A review of guidelines for implant rehabilitation of the edentulous maxilla

Patrick J. Henry, BDSc, MSDa

The Brnemark Center, West Perth, Australia
This review suggests some guidelines and protocols for treatment of the edentulous maxilla with osseoin-
tegrated implants. Evidence-based treatment options are discussed with reference to risk assessment.
Developing technologies applicable to diagnosis, clinical procedures, and laboratory techniques are also
discussed. Osseointegrated implants are increasingly advocated as a treatment option for maxillary eden-
tulism and in many situations are the treatment of choice. (J Prosthet Dent 2002;87:281-8.)

T he predictability of successful osseointegrated

implant rehabilitation of the edentulous jaw, as
described by Brnemark et al,1 introduced a new era
of management for the edentulous predicament.
Subsequently, much effort has been expended on
reducing the logistic cost of implant treatment with
the aim of expanding the patient selection base and
making treatment more affordable and possible for
greater numbers of patients. However, only one 10-
year report on the simplification of treatment, in
terms of the number of implants that would reduce
costs and logistic requirements, exists.2 This retro-
spective study calculated survival rates for both
prostheses and individual implants. A series of 156
consecutive, fully edentulous patients were rehabili-
tated by means of fixed prostheses on either 4 or 6
screw-shaped titanium implants. Although a tenden-
cy for increased failure rate existed in patients with
only 4 implants, the survival rate for both individual
implants and prostheses was the same in both groups
at the end of the 10-year observation period. The
authors concluded that the tendency of some clini-
cians to place as many implants as possible should be
questioned.
In light of high survival rates, the envelope of treat-
ment continues to widen. Single-stage surgery and
immediate loading concepts have been introduced to
further accelerate treatment schedules, reduce costs,
and decrease the negative aspects of multiple surgical
phases and the difficulties associated with interim man-
agement.3 While significant progress has been made in
this area with treatment of the edentulous mandible,
the difficulties associated with the maxilla are such
that, thus far, results are less well developed, less pre-
dictable, and somewhat experimental.4 This article
provides an overview of some of the current treatment
options for the edentulous maxilla.
Presented at the 50th Annual Meeting of the American Academy of
Fixed Prosthodontics, Chicago, Ill., February 24, 2001.
aChairman.
TREATMENT PLANNING
CONSIDERATIONS
Because the consequences of edentulism often
result in advanced atrophy of the residual alveolar
bone and loss of facial support, prevention has always
been a cardinal rule. Realistically, implant treatment of
the edentulous maxilla can be a complex scenario, and
outcomes do not always fulfill expectations in terms of
esthetic need and demand. Furthermore, survival rates
for implant treatment of the partially edentulous jaw
have encouraged many clinicians to retain compro-
mised dentitions that previously were electively
rendered edentulous for cost-effective reasons. Thus,
the results of clinical trials have been extrapolated and
applied to implants used in combination with peri-
odontal prostheses, removable partial dentures, and
limited treatment plans involving shortened dental
arches where functional requirements are not demand-
ing. Although such procedures can be successful and
form the basis of many clinical reports, prospective
long-term multicenter clinical trials do not exist to
accurately evaluate treatment outcomes. At best, such
options are possible in patients with a strong psycho-
logical determination to conserve a residual dentition;
at worst, these procedures can be interpreted as transi-
tional and delaying the inevitable.
Risk assessment and an evidence-based practice
approach are receiving increased emphasis both in the
literature and in litigation.5,6 Patient decision-making
is based on a multitude of considerations, including
success and survival rates and concern about the risk of
complication. A code of clinical reporting has been
described and includes a 4-field table in which every
implant is categorized under success, survival, unac-
counted for, or failure.7 The success category
comprises implants that meet specific criteria evaluated
with, for example, stability tests and individual radio-
grams. The survival category comprises unattached
implants that were not checked for mobility, implants
for which periapical films were not made, and prosthe-
ses not removed at evaluation for other reasons. Such
implants can never be regarded as successful because

