Decision making for rehabilitation of the atrophic maxillary arch with tilted implants through TTPHIL:ALL TILT® Protocol: A proposed classification of various situations

doi:10.21203/rs.3.rs-4616140/v1

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Research Article

Decision making for rehabilitation of the atrophic maxillary arch with tilted implants through TTPHIL:ALL TILT® Protocol: A proposed classification of various situations

https://doi.org/10.21203/rs.3.rs-4616140/v1

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Purpose

Majority of classifications for implant placement is based on the morphology of the available bone. The entry and exit points of implant in all forms of atrophy are not emphasized. The purpose of this article is to classify the entry points, angulations and exit points for 6 tilted maxillary implants in anterior-posterior distribution for prompt decision making, the ease of surgery and to capitalize on the available bone width.

Methods

Retrospective radiographic analysis was done for 150 maxillary arch edentulous patients restored with fixed prosthesis supported by six tilted implants between April 2021 to April 2023. Post operative Orthopantomograph (OPG) tracings were done for maxillary sinus borders to classify the sinus pneumatization and the entry and exit points of implants were noted with respect to the prosthetic teeth, basal anchoring bone and implant angulations.

Results

Of the arches treated, 63 were SP1, 34 were SP2, 16 were SP3 in the maxilla. Many combination arches were encountered as well including 32 cases of SP1 + SP2 and 5 of SP2 + SP3 combinations. The common preferred entry points were canine, second premolar and second molar areas.

Conclusions

A functional surgical classification aids in placing all-6 tilted bicortcal implants for immediate function while being versatile enough to be used in delayed cases as well. The knowledge of this classification helps to visualise the entry/fixation points minimising unpredictable and morbid grafting surgical procedures. It also aids in efficiently delivering patient-centric minimally invasive, predictably stable, biomechanically sound, fixed implant treatments without cantilever in complete edentulism.

atrophic maxilla

dental implants

pterygoid implants

sinus lift

treatment planning

zygomatic implants

Dental implants are preferred over other conventional treatment options owing to their ability of providing fixed teeth with better functional efficiency. However, despite their increasing popularity in restoration of single or multiple teeth, full arch rehabilitations can still be challenging because of alveolar bone atrophy associated with tooth loss. This challenge is even more exaggerated in the maxilla, which comprises majorly of cancellous/ porous bone, and undergoes dual resorption of maxillary alveolar bone in the superior-posterior direction due to tooth loss-related non-use atrophy, (according to the Wolff’s law) and due to the pneumatization of the maxillary sinuses. [1, 2] Pneumatization is a physiologic process that occurs in all paranasal sinuses during the growth period, causing them to increase in volume. [3]

Extensive bone resorption and sinus pneumatization (SP) in many maxillary edentulous cases often preclude insertion of implants without additional surgical procedures, such as sinus lifts and bone grafts. Examples of maxillary full-arch implant treatment without the need for sinus lifts and bone grafts include zygomatic implants [4], pterygomaxillary implants with zygomatic and conventional implants [5], the Marius bridge for the resorbed edentulous maxilla [6], ‘‘All-on-4’’ technique with 4 immediately loaded implants [7], ‘‘13-23-30’’ anatomic maxillary technique of implant distribution along the alveolar arch [8], the V-II-V technique of immediate placement and loading of implants into an edentulous maxilla without bone grafting [9], treatment of atrophic maxilla with short implants using an osteotome procedure [10], optimal use of anatomic features of the maxillary arch with tilted implants, and others. [11, 12]

The decision for selecting the implant technique depends on the amount of available bone, the anatomic factors, and the biomechanical factors of chewing forces and cantilever forces on the prosthesis. Most of the full arch graftless implant rehabilitation techniques provide a posterior cantilever in the prosthesis, restoring only upto the first molar. [4–12] Other techniques like pterygomaxillary or zygomatic implants are associated with increased surgical complexity.

TTPHIL: ALL TILT^® (Tall Tilted PinHole Immediate Loading) technique is a versatile protocol for all forms of maxillary ridge atrophy where 6 tilted implants are employed for immediate function. [13] In full mouth cases, superstructures supported by 6 implants have been found to have more favourable bone response than those supported by 4 implants. [14] Further, optimum implant distribution in anterior-posterior region results in significantly better outcome in comparison to implant distribution concentrated in anterior region. [15] Using anatomic bony features in the posterior regions can result in restoration of second molars along with complete elimination of cantilever. [13]

However, studies have proven that the inability to predict realistic outcomes of treatment may lead clinicians to several problems during the execution of treatment, increasing the risk of biological and technical complications, which can result in a treatment failure. [16] Also, clinicians find it relatively difficult to insert the posterior tilted fixtures such that maximum anchorage of the bone can be obtained for enhanced primary stability. [17]

Therefore, the aim of this study is to derive a classification to simplify the entry points, angulations, direction and exit points for tilted implants, in various scenarios of maxillary bone atrophy, to bypass vital structures, while achieving prosthetically-driven substantial primary stability with minimally invasive surgery, making use of the maximum amount of available bone for immediate loading.

