
structure is available, the surgeon may place the apical portion of the
implant in the pterygoid process of the sphenoid bone and/or the
pyramidal process of the palatine bone.
To further summarize should implants be placed in the
pterygoid process or the pterygomaxillary region?
The findings in the literature showed no clear differences
between pterygoid and pterygomaxillary implants. The classic

173
technique of pterygoid implants was described by Tulasne, in which
implants were anchored in the pterygoid plate, which provides a
stable anchor as it is a very dense bone. This technique used 22-mm-
long implants. Many researchers have subsequently modified the
technique without changing the nomenclature, and increasingly more
implants are placed in the pterygomaxillary region without anchorage
in the pterygoid process. These implants are shorter and parallel to
the posterior wall of the maxillary sinus.
Some researchers, including Bahat and Balshi, have placed
implants as long as 7 or 8.5 mm in this region. No consensus exists
regarding the nomenclature of these implants; it would be interesting
to distinguish between the 2 anatomic retromolar locations in which
implants are placed, the pterygomaxillary region and the pterygoid
process.

By analyzing all the aspects it can be concluded that the atrophic

posterior maxilla should be evaluated and classified not only in terms
of residual bone height and width, but also vertical and horizontal
inter-maxillary relationships to optimize implant placement from a
functional and esthetic point of view.

For posterior atrophic areas, where esthetics is not a prime

concern, contemporary treatment options such pterygoid implant can
be the treatment of choice taking into account that they may result in
a prosthetic and functional compromise.

174
 It is graftless solution for atrophic maxillary rehabilitation making it
cost effective and removing the burden of multiple surgical procedure
for the patients reducing patient morbidity and increasing patient
compliance.

Pterygoid implants have high success rates, similar bone loss

levels to those of conventional implants, minimal complications, and
good acceptance by patients; therefore, Pterygoid implants are the
ray of hope for thousands of people with atrophic posterior maxilla.
For the way foreword…..
In literature highest success rate of pterygoid implants has been
mentioned. However, to draw the more definitive conclusion, more
studies with longer follow up period involving adequate number of
pterygoid implants are needed. This will help to obtain a better
understanding of the survival of pterygoid implants.

175
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