MARCH 2002 THE JOURNAL OF PROSTHETIC DENTISTRY 281

THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Long Zygomaticus implants can provide posterior
maxillary anchorage for fixed prosthodontics when bone
graft alternative is declined. Single-stage surgery and imme-
diately loaded Brnemark Novum fixed partial denture were
utilized for mandible.
there are not enough data to evaluate them as such.
When correctly applied, this approach enables an
improved diagnosis of the outcome of oral implants
and facilitates risk assessment and decision-making.
Unfortunately, systematically developed, evidence-
based guidelines have not been developed for the
myriad prosthodontic alternatives that exist for the
treatment of debilitated dentitions. Such treatment
plans therefore must be carefully considered on an
individual basis with patient counseling and cog-
nizance of the limitations associated with such risk
assessment. While the decision to render a patient
edentulous must never be taken lightly, it is often
inevitable in light of a risk assessment based on need
and demand. Before such a decision is finalized, how-
ever, the patient should be evaluated from the
perspective of the edentulous protocol so that the
prosthodontic ramifications can be fully ascertained
and evaluated. The transition to the edentulous state
can thereby be optimized.
TREATMENT PLANNING OPTIONS
The edentulous jaw may be treated with a complete
denture prosthesis, a complete denture overlay pros-
thesis supported and retained by implants, or an
implant-supported prosthesis. A great diversity of opin-
ions exist regarding treatment of the maxilla, and many
fundamental questions remain unanswered.3 Success
rates in the maxilla are significantly different than in the
mandible and have been related to differences in resid-
ual ridge structure, anatomy, bone quality and quantity,
biomechanics, phonetics, and esthetic requirements.
Higher failure rates in the maxilla are common to both
fixed and removable prostheses. Furthermore, some
implant success rates reported for implant-supported
and implant-retained overdentures do not meet the
282
HENRY
advocated minimally acceptable criteria for implant suc-
cess.8 The challenge in the maxilla is frequently related
to esthetic demand with respect to facial support, as
well as dental and gingival visibility factors. In patients
with high expectations, it may be impossible to meet
the requirements with a fixed prosthesis if the facial
support previously afforded with a denture flange is
lost. In such situations, an overdenture or detachable
hybrid prosthesis should be considered the appropriate
treatment.
The fixed option comes closest to optimal rehabili-
tation in terms of functional and proprioceptive
capability. It is electively sought by many patients who
are transitioning from the partially edentulous state
and refuse to consider complete denture status, even at
the interim or diagnostic phase. Long-term studies in
edentulous patients have shown that excellent results
can be achieved with 6 implants in the maxillary
arch.1,8 The standard maxillary implant-supported
prosthesis based on 6 implants provides adequate func-
tion with a shortened dental arch to the first molar
position. Edentulous patients indicated for bone graft-
ing procedures present the greatest challenge and
require careful management by experienced teams.
One report emphasized that 4 implants are fre-
quently sufficient for adequate support of the fixed
prosthesis in the grafted maxilla and that short
implants can function well when indicated.9
Conversely, other treatment centers advocate place-
ment of 8 implants in such patients because implant
loss is documented to be higher in grafted treat-
ments.10,11 Although progress in site augmentation
and bone graft technology have resulted in rapid
improvements and wider applications in the last
decade, many patients demonstrate reluctance to bone
grafting and decline treatment. Alternative procedures
that utilize existing anatomical sites that offer reduced
morbidity and minimal invasion of existing structures
have emerged.3,4 For example, the Brnemark System
Zygomatic implant (Nobel Biocare AB, Gteborg,
Sweden) offers exceptional anchorage and is indicated
where limited bone exists inferiorly to the maxillary
sinus. Figure 1 illustrates a situation in which bone
grafting was declined by a 54-year-old man. Two 50-
mm Zygomatic implants were placed distobuccally
from the premolar region to engage the zygomatic
bone inferolateral to the orbital rim and thus provide
anchorage for a fixed prosthesis in conjunction with
anterior implants.
Protocol and sequencing
Basic protocols applicable to the different classifica-
tions of treatment are well established.12 Recent
developments in computer software and derived hard-
ware products have expanded the possibilities of
visualizing residual structures. Computer-guided
VOLUME 87 NUMBER 3
HENRY
B
Fig. 2. A, Three-dimensional reconstruction of edentulous
maxilla CT. B, Biomodel derived from 3-dimensional CT
information transfer.
implant dentistry (such as SurgiCase; Materialise, Ann
Arbor, Mich.) can optimize transfer from the preoper-
ative plan to actual surgery and facilitate the clinical
outcome via collaboration between clinical prostho-
dontic and dental laboratory service personnel. In
conjunction with clinical evaluation, radiological
assessment will determine whether augmentation pro-
cedures are needed to re-establish adequate bone mass
