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Paranasal Bone: The Prime Factor Affecting the Decision to Use Transsinus
vs Zygomatic Implants for Biomechanical Support for Immediate Function in
Maxillary Dental Implant Reconst...

Article in The International journal of oral & maxillofacial implants · January 2014
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Paranasal Bone: The Prime Factor Affecting the
Decision to Use Transsinus vs Zygomatic Implants
for Biomechanical Support for Immediate Function in
Maxillary Dental Implant Reconstruction
Ole T. Jensen, DDS, MS1/Mark W. Adams, DDS, MS2/Edmund Smith, MSc3

Paranasal bone affects the decision-making process for placement of implants for immediate
function in the highly resorbed maxilla. The most important bone for apical fixation of implants in
this setting is the lateral nasal bone mass. Maximum available bone mass found at the pyriform
above the nasal fossa, designated M point, can most often engage two implants placed at
30-degree angles. The second most important area of paranasal bone mass is the subnasal bone
of the premaxilla, which is required to engage an angled implant at the alveolar crest. However,
only 4 to 5 mm in height is needed when implants are angled posterior to engage M point. The third
most important paranasal bone site for implant fixation is the midline nasal crest extending upward
to the vomer. This site, which is usually type 1/2 bone, can engage implants apically and provide
enough fixation for immediate function even if implants are short. These anatomical bone sites
enable placement of implants to obtain a 12- to 15-mm anterior-posterior spread, which is favorable
for immediate function. Int J Oral Maxillofac Implants 2014;29:e130–e138. doi: 10.11607/jomi.te52

Key words: anterior-posterior spread, immediate function, M-4, M point,

pyriform rim, V point, vomer/nasal crest, zygomatic implants

T
reatment planning decisions made from com-
puted tomography (CT)-scan images for max-
illary reconstruction in conditions of severe
atrophy will be affected by available bone mass, the
need for anterior-posterior (A-P) spread, and desire
for immediate function.1–3 The surgical-prosthetic
team needs to know whether immediate function is
possible or if bone grafting is necessary, as well as
whether transalveolar placement of implants is pos-
sible or if zygomatic implants will be required.4–6
If implants can be placed with sufficient insertion
torque and A-P spread, then immediate loading is
possible; if not, a submerged technique will be neces-
sary.7–9 The number of implants required will vary, with
1ClinicalAssistant Professor, Department of Oral and
Maxillofacial Surgery, University of Michigan; Private Practice,
ClearChoice, Denver, Colorado, USA.
2P rosthodontist, ClearChoice, Denver, Colorado, USA.
3 B iomechanical Engineer, ClearChoice, Denver, Colorado, USA.
Correspondence to: Dr Ole T. Jensen, 8200 East Belleview
Avenue, Suite 500, Greenwood Village, CO 80111, USA.
Email: Ole.Jensen@clearchoice.com
©2014 by Quintessence Publishing Co Inc.
a minimum of four implants recommended.10–13
Despite the high incidence of severe maxillary atro-
phy, zygomatic implants remain relatively infrequently
used since the advent of the transsinus implant ap-
proach.14 The key decision factor for when or when
not to prescribe zygomatic implants is largely based on
the presence of paranasal bone, especially the lateral
pyriform rim, which historically has been used for cra-
niofacial fixation in orthognathic surgery and now api-
cal fixation of dental implants.14–16 Important features
of paranasal bone mass include the thickness of the
lateral nasal wall, the presence of subnasal bone, and
the height of the midline suture including the vomer/
nasal crest bone mass.17
In a four-implant scheme, such as All-on-4 (Nobel
Biocare), posterior implants rely on cortical bone
found anterior at the lateral nasal wall. Because the
alveolar crest remnant is often reduced to form the
All-on-4 bone shelf, alveolar cortical bone is removed,
making crestal fixation difficult, if not impossible.18
The two anterior implants are optimally angled poste-
riorly to also engage the lateral pyriform rim, but they
can sometimes be angled toward the midline bone
mass for fixation there when vertical bone mass is in-
sufficient.18

