CLINICAL RESEARCH

Anatomic Site Evaluation

of Edentulous Maxillae
for Dental Implant Placement
Ramin Raxaui, DMD, MS, * Robert B. Zena, DDS,f Zafilla Khan, DDSJ
and Alan R. Gould,DDSg

Purpose: This study evaluated 17 edentulous cadavers for bone quantity and quality of the
alveolar process of the maxilla for the purpose of dental implant placement.
Materials and Methods: The maxillary arch was divided into four anatomically defined regions
for measurements of bone quantity. Bone quality was assessed histologically and described by
trabecular bone patterns and tissue composition.
Results: Average bone height with a minimum thickness of 4 mm was as follows: region 1,
12.1 k 4.9 mm; region 2, 14.1 f 7.2 mm; region 3, 6.1 f 2.8 mm; and region 4, 8.5 2 2.2 mm.
Histological evaluation showed increased trabeculation and thicker cortex in the maxillary anterior
area, regions 1 and 2. Region 3, the floor of the maxillary sinus area, had the least amount of bone;
however, the quality of bone was superior t o that of region 4, the maxillary tuberosity area.
Trabecular distance or marrow spaces ranged from 40 pm t o 2 mm with larger spaces associated
with the posterior maxilla.
Conclusions: Maxillary tuberosity is the least desirable site for the placement of implants in the
maxilla. The area corresponding t o the first and second molars had the least bone thickness. All
measures of bone preservation need to be considered, especially in this area.
J Prosthod 1995;4:90-94. Copyright o 7995 by the American College of Prosthodontists.

INDEX WORDS: bone quality, bone quantity, implant placement, histomorphometric evaluation,
maxillary alveolar bone

U SE OF ENDOSSEOUS dental implants has

become increasingly popular in the treatment
of complete arid partially edentulous patients. The
success of implant treatment has improved with the
use of better diagnostic, surgical, and prosthetic
techniques. Many studies are indicative of this im-
provement; however, investigators report a lower
success rate in the implant treatment of the maxil-
lary arch and attribute this to decreased bone quality
*ilrsirtant Pr&w and Director. Dental OncoloQ and Madlofacial
Pmthetics, Department of Otolayngolou, Head and Neck Surgeiy,
Georgetown Uniuersip Hospital, Washington, DC.
)'Clinical Assistant Prqjsmr, Departmenl q[Prvsthodontics, Uniuenity
OfLouisville School ojDentisty, Louisville, Ky.
$F+ofessor, Department ofPmsthodonlics, Uniuersit);OfLouisoille School
fDenlisty, Louisuille, KY
$Projessor, Depadnient ofHorpital and Surgical Dentistv, Univtmip of
Louisville School ofDentisty, Louisville, KY.
Presented at the annual meeting ofthe American Association ofDental
Research on March 7-11, 1990,in Cincinnali, OH.
Correspondence to: Ramin Kazaui, DMD,IMS, Dental Oncology and
Man'llc$&ial hsthetia, Departmmt gOtda?yngology, Georgetoum Univer-
s i p Hospital, Wayhinston, D C 20007.
Cojyight 0 1995 b y theAmerican College ofProsthodontists
1059-941XI95/0+02-000485.00/0
and quantit) in the ~naxilla.'-~ Although surgical
techniques and prosthetic rehabilitation are the main
determinants of successfulimplant treatment, longev-
ity of the bone-implant interface remains the most
critical determinant of implant survival.
Pendleton5--idescribes the anatomy of denture-
bearing areas and established areas best suited for
withstanding the force.; of mastication. He notes that
the quality and quantity of bone varies for each
specimen studied, but he concludes that the micro-
anatomy of the maxilla and mandible showed consis-
tency in the type, location, and distribution of tissues
found in each section. These findings are well known
to practitioners today; however, intrapatient differ-
ences in bone quality remain variables that are of
importance for implant sunival.
Another anatomic factor well defined and docu-
mented by Atwood,B-" Tallgren,'* and others is the
continuous residual ridge resorption after the extrac-
tion of teeth. Although Atwood reports that the
resorption of the residual mandibular ridge is four
times greater than in the maxilla, the maxilla most
often lacks sufficient bone compared with the man-
dible for ideal placement of dental implants.