Study design:

The following retrospective radiographic study was conducted according to the principles of Declaration of Helsinki of 1975, as revised in 2000, and the research protocol was approved by the Institutional Ethics Committee (MeenakshiAmmal Dental College and Hospital, Chennai) (MADC/IEC/III/86/2023). An analysis of 150 randomly selected subjects with maxillary edentulous arch restored with six dental implants through the TTPHIL: ALL TILT® protocol at the Institute for Dental Implantology, Hyderabad, from April 2021-2023 was done. Written informed consent was obtained from all participants for their treatment and for radiographs required during the treatment. The inclusion criteria were:

1. All patients above 18 years of age

2. Patients who have undergone maxillary full arch implant rehabilitation with six tilted implants through the TTPHIL: ALL TILT® protocol.

3. All patients who received immediate prosthetic rehabilitation for full arch fixed implant supported prosthesis, latest by 48 hours after the surgery.

Post operative Orthopantomographs (OPG) for each patient were obtained after the surgical procedure and after completion of their prosthetic rehabilitation. OPG tracings were done for maxillary sinus borders to classify the sinus pneumatization and the entry and exit points of implants were noted with respect to the prosthetic teeth, basal anchoring bone and implant angulations. A classification was thus formed with the obtained information when subjected to descriptive statistical analysis.

Site Classification:

The sagittal section of the maxilla was categorized into 8 segments modelled on the FDI tooth numbering system where each segment was numbered 1 to 8 in a mesial to distal direction corresponding to the tooth numbers. Three tilted implants were placed on each side (right and left) in the maxilla and they were numbered from anterior to posterior as A, B, C in the sagittal maxillary segment. (Figure 1) The Entry/Exit points of implants were based on the extent of anatomical limiting structure of maxillary sinus.

The maxillary sinus pneumatization was considered from the anterior aspect, posterior aspect and the supero-inferior aspect. (Figure 2)

The pneumatization of the sinus along its anterior border (ASP) was classified according to Tolstunav and associates[18,19] as the distance of the anterior wall of the sinus from the midline intoSP0 (>30 mm), SP1 (>25 mm), SP2 (21-25 mm), SP3 (16-20 mm), SP4 (<15 mm).

For pterygoid implants, Luis et al. [20,21] proposed the classification of diagnostic prediction PARP (Pterygoid Anatomic Radiographic Prediction), which was used for posterior pneumatization extent of the maxillary sinus (PSP).It was based on the extent of maxillary sinus invasion and the consequent available width of bone in the pterygoid region, categorized as PARP 1 (>15 mm), PARP 2 (11-15 mm), PARP 3 (5-10 mm)and PARP 4 (<5 mm).

The inferior pneumatization of the sinus towards the alveolar ridge was classified according to Misch's subantral classification [22,23] of remaining bone (RB) as RB 1 (>10 mm), RB 2 (5-9 mm) and RB 3 (<5 mm). This was measured as the distance from the inferior border of the maxillary sinus to the alveolar ridge crest.

Utilizing these three classifications, the availability of bone in relation to the maxillary sinus was determined which is a key factor in the decision making. The ideal implant placement sites were considered to be 3-5-7 (canine region- second premolar- second molar) on either side of midline, for appropriate antero-posterior spread (AP spread) and elimination of cantilever. A minimum of 5 mm of supero-inferior bone height was desired at the proposed entry point of implant, otherwise alternate entry point was used.

The TTPHIL:ALL TILT® protocol implants were used for immediate loading and so achieving basal cortical anchorage was important which was decided based on the extent of sinus pneumatization, to plan which bone to use for the anchorage and angulation as the exit point of implant. A minimum of 16 mm length of implant was used for optimum bone-implant contact which further influenced the exit point of the proposed implant.