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Fig 1   In this atrophic maxilla with the sinus and nasal fossa ex-
posed, the posterior implant is inserted to pass transsinus into the
pyriform rim.
A-P spread is also an important factor for biome-
chanical stability.19 Implants must be 12 to 15 mm
apart, anterior to posterior, to gain adequate A-P
spread for a fixed maxillary restoration.20 To achieve
this amount of spread, the posterior implants need to
be placed in areas where fixation cannot be obtained,
due to loss of alveolar crest and proximity to the sinus
cavity. Implants placed as such have little or no inser-
tion torque as they pass transsinus and will require
bone grafting (Fig 1). Though four implants could be
placed in a relatively straight line in available subna-
sal bone, there would be minimal A-P spread, which
would not be favorable biomechanical support for ex-
tended cantilever function.21 Insertion torque, there-
fore, takes a back seat to A-P spread despite lack of
fixation of the posterior implants. These posterior im-
plants angle anteriorly to engage the lateral pyriform
rim even as anterior implants angle posteriorly to the
pyriform (Fig 2), the implants often touching apically
(described previously as the M-4 configuration for All-
on-4 therapy).14,22
Implant reconstruction to gain adequate inser-
tion torque for immediate loading is determined by
the lateral nasal cortical bone, the subsinus alveolar
crest bone residuum, available subnasal bone mass,
and the nasal crest, all used to develop a favorable
A-P spread. The occlusal scheme of the provisional
prosthesis is also an important biomechanical factor
to consider, as fragile primary implant stability can be
overcome by occlusal load.
© 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Jensen et al
Fig 2   The anterior implant is angled 30 degrees posteriorly to
avoid the nasal fossa and insert into the pyriform rim; this creates
an M-4 pattern when viewed on a panoramic radiograph post-
placement.
LATERAL NASAL WALL
Midface osseous atrophy follows a pattern of volumet-
ric reduction in all dimensions, with the alveolus lost
first, then basal bone, and then lateral pyriform rim.23
But the pyriform, nasal crest, and zygomatic bones are
somewhat unaffected by disuse atrophy of the maxilla,
with the zygomatic bone least affected.22
In patients with severe maxillary atrophy and a re-
duced alveolar bone stock combined with reduced
lateral nasal wall thickness of 1 mm or less, there may
be insufficient bone to engage using a transsinus ap-
proach; in such cases, a zygomatic implant can be
considered.23 In the vast majority of patients, however,
the lateral nasal wall will be 2 mm or greater, enough
to engage an implant transsinus, but only if there is
also sufficient bone at the alveolar crest to stabilize
the implant.14 In situations where there is confluence
between the nasal fossa and the sinus cavity, the zy-
gomatic implant is a good choice.23
SUBSINUS ALVEOLAR CREST
BONE HEIGHT
Subsinus bone residuum after reduction for the bone
shelf must be of sufficient height to warrant trans-
sinus implant placement. Implants placed at 30-
degree angles anteriorly into the lateral pyriform above
the nasal fossa will gain stability even if there is very
The International Journal of Oral & Maxillofacial Implants e131
Jensen et al
M point
Fig 3   M point is the maximum bone mass at the lateral pyriform
rim above the nasal fossa, where implant apices can engage corti-
cal bone for primary stability.
little bone available, as stability is assisted by implant
splinting.12 When there is an absence of bone at the
lateral pyriform, consideration should be given to the
use of zygomatic implants.23 Alternatively, when there
is minimal crestal bone available but enough bone at
the lateral pyriform to gain primary stability, the implant
can still be placed and grafted within the transsinus
passage, though it may be considered too unstable for
immediate loading. Experienced surgeon/prosthodon-
tist teams have determined that even if an implant is
mobile and can be hand turned, as long as it is verti-
cally stable, having a vertical stop, it can be splinted
into an immediate-function provisional restoration
(Jensen OT, Adams MR, unpublished data, 2012).24
In maxillae that have very thin alveolar width as well
as insufficient subsinus bone height, the entry point
for implant placement is palatal, then directed transal-
veolar (medial to lateral transsinus) to engage cortical
bone at the lateral pyriform at M point. This method
provides bicortical engagement and higher torque val-
ues, and may not require sinus grafting despite trans-
sinus passage.24
SUBNASAL ALVEOLAR HEIGHT
In the highly atrophic maxilla, the alveolus can be almost
absent subnasally; however, implant fixation can often
still be obtained by directing angled implants later-
ally into the nasal wall, where there is generally enough
bone to secure both posterior and anterior implants at
M point (Fig 3).14 When this is not possible, two anterior
implants can be angled toward V point at the midline
into the vomer/nasal crest area (Fig 4).17 This is done
without entering the nasal fossa. Implants placed in this
e132 Volume 29, Number 1, 2014
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V point
Fig 4   V point is the maximum bone mass found at the nasal crest
in the midline, where midline-directed implants can engage corti-
cal bone for anterior implant stability.
way are generally short—approximately 10 mm—but
often well fixed, with insertion torques above 50 Ncm
(Jensen OT, Adams MR, unpublished data, 2012).17,25
When there is minimal subnasal bone available and
the entire maxilla is extremely atrophic except for the
midline, two 30-degree–angled vomer/nasal crest im-
plants can be complemented by bilateral posterior zy-
gomatic implants.26 However, when there is complete
absence of both M point and V point bone mass, a
quad zygomatic approach is suggested if immediate
function is desired.23,26
ANTERIOR-POSTERIOR SPREAD
Implants placed into available bone mass in an atrophic
maxilla with a relatively anterior sinus cavity deflection
will lead to a short A-P span between implants, some-
times only 5 to 6 mm if implants are placed vertically.
The consequence of this is a long, biomechanically un-
favorable cantilever. A narrow spread is generally inad-
equate for a full-arch fixed restoration.27 Angulation of
the posterior implants facilitates increased A-P spread
(Figs 5 and 6). The minimum A-P spread should be
12 mm, but 15 mm is optimal.19 This will provide ad-
equate support for the titanium bar to enable an ap-
proximate 10-mm cantilever for first-molar occlusion
(Figs 7 and 8). Adequate A-P spread is one reason
the transsinus implant approach was developed; if not
transsinus, zygomatic implant placement facilitates
A-P spread for immediate provisionalization.14,25
Ectomorphic individuals with small overall bone
dimension can sometimes be treated with a three-
implant scheme, as a reduced A-P spread may be ac-
ceptable in both jaws.