90 Journal ofProsthodontics, Vo14,No 2 (Junej, 1995:pp 90-94

 June 1995, Volume 4, Number 2
Crum and Rooney,13Stanley," and others studied
bone preservation around implants and retained
roots. They show that the placement of conical
implants in extraction sites and the placement of
retained roots in overdenture treatments can de-
crease the rate of residual ridge resorption and
conclude that retained roots and implants prevent
alveolar ridge bone loss. Their findings suggest that
the early placement of implants will preserve alveo-
lar bone. This is especially important in areas where
the least bone mass is encountered. Early placement
of dental implants in these areas may eliminate the
need for procedures such as augmentation and sinus
elevation that may be necessary to provide adequate
bone for the placement of dental implants.
This study was undertaken to quantify bone mass
and to evaluate bone quality in different regions of
the edentulous maxilla for the purpose of endosseous
dental implant placement.
Materials and Methods
Seventeen edentulous cadavers, eight men and nine women
of ages ranging from 59 to 90 years, were studied. The
maxillary alveolar processes of each cadaver were dissected
and removed for anatomic evaluation. Each maxilla was
sectioned into four regions (Fig I). These regions consisted
of the following: region 1, the section of bone lateral to the
anterior nasal spine and medial to the lateral wall of the
anterior nasal aperture; region 2, the section lateral to the
lateral wall of the anterior nasal aperture and medial to
anterior wall of the maxillary sinus; region 3: the section of
bone inferior to the floor of the maxillary sinus; and region
4, the section of bone distal to the posterior wall of the
maxillary sinus and mesial to the pterygoid plates. There
Figure 1. Location of regions 1 through 4. Note the
rclation of region 3 to the maxillary sinus.
91
Table 1. Mean Thckness of Bone
Region Region Region Region
I 2 3 4
Mean thirk-
ncss of
bone* 12.1k4.9 14.127.2 6.1k2.8 8.5k2.2
Kate: Although more bone was encountered in region 4, the
quality of bone in region 3 is better suitcd for dental implant
placement.
*Mean bone thickness with a minimum width of 4 mm.
were two sections for each region, left and right, for a total
of eight maxilla sections per cadaver.
The dimensions of each section w-ere measured using a
caliper. To make these measurements meaningful for
dental implant placement, the thicknesses of each section
were measured only at points with a minimum width of 4
mm. Six maxillae were selected from three cadavers (left
and right maxillae), representing minimum, average, and
maximum bone thickness in the study. Five cuts of each
section were evaluated under a lowpower light microscope
after fixation, decalcification, and hematoxylin-eosin stain-
ing. Each section was evaluated for trabecular bone pat-
tern, cortex thickness, and soft tissue composition using a
linear vernier microscope (Griffin Co, London, England).
Results
The mean thickness of each section is listed in Table
1, and the representative microanatomy is shown in
Figure 2. The mean thickness of bone encountered
was 12.1 k 4.9 mm in region 1, 14.1 k 7.2 mm in
region 2,6.1 ? 2.8 mm in region 3, and 8.5 k 2.2 mm
in region 4. Histological sections showed trabecular
bone in all of the regions with increased trabecula-
tion noted in the anterior maxillary area (Fig 2A and
B). Regions 1 and 2 were associated with a thicker
cortex than regions three and four. These were also
associated with depositional bone activity (Fig 3) and
hematopoietic marrow (Fig 4). Hematopoietic bone
marrow was more evident in the maxillary anterior
region, whereas fatty marrow and loose connective
tissue were associated with region 4 (Fig 5 ) .
Depositional bone activitywas visible in the maxillary
anterior region while totally absent in the tuberosity
area. Region 3 had the least average bone thickness;
however, it showed thicker cortex than region 4 and
also contained more hematopoietic tissue. Region 4,
clinically associated with the tuberosity, consisted of
fatty marrow, increased connective tissue content,
and decreased trabeculation.
Marrow spaces ranged from 40 p,m to 2 mm in
diameter. Larger spaces (1,000 to 2,000 km) were
92 Anatomic Site Evaluationfbr Dental Implants R-vi el a1