for implant anchorage and adequate contour to fulfill
the esthetic expectations of the treatment objective.
Subsequently, a 3-dimensional format can be used to
fabricate a life-sized replica or biomodel of the eden-
tulous jaw. The biomodel is advantageous in planning
bone graft treatments in that the location and volume
of bone required can be predetermined (Fig. 2). The
biomodel also can be duplicated, mounted inter-
changeably in the articulator, and used to plan the
situation with respect to implant installation sites and
to generate proposed occlusal schemes and provision-
al or transitional interim appliances.
Biomodels are solid plastic replicas of anatomical
structures and are used in the assessment and planning
of surgery. They originally were produced by the rapid
prototyping technique of stereolithography and
MARCH 2002
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Stepwise sequencing of biomodel-derived informa-
tion. Preformed framework can be fixed to interim
components with direct luting at time of immediate loading.
allowed surgeons to rehearse procedures and improve
communications between colleagues and patients.13
Current medical uses of stereolithography include pre-
operative planning of orthopedic and maxillofacial
surgeries, the fabrication of custom prosthetic devices,
and the assessment of the degree of bony and soft tis-
sue injury caused by trauma; a potential application in
forensic medicine also exists.14 More recently devel-
oped technology permits the creation of hollow
models with increased accuracy. Thus, life-sized, phys-
ically accurate anatomical models that make use of the
fused deposition modeling process are possible from
data obtained with medical scanners (computed
tomography [CT] and magnetic resonance imaging,
for example). The plastic construction can be drilled
and cut to simulate operating procedures. Accordingly,
the biomodel can be used to develop an accurate sur-
283
THE JOURNAL OF PROSTHETIC DENTISTRY
gical template after a simulated operating procedure.
The biomodel also can be used to develop the provi-
sional restoration used in single-stage surgery and
immediate loading protocols, as illustrated in Figure 3.
At the practical level, CT data can be transferred to a
biomodel manufacturing facility by either electronic
transfer or a rewritable optical disc (DEC-702 Optical
Disk; Pioneer Communication of America Inc, Upper
Saddle River, NJ); this process is not dependent on
proprietary software programs.
Identification of high-risk categories
A number of risk factors associated with high fail-
ure rates have been identified through clinical
experience.15 Poor-quality bone, bone grafts, irradi-
ation, immunosuppressive medications, and selected
disease states are universally recognized as risk fac-
tors. Furthermore, factors such as bruxism,
alcoholism, tobacco smoking, and osteoporosis have
been identified as relative contraindications whereby
treatment results may be compromised. Success and
survival rates associated with some of these condi-
tions may be controlled by the application of altered
protocols. Definitive cause-and-effect relationships
have not been reported in multicenter trials. Clinical
judgment, prudence, and informed consent are
desirable before treatment is routinely applied in
high-risk patients,4 who generally are planned for 8
implants.
Bruxism, smoking, and osteoporosis require more
detailed consideration because they are relatively com-
mon in patients seeking implant treatment. Bruxism
and parafunction were defined as contraindications in
early research on osseointegration.1 In the edentulous
jaw, bruxism has been implicated in higher failure rates
and increased incidence of screw loosening as well as
prosthetic fractures16 and increased loss of bone asso-
ciated with poor plaque control.l7 It is generally agreed
that excessive loading or undue stress may induce bone
loss and that secondary bone quality and quantity fac-
tors may contribute to this outcome.15 Bruxism
should be managed in implant candidates in the same
manner as in general prosthodontic patients, with
careful attention to the design of the occlusal scheme
and the nocturnal utilization of an occlusal splint as
required.8
Smoking is increasingly incriminated in a number of
health issues and is often discussed in relation to
implants. Several studies have shown that smoking can
be associated with higher failure rates, complications,
and altered soft tissue conditions.18-24 In general,
patient profiles can be significantly correlated to
implant loss with bruxing and smoking in maxillary
bone graft patients.25 While a nonsmoking period that
covers the treatment phase has been recommended,26
complete cessation of smoking also has been suggest-
284
HENRY
ed because of the higher incidence of maxillary peri-
implantitis in smokers.27 Additional studies are needed
to determine whether the adverse effects of smoking
on peri-implant tissues are reversible if the patient
stops smoking, as has been shown with the reduction
of periodontal disease in former smokers compared
with active smokers.28
Many female patients are concerned that osteo-
porosis will preclude them from considering dental
implant treatment because of a lack of bone density
and perceived loss of confidence with respect to
risk. Although osteoporosis has been considered a
risk factor, particularly for postmenopausal women,
no clinical studies on this matter have been pub-
