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22 Maxillary Posterior Edentulism - Pocket Dentistry
22 Maxillary Posterior Edentulism - Pocket Dentistry
22 Maxillary Posterior Edentulism - Pocket Dentistry
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Chapter 22
Maxillary posterior partial or complete edentulism is one of the most common occurrences in dentistry. Seven percent of the adult population in the United
States (12 million people) are missing all of their maxillary teeth and have at least some mandibular dentition—a condition that occurs 35 times more
frequently than complete mandibular edentulism opposing maxillary teeth.1,2 The complete edentulous rate of the adult population is 10.5%. Therefore, 30
million people in the United States or 17.5% of the adult population are missing all of their maxillary teeth. In addition, 20% to 30% of the adult partially
edentulous population older than 45 years of age are missing maxillary posterior teeth in one quadrant, and 15% of this age group are missing maxillary
dentition in both posterior regions.2 In other words, approximately 40% of adult patients are missing at least some maxillary posterior teeth. Therefore, the
maxillary posterior region is one of the most common areas to be involved in an implant treatment plan to support a fixed or removable prosthesis.
The maxillary posterior edentulous region presents many unique and challenging conditions in implant dentistry. However, existing proven treatment modalities
make procedures in this region as predictable as in any other intraoral region. Most noteworthy surgical methods include sinus grafts to increase available
bone height, onlay grafting to increase bone width, and modified surgical approaches to insert implants in poorer bone density.3 This chapter addresses the
treatment planning concepts specific to the maxillary posterior partial or complete edentulous regions.
Box 221
Unique Implant Treatment Plan Considerations
1. Bone width
2. Crown height space
3. Bone density
4. Bone height
5. Occlusal forces
6. Implant size
7. Implant number
8. Implant design
Bone Width
The dentate posterior maxilla has a thinner cortical plate on the facial compared with the mandible. In addition, the trabecular bone of the posterior maxilla is
finer than in other dentate regions (Figure 221). The loss of maxillary posterior teeth results in an initial decrease in bone width at the expense of the labial
bony plate. The width of the posterior maxilla decreases at a more rapid rate than in any other region of the jaws.4 The resorption phenomenon is accelerated
by the loss of vascularization of the alveolar bone and the existing fine trabecular bone type. However, because the initial residual ridge is so wide in the
posterior maxilla, even with a 60% decrease in the width of the ridge, adequatediameter root form implants usually can be placed.
Figure 221 The posterior dentate maxilla has a thinner cortical plate on the facial and finer trabecular bone than the mandible.
Unlike the resorbed atrophic mandible, the maxillary posterior resorbed ridge progressively shifts toward the palate until the ridge is resorbed into a medially
positioned narrower bone volume5 (Figure 222). This results in the buccal cusp of the maxillary final restoration in the moderate to severe atrophic ridges often
being facially cantilevered to satisfy esthetic requirements at the expense of biomechanics for occlusal loading (Figure 223).
Figure 222 The loss of posterior teeth causes resorption of the posterior maxilla. As the edentulous ridge resorbs from division A to division D,
the crest of the ridge shifts toward the palate. As a consequence, without facial augmentation, the endosteal implant may be placed under the
lingual cusp of the original natural tooth position.
Figure 223 The resorbed width of the bone requires augmentation in width or a facial cantilevered prosthesis in the esthetic zone.
Figure 225 The bone–implant contact is the lowest in D4 bone, which is often found in the posterior maxilla.
In the posterior maxilla, the deficient osseous structures and an absence of cortical plate on the crest of the ridge further compromise the initial implant
stability at the time of insertion (Figure 226). The labial cortical plate is thin, and the ridge is often wide. As a result, the lateral cortical BIC to stabilize the
implant is often insignificant. Therefore, initial healing of an implant in D4 bone is often compromised, and clinical reports indicate a poorer initial healing
success than with D2 or D3 bone.
Figure 226 The density of the bone in the edentulous posterior maxilla is poorer than in any other region. Because of the lack of cortical bone on
the crest, the thin trabecular bone is less strong and has a lower modulus of elasticity.
Bone Height
Local anatomical conditions of the edentulous alveolar ridges in the posterior maxilla may be unfavorable for implant placement. The available alveolar bone
height is lost in the posterior maxilla as a result of periodontal disease before tooth loss. The maxillary molar regions have distal furcation involvement
frequently because the furca is directly under the distal contact and has no facial or palatal access for hygiene. The furca is also narrower than many dental
curettes, and it is difficult to eliminate calculus after it has formed. As a result, periodontal disease is common and is associated with loss of bone height
before tooth loss.