Figure 2. Representative cross-section of regions (A) 1, (B) 2, (C) 3, and (D) 4. Regions 1 and 2 concavities are located in
the nasal antrum. The concavities of regions 3 and 4 are located in the niavillary sinus.

associated with the tuberosity area, but clusters of
bone with trabeculation distanced by 500 to 1,000
pm could also be found in this area. In region 3, the
distances ranged from 40 to 500 pm. Regions 1 and 2
had similar marrow spacing, ranging from 30 to 100
CLm.
Discussion
Long-term success of dental implant restoration is
related to the design of dental implants and implant
restorations; the magnitude and direction of forces
that are applied; the nature of tissue integration of
the implant, as in osseous versus fibrosus; and the
quantity and quality of bone in which the dental
implant is placed. Although surgical techniques and
restorative designs are important in the long-term
success of dental implants, the selection of patients
with adequate bone quality and quantity remains the
most important factor.
As with natural teeth, the prosthetic restoration
needs to be planned with emphasis on the load-
 June 1995, Volume 4, Number 2
Figure 3. Active bone turn-over indicated by deposi-
tional bone activity and the presence of osteoblasts.
bearing capability of the implant. Clinicians should
be aware of the bone quality encountered during
implant placement and plan prosthetic loading ac-
cordingly. Although there are no studies to link the
quality of bone to the limits of vertical and shear
forces it may withstand, the prosthetic design can be
modified according to the quantity and regional
quality and anticipated functional demands.
Overdenture studies by Crum and RooneyI3 and
Stanleyi4 discuss the value of retained roots and
conical implants in the preservation of alveolar bone.
The role of endosteal implants in preserving alveolar
bone in different regions of the maxilla has not been
established; however, it would be reasonable to as-
sume that under physiological forces, the bone would
be maintained rather than undergoing atrophic
changes.
Atrophic changes are especially important in re-
gion 3, which corresponds to the maxillary first and
Figure 4. Bone marrow represents the potential for
developing bone-forming cells.
93
Figure 5. Fatty marrow is the least desirable site for
implant placement.
second molar area. Lack of bone in this area limits
prosthetic options to distal extension removable
partial dentures and/or a cantilevered fixed partial
denture. Surgically inadequate bone will necessitate
an augmentation procedure that is more costly and
time consuming and less predictable.
This study indicates anatomic variations that
exist in edentulous maxillae. With the extensive use
of dental implants, it is imperative to recognize all
possible variations that exist in the treatment of
every patient. Use of linear and computed tomogra-
phy can aidin the determination of the bone architec-
ture; however, accurate methods need to be devel-
oped to assess the exact nature of the bone in which
the implant is placed. Furthermore, early replace-
ment of lost teeth by dental implants should be
considered, and the long-term ability of the implants
to maintain the bone levels in regions with less bone
should be evaluated.
Conclusions
Maxillary tuberosity in region 4 has significantly
more bone than region 3; however, it is less
desirable for implant placement because of de-
creased trabeculation and large fatty marrow
spaces.
Maxillary anterior regions 1 and 2 are better
suited for the placemmt of implants because of
increased trabeculation, increased blood supply,
evidence of active bone deposition, and the pres-
ence of hematopoietic tissue.
The ability of dental implants to maintain alveolar
bone height, especially in areas where the least
bone was encountered, should be investigated.
94 Anatomic Site Evaluationfm Dental Implants
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