lished. One literature review suggests there is no
scientific background to confirm osteoporosis as a
risk factor for oral implants. 29 Currently, such
patients are advised that treatment is indeed possi-
ble, but prolonged healing periods and careful
conservative prosthetic management are desirable.
A similar recommendation can be applied to dia-
betes in light of the recent consensus that
placement of implants in patients with metabolical-
ly controlled diabetes mellitus does not result in a
greater risk of failures than in the general popula-
tion.30 However, the duration of diabetes may be
associated with implant failure, and longer implants
experience fewer failures.31
Clinical and technical considerations
An anticipated maxillary complete-arch implant
prosthesis with extensive bone grafting presents a
long-term, complicated, and extensive challenge for
both patient and prosthodontist. Detailed planning
and treatment are mandatory if the patients function-
al and esthetic requirements are to be fulfilled. As with
conventional prosthodontics in the esthetic zone, the
provisional restoration is paramount to a successful
outcome.
Interim restorative phase
Interim restorations may be utilized for 1 year or
longer.32 Implants of questionable stability can be
monitored during this period with resonance frequen-
cy analysis (Ostell, Gothenburg, Sweden).33 This
instrumentation measures the stability of the implant
to which it is attached. A transducer is screwed onto an
implant or abutment; when the measure key on the
instrument is activated, an electronic signal is sent to
the transducer. The response is displayed on the
instrument graphically and given a numerical value
called the implant stability quotient (ISQ). The ISQ is
scaled from 0 to 100 and is a measure of implant sta-
bility derived from the resonance frequency value
obtained from the transducer. An increase in the ISQ
is representative of improved interfacial osteogenesis,
VOLUME 87 NUMBER 3
HENRY
Fig. 4. Choice of impression registration protocol is dependent on design criteria and labora-
tory sequencing. (Henry PJ. Tooth loss and implant replacement. Aust Dent J 2000;45:150-72.
Reproduced with permission from the Australian Dental Journal.)
and experience has shown that over 3 to 6 months,
many implants give improved readings from 35 to 40
to in excess of 60 units. Such technology is prognostic
and may give credence to the clinical concept of func-
tional remodeling. Furthermore, resonance frequency
analysis with periodic radiographic marginal bone
height assessment is used as part of long-term mainte-
nance protocols.34,35
Impression registration
An impression procedure is carried out at Stage 1
surgery if an interim restoration is planned for inser-
tion at Stage 2 surgery. In some situations, this
procedure facilitates soft tissue healing after Stage 2
surgery and simplifies postoperative restorative man-
agement. At the Stage 2 surgical procedure,
impression transfer copings can be linked directly to
the surgical template with autopolymerizing or light-
polymerizing resin.36,37 The registration is retrofitted
to a duplicate of the original, interchangeably
mounted study cast with the use of a split cast sys-
tem.8
Restorative procedures can be finalized any time
after Stage 2 surgery as dictated by soft tissue healing
and whether provisional restorations are employed.
The first stage in the restorative phase is fabrication of
the master cast. This cast is derived from an impres-
sion made at Stage 2 surgery or after resolution of the
soft tissue healing several weeks later. Impressions
may be at the implant level or at the abutment level.8
A number of different impression techniques may be
utilized depending on the complexity of the situation
and the anticipated design of the final restoration, as
MARCH 2002
THE JOURNAL OF PROSTHETIC DENTISTRY
illustrated in Figure 4. Implant-level impressions and
soft tissue casts give the laboratory the most flexibili-
ty in developing proper contours and emergence
profiles. Abutment-level impressions are indicated
when definitive abutments have been selected and
connected to the implants. This may be prior to or
subsequent to the outcome of the provisional phase of
treatment.
Framework technology
A number of protocols and technological patterns
are available for framework design and fabrication. The
casting of complex frameworks and problems associat-
ed with distortion by various veneering materials can
result in management problems at both the clinical
and technical levels. Historically, these dilemmas have
been addressed with various technologies, including
spark erosion, laser-welding, and the use of adhesive
systems to locate abutments within the framework to
achieve a passive fit.38
Recently, computer-numeric-controlled (CNC)
frameworks milled from a solid block of titanium have
become available. These frameworks provide an alter-
native to conventional castings and have demonstrated
comparable accuracy of fit as well as similar clinical and
radiological performance at follow-up.39,40 The proto-
col for framework production is industrial (All-in-One;
Nobel Biocare AB), which eliminates many of the fac-
tors related to the manual handling of conventional
castings. Manufacturing costs are similar to those for
conventionally cast frameworks. The framework can be
designed to suit any implant-supported complete den-
ture work authorization, including metal-ceramic
285
THE JOURNAL OF PROSTHETIC DENTISTRY HENRY