Although the maxillary sinus maintains its overall size while the teeth are present, an expansion phenomenon of the maxillary sinus occurs with the loss of
posterior teeth9 (Figure 227). The antrum expands in both inferior and lateral dimensions. This expansion after loss of posterior teeth may even invade the
canine eminence region and proceed to the lateral piriform rim of the nose. It also expands toward the crest of the edentulous ridge, often until only a thin layer
of cortical bone separates the antrum from the crest of the residual ridge (Figure 228). The sinus expansion is more rapid than the crestal bone height
changes. The dimension of available bone height of the posterior maxilla is greatly reduced as a result of dual resorption from the crest of the ridge and
pneumatization of the sinus after the loss of teeth. As a result of the inferior sinus expansion, the amount of available bone in the posterior maxilla greatly
decreases in height. As a consequence, knowledge of the maxillary sinus and bone augmentation to the antral floor is necessary to develop an ideal treatment
plan.
Figure 227 When a posterior maxillary tooth is lost, the maxillary sinus begins to expand into the residual bone and decrease available bone
height for an implant. (From Watzek G: Implants in qualitatively compromised bone, London, Quintessence Publishing Company, 2004.)
Figure 228 When all maxillary posterior teeth are lost, the sinus expansion often extends to the crest of the residual ridge. A, Nasal spine. B,
Anterior maxillary ridge. C, Posterior maxilla. D, Maxillary sinus. (From Watzek G: Implants in qualitatively compromised bone, London,
Quintessence Publishing Company, 2004.)
During the child’s first year, the maxillary sinus expands laterally underneath the infraorbital canal, which is protected by a thin bony ridge. The antrum grows
apically and progressively replaces the space formerly occupied by the developing dentition. The growth in sinus height is best reflected by the relative
position of the sinus floor. At 12 years of age, pneumatization extends to the plane of the lateral orbital wall, and the sinus floor is level with the floor of the
nose. During later years, pneumatization spreads inferiorly as the permanent teeth erupt.
The main development of the antrum occurs as the permanent dentition erupts and pneumatization extends throughout the body of the maxilla and the
maxillary process of the zygomatic bone. Extension into the alveolar process lowers the floor of the sinus about 5 mm. Anteroposteriorly, the sinus expansion
corresponds to the growth of the midface and is completed only with the eruption of the third permanent molars when the young person is about 16 to 18 years
of age.13 The adult sinus has a volume of approximately 15 mL (34 mm × 33 mm × 23 mm) (Figure 2210).
Figure 2210 A, The adult maxillary sinus is formed by age 16 to 18 years. The average anteroposterior and coronalapical dimension is 34 mm ×
33 mm, lying above the posterior roots of the second premolar to third molar. 1, Maxillary sinus; 2, frontal sinus; 3, ethmoid sinus; 4, sphenoid
sinus. B, Coronal section of the posterior region of the edentulous human maxilla. Note expansion of the sinus floor inferiorly far below the level
of the floor of the nose. Bone of alveolar ridge is markedly atrophied while the ridge submucosa became fibrotic (×2.4). Stained with Resorcin
Fuchsin stain and counterstained with van Gieson. (B, Courtesy Mohamed Sharawy, Augusta, GA.)
In an adult, the sinus appears as a pyramid of five bony walls, the base of which faces the lateral nasal wall and the apex of which extends toward the
zygomatic bone (Figure 2211). The floor of the maxillary sinus cavity is the opposing landmark of available bone height and reinforced by bony or
membranous septa joining the medial or lateral walls with oblique or transverse buttresslike webs. They develop as a result of genetics and stress transfer
within the bone over the roots of teeth. These have the appearance of reinforcement webs in a wooden boat and rarely divide the antrum into separate
compartments. These elements are present from the premolar to the molar region and tend to disappear in the maxilla of the longterm edentulous patient when
stresses to the bone are reduced. Karmody et al. found that the most common oblique septum is located in the superior anterior corner of the sinus or
infraorbital recess (which may expand anteriorly to the nasolacrimal duct).14 The medial wall of the maxillary sinus is juxtaposed with the middle and inferior
meatus of the nose.
Figure 2211 The adult maxillary sinus has five bony walls and extends toward the zygomatic process.
After periodontal disease, tooth loss, and sinus expansion, frequently less than 10 mm of available bone remain between the alveolar ridge crest and the floor
of the maxillary sinus, resulting in inadequate bone quantity for implant placement. A limited review of the literature reveals implants that were 9 mm or less in
height may have a 16% lower survival rate compared with implants longer than 10 mm.7 Therefore, the height of bone is of primary importance for predictable
implant support. This limited dimension is compounded by the decrease in bone density and the problem of the resultant medial posterior position of the ridge
after resorption of bone width. As a result, failure and complications in the long term of many endosteal implant systems are reported.
Figure 2212 The posterior molars have the largest diameter and most surface area of root support compared with any other teeth in the mouth.