Anterior-posterior
spatial maxilla
Fig 5   Anterior-posterior spread is improved in the mandible by
tilting the posterior implants 30 degrees distally.
10 mm
10 mm
Fig 7   Once bone reduction is completed to create a level bone
shelf (a total bone reduction of approximately 14 to 15 mm in each
arch), there is enough room for a 4-mm titanium bar. However,
without tilting the back implants, the bar will need to support a
longer cantilever and bar fracture may occur.
OCCLUSAL SCHEME
In the provisional stage for immediate function, the
occlusion should be limited to equal contacts and
equal, symmetric distribution of contacts between the
implants,25 avoiding both anterior and posterior canti-
lever extensions.27 Cantilevers are not used in the pro-
visional restoration so as to reduce bone strain from
lever moments of force.28,29 Adjustments are made
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Jensen et al
Anterior-posterior
spatial mandible
Fig 6   Anterior-posterior spread is improved in the maxilla by tilt-
ing the posterior implants 30 degrees distally.
10 mm
10 mm
Fig 8   Following bone reduction and placement of posterior tilted
implants, the bar is well supported and results in a shorter cantile-
ver than for vertical implant placement.
in lateral movements to eliminate interferences, and
cusps are flattened slightly to minimize lateral forces
and distribute them over a large area.30
Along with a limited occlusal scheme, there is a re-
quirement for a mechanical soft diet until the implants
undergo early osseointegration from bone modeling at
about 6 weeks.29 When sinus grafting for low–insertion-
torque transsinus implants is done, 4 to 6 months of an
occlusion-sparing regimen should be prescribed.12
The International Journal of Oral & Maxillofacial Implants e133
Jensen et al

Fig 9   The “M” pattern of M-4 implant placement as seen on a postoperative panoramic radiograph is an excel-
lent method to gain adequate A-P spread using cortical bone found at the lateral pyriform rim.

CASE STUDY

A 36-year-old man presented with an edentulous maxilla, having worn a maxillary complete
denture for 3 years. There was moderate to severe alveolar-width atrophy but still adequate
height for placement of implants. Implants were placed at 30-degree angles using the M-4
technique, engaging M point with implant apices bilaterally (Fig 9). This enabled placement
of the implants into wider bone so that facial dehiscence grafting was not required. The M-4
angulation strategy easily avoided the nasal and sinus cavities. Long implants, which gain
high insertion torque (greater than 50 Ncm) and an A-P spread of 12 to 15 mm for immedi-
ate function (Figs 10a to 10c), were used. Following placement of the implants, a provisional
restoration was placed to splint all of the implants into cross-arch stabilization (Fig 11).