B C
Fig. 5. A, Panoramic radiograph shows deficient maxillary bone status and extrusion of
mandibular anterior segments. B, Maxillary provisional prosthesis at implant level supported
by 8 implants and maxillary bone graft. Mandibular arch was treated with single-stage surgery
with immediate loading and CNC-milled, 1-piece titanium framework. C, Final maxillary
restoration with CNC-milled titanium framework.

prostheses and hybrid designs used to support and
retain denture teeth. Specific low-fusing porcelains can
be applied directly to the framework, resulting in min-
imal distortion because of the high melting point of
titanium. The framework is also suitable for other
applications such as the bonding of gold alloy metal-
ceramic sections with intermediary composite bonding
systems.
The application of contemporary technology is
illustrated in Figure 5, in which the classic conse-
quences of combination syndrome are evident:
extrusion of the anterior mandibular teeth and gross
resorption of the anterior maxillary residual ridge.
The 50-year-old patient was considered high risk due
to a history of smoking, alcoholism, and bruxism.
After the patient underwent counseling and stopped
smoking for 3 months, a treatment plan involving
maxillary bone grafting and implants was implement-
ed. After placement of the provisional prosthesis at
Stage 2 surgery, the implants were monitored with
resonance frequency analysis and demonstrated ISQ
improvement from 40-45 to 60+ in the following 12-
month provisional phase of treatment (Fig. 5, B).
Final reconstruction of the maxillary arch was accom-
plished with an All-in-One framework (Nobel Biocare
AB) with directly bonded composite tooth and gingi-
val sections.
Single-stage surgery and immediate loading
in the maxilla
Single-stage surgery with immediate loading is an
accepted treatment approach in the mandible and has
resulted in high success rates in selected patients. This
procedure has been widely documented for prosthesis
design on 4 or more implants.3,4 A recent protocol has
made use of preformed components placed on 3
implants, with the entire treatment completed in 7 to
8 hours.41 Unfortunately, results from similar con-
trolled, prospective studies in the maxilla have not
been forthcoming. Nevertheless, limited reports are
accumulating and indicate that in certain circum-
stances, successful results can be achieved.42 There is a

286 VOLUME 87 NUMBER 3

HENRY
clear tendency to utilize a larger number of implants
because prognosis is doubtful and risk assessment is
not based on long-term data or established, evidence-
based guidelines. Single-stage surgery with immediate
loading in the edentulous maxilla must be considered
experimental and should be performed with consider-
able caution in select situations only.
SUMMARY
Rehabilitation of the edentulous maxilla continues
to be comparatively more challenging than rehabilita-
tion of the edentulous mandible. Although
single-stage surgery with immediate loading concepts
are well established in the mandible, they should be
considered experimental in the maxilla until long-
term, evidence-based data and guidelines are
established. Recent advances in diagnostic imaging
modalities, bone grafting protocols, and prognostic
technology able to monitor the functional responses of
implants are encouraging. The implant option for the
edentulous maxilla is increasingly becoming the treat-
ment of choice for many patients.
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Bone cell attachment to dental implants of different surface

Noteworthy Abstracts characteristics.
of the Lumbikanonda N, Sammons R. Int J Oral Maxillofac Implants
Current Literature 2001;16:627-36.

Purpose. Studies that evaluate the effect of surface characteristics of dental implants on bone cell
behavior have not used actual implants in the test system. This study used as-manufactured
implants with smooth titanium, titanium dioxide-blasted, titanium plasma-sprayed, and hydroxy-
apatite plasma-sprayed surfaces for comparison. This study was performed to investigate bone cell
migration, proliferation, and differentiation on different implants.
Material and methods. Smooth surface (Astra Tech), titanium oxide-blasted surface (Astra
Tech), titanium plasma-sprayed surface (ITI/Straumann and IMZ Friatec AG), and hydroxyap-
atite-coated (IMZ Friatec AG) implants were used in their manufactured states. These implants
were exposed to neonatal rat osteoblast cell suspensions for a 20-minute period. Scanning elec-
tron microscopy was used to classify and to stage the attachment of cells to implants.
Results. Cells spread more rapidly on the titanium plasma-sprayed implants. Full spreading of cells
occurred on smooth titanium implants; these cells were closely adherent to the implant surface.
In contrast, there was no adaptation of cells to the irregularities of the titanium dioxide-blasted
implant surface. Cell adherence with hydroxyapatite-coated implants occurred only on the smooth
areas.
Conclusion. The method used in this study allowed evaluation of rat osteoblast cell adherence to
actual implant surfaces rather than simulations of such surfaces. 32 References.SE Eckert

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