An implant treatment plan should duplicate this support.
Implant Size
Implant treatment plans should attempt to simulate the conditions found with natural teeth in the posterior maxilla. Because stresses occur primarily at the
crestal region in good bone quality, biomechanical designs of implants to minimize their noxious effects should be implemented.15 Implant diameter is an
effective method to increase surface area at the crestal region.16 Ideally, division B implants (narrower diameter) are not used in the posterior maxilla. Instead,
implants of at least 4 mm in diameter are suggested, and 5 to 6mm implants are encouraged in the molar region.
The length of the implant is directly related to the implant width, design, amount of the forces, and bone density. Because implant success after loading is
reduced in implants 10 mm and shorter, it is logical to plan for longer implants in the region. In general, 4mm threaded root form implants should be at least
12 mm in length when the bone density is poor (D3). This usually provides adequate BIC to dissipate the loads applied to the prosthesis. When the bone
density is very poor (D4), 5mm implants (or two implants per tooth) are suggested, also at least 12 mm in length.
Implant Number
Key Implant Number
The key implant positions for a posterior maxilla primarily relate to (1) no cantilever, (2) no three adjacent pontics, and (3) the first molar rule. The key implant
positions are determined before the available bone evaluation. Hence, when the second premolar, first molar, and second molar are missing, three key implant
positions are required: the first premolar and second molar (rule 1) and the first molar (rule 3).When the first premolar, second premolar, and first molar are
missing, the key implant positions are the first premolar and first molar (rules 1 and 3).
A common treatment plan is to cantilever a first molar from two or more implants placed in the premolar region. As previously stated, the first molar region has
twice the bite force as the premolar region. As a result, a molar with 2.4 times more surface area is placed in that location. When a cantilever replaces the
molar, the highest bite force is then multiplied to the anterior implants. Uncemented restorations, screw loosening, crestal bone loss, and implant failure risk
are increased (Figure 2213). The “no cantilever” rule for fixed prostheses should especially apply to the molar regions of the mouth.
Figure 2213 A common treatment plan to avoid the maxillary sinus is to place two premolar implants and cantilever to the first molar with the
restoration. The bone loss on these two implants is one of the increased risk of this treatment option.
Additional Implants
Additional implants are used when the bone density is poor or the patient force factors are large. For example, when the bone density is D4 or the patient is a
bruxing male, an additional implant is required. Implant number is an excellent method to decrease crestal stresses. As a general rule in this area, one implant
is often used for each missing tooth (Figure 2214). If stress factors are magnified or the ideal implant diameter is reduced, two implants for each missing
molar are suggested. Implants should always be splinted together to reduce stresses to the bone, reduce abutment screw loosening, and increase retention for
the prosthesis. In general, more implants are indicated in the maxilla compared with the mandible (Figure 2215).
Figure 2214 When the bone density is poor or the patient force factors are moderate to high, one implant per missing tooth is often indicated.
Figure 2215 A, Maxillary and mandible fullarch fixed prosthesis. B, A panoramic radiograph of maxillary and mandibular fixed restorations. More
implants are most often indicated in the maxilla compared to a mandible.
Implant Design
Implant design can increase surface area of support. A threaded design implant has 30% to 200% greater surface area compared with a cylinder implant of the
same size. Although more difficult to place, the threaded implant in poorer density bone is strongly encouraged. Biomechanical aspects of thread designs also
affect the total increase in the surface area (i.e., thread pitch, shape, and depth).17
Roughened surface conditions or hydroxyapatite coating on the implant has been shown to increase the rate of osseous adaptation to implants and provide
greater initial rigid fixation. In addition, an increase of surfacetobone contact and amount of lamellar bone and the relatively greater strength of the coronal
bone around the roughenedsurface implants occur when compared with machined or smooth titanium implants.18,19 Therefore, coatings or roughened
surfaces on implant bodies are suggested in the compromised D3 or D4 bone density (Figure 2216).
Figure 2216 Implants in the posterior maxilla should have more surface area. The implant on the right has more surface area than the implant on
the left. It is longer, has more threads, and has a rougher surface condition.
A rule in traditional prosthetics is that a fixed prosthesis is contraindicated when the canine and two adjacent teeth are missing. Therefore, when the canine
and both premolars are missing, a fixed restoration is contraindicated. A patient missing a first premolar, canine, and lateral is also contraindicated for fixed
prostheses. When the patient is missing a canine, lateral, and central incisor, the patient is also contraindicated for a fixed prosthesis.
A removable prosthesis that is completely implant supported and has no movement under function is considered a fixed prosthesis for the implant support.
Therefore, the rigid implant />
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Jan 7, 2015 | Posted by mrzezo in Implantology | Comments Off on 22 Maxillary Posterior Edentulism
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