DISCUSSION bone remains the most easily accessed in the majority

Several factors affect decision-making regarding im-
mediate function in the edentulous maxilla, one of the
most important being engagement into cortical bone.
Because the alveolar crest is frequently removed to
create a bone shelf, the search for cortical bone be-
comes complicated and there are few options avail-
able in a well-aerated midface. Though pterygoid and
zygomatic cortex are possibilities, the use of paranasal
of cases. But how much cortical fixation is required for
dependable full-arch provisionalization?
For single implants placed into extraction sites and
temporized on the same day, it has been suggested
that a minimum of 6 mm of apical cortical bone is re-
quired for immediate function.31 In cross-arch splinted
schemes, the absolute requirement of cortical fixation
has not been determined, though it must be substan-
tially less, as evidenced by multiple All-on-4 maxillary

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 Jensen et al

a b
Figs 10a to 10c   By using an M-4 strategy with four 30-degree
angled implants instead of sinus grafting for vertical implant place-
ment, A-P spread is found to be 12 to 15 mm, as demonstrated
in this patient.

Fig 11   The provisional restoration remains stable after 6 weeks

of loading.

treatments done successfully with minimal bone avail-
ability.11,32 In fact, full-arch splinted restorations often
are based on a relatively low composite torque (the
sum of all four insertion torque values). Our studies
suggest that a composite torque value of 120 Ncm,
allowing for a maximum value of 50 Ncm for any single
implant, is sufficient for immediate loading. This has
been done even when two of four implants are some-
what mobile (Jensen OT, Adams MR, unpublished
data, 2012).
One study demonstrated that an implant placed
completely out of contact with bone but splinted to
adjacent implants in a mandibular fixed prosthesis still
osseointegrated.31 In the maxilla, with the economy
of four implants in type 3/4 bone, it would seem that
all four implants need to be fixed for osseointegration
to occur. This has been shown clinically not to be re-
quired.31 However, when adjacent implants are of low
insertion torque and have minimal cortical bone con-
tact, the entire appliance can be overcome by occlusal

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Jensen et al
load, leading to catastrophic failure of all four implants
(Jensen OT, Adams MR, unpublished data, 2012).
The key is to use available bone mass in creative
ways, such that insertion torque is maximized and a fa-
vorable A-P spread is still realized. Implant angulation
accomplishes this, with the most favorable angle—
surgically and prosthetically—being 30 degrees.
Implant angulation at 30 degrees does three things:
1. It increases the length of the implant in bone by
50%.33,34
2. It increases occlusal load resistance form.34–36
3. In splinted configurations, it leads to subosseous
conformation that is highly resistant to shear
force.35,36
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Fig 12a   The medical model of a maxilla
showing ideal placement of zygomatic and
M-4 distribution implants.
Fig 12b   The emergence of the zygo-
matic and transsinus implants are both
near the second premolar area, giving a
near equivalent A-P spread for prosthetic
stability.
Increased length will increase load-bearing capac-
ity, both for immediate function and once osseontegra-
tion occurs (Jensen OT, Adams MR, unpublished data,
2012). Since there is an absence of cortical bone at
the crest after bone reduction, resonance frequency
analysis is generally not helpful. The surgeon must
therefore rely on insertion torque as the main clini-
cal guide. By placing longer angled implants, there is
potentially greater implant surface area to gain inser-
tion torque, though it still may be relatively low (Jensen
OT, Adams MR, unpublished data, 2012). In addition,
implants lying “sideways” have potentially more resis-
tance form to compression and pullout force as well as
shear force.35 In this setting, cancellous bone may ac-
tually contribute to load-bearing capacity when com-
pared to vertically placed (shorter) implants.

Adjacent implants placed at 30-degree angles can
be as much as 60 degrees convergent/divergent from
each other within bone. In most cases, four implants
placed with various divergence angles will add com-
plex secondary resistance form to augment prosthetic
splinting.14,36
However, the major determinant of load-bearing
capacity of newly placed implants in a maxilla with de-
ficient bone mass is finding cortical bone to fix four
implants apically for adequate A-P spread, as there is
seldom substantial bone contact available anywhere
else except apically. Though bone contact may be
minimal at the alveolar crest, the prosthesis will serve
to immobilize the implants by what could be termed
secondary stabilization.37–40
In summary, the residual cortical areas of common-
ly available paranasal bone, including subnasal basal
bone, the vomer/nasal crest, and the lateral pyriform
rim, should be considered prior to selecting the zygo­
matic implant option. The clinician should remember
that transsinus implant emergence in the alveolar pro-
cess is nearly equivalent with that of the zygomatic
implant (Figs 12a and 12b) and that the transsinus
implant does not have as high an incidence of oro-
antral fistulae as the zygomatic implant.14,34,41–43 It is
only when paranasal sites have inadequate bone that
extramaxillary bone stock should be considered for
All-on-4 immediate function.
Acknowledgments
The authors reported no conflicts of interest related to this study.
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