The major bones that are utilized for basal anchorage as exit points are: nasal floor (NF) for the anteriors, nasal floor (NF) and lateral wall of nose (LWN) for Premolars, and Pyramidal process of Palatine bone (PPP) for molars. In case the residual alveolar bone height is less than 16mm from the ridge crest to the planned basal bone, then the entry point can be modified and basal anchorage can be achieved from Vomer (V) for anteriors, Naso Maxillary Buttress (NMB) and Zygomatic bone (Z) for premolars, and Medial Pterygoid Plate (MPP) and Zygomatic Bone (Z) with/without trans-sinus (TS) implant for the molars.

Radiographic data of 150 maxillary edentulous arches consecutively between April 2021 to April 2023, treated with 6 tilted implants establishing immediate function had been used in the classification. Each arch was classified by the site classification for tilted implants. All patients received 6 implants (Bioline I, Bioline Dental GmbH&Co.KG, Berlin, Germany) placed into immediate function within two days of surgery. Of the arches treated, 63 were SP 1, 34 were SP2, 16 were SP3 in the maxilla. Many combination arches were encountered as well including 32 cases of SP1 + SP2 and 5 of SP2 + SP3 combinations. This short-term retrospective analysis deduced that all arches could be rehabilitated to immediate function without grafting/sinus lifts while engaging basal cortical bone with each implant exhibiting minimum insertion torque of 50 Ncm.

Furthermore, all patients received first and second molar occlusion, without cantilevers thus enhancing the biomechanical stability. The main thrust of this classification is the prosthetic ability to load transitional immediate prosthesis without any augmentation using TTPHIL ALL TILT^®technique completely eliminating posterior cantilever in complete edentulous maxillary arches.

Decision making for sinus pneumatization:

The anterior, posterior and inferior extent of sinus pneumatization was determined to decide the possible options of implant entry and exit. The authors came up with 8 different situations that could satisfy most of the possible permutations and combinations of maxillary sinus pneumatization. (Table 1 and 2)

Table 1: Situations according to available bone based on anterior and posterior sinus pneumatization.

PARP1

No bone invasion

PARP2

sinus invasion but bone(y=) > 10mm

PARP3

sinus invasion but bone between (y=) 5-9mm (till 2^nd molar)

PARP4

sinus invasion bone (y=) < 5mm (till 8)

SP0

X=Greater than 30mm (no pneumatization)

Situation 1

Situation 5

SP1

X=Greater than 25 mm (till 2^ndpre-molar)

SP2

X=21-25mm (till 1^st pre-molar)

Situation 2

Situation 6

SP3

X=16-20mm (till canine)

Situation 3

Situation 7

SP4

X=Less than 15mm (extreme)

Situation 4

Situation 8

Table 2: Entry and exit points for implants for different situations.

Situation no.

Entry points

Exit points

Alternate option when RB<5mm at the preferred site

Implant A

Implant B

Implant C

✔

PPP

2NF - 5NF- 7PPP

✔

NF/V

PPP

1NF - 4NF- 7PPP

✔

NF/V

PPP

2V - 5Z - 7PPP

✔

NF/V

PPP

3Z - 5Z- 7PPP

✔

LWN/NF

PPP/TS

2NF - 5LWN - 8PPP

✔

NF/Z

TS/PPP

3NF - 5Z - 7TS - 8PPP

✔

NF/V

PPP/TS

2NF- 5Z - 7TS - 8PPP

✔

NF/V

PPP/TS/MPP

3NF - 5Z - 7TS - 8PPP or Quad Zygoma

* ✔ indicates preferred entry point, NF: Nasal floor, V: Vomer, Z: Zygoma, LWN: Lateral wall of nose, PPP: pyramidal process of palatine bone, TS: trans-sinus, MPP: medial pterygoid plate

Situation 1: If the distance between anterior extent of sinus pneumatisation and midline exceeds >25mm i.e SP1 or SP 0, alongwith minimal or no posterior pneumatization, then the point of entry of implant B is segment 5. Segment 3 is used for implant A and segment 7 for implant C.(Figure 2A,B) . If RB in segment 3 is less than 5 mm, then the anterior most implant can be shifted to segment 2 to engage the vomer. In rare cases, it might be necessary to put implant in segment 1 while engaging the nasal floor. The implants are angulated disto-mesially, bucco-palatally and axially with angulations ranging between 15-45⁰ exiting at the medial wall of the maxillary sinus / lateral wall of nose. (Figure 3)

Variations: 1A: 3 NF - 5 NF - 7 PPP, 1B: 2 NF - 5 NF - 7 PPP, 1C: 2 V - 5 NF - 7 PPP, 1D: 2 P - 5 NF - 7 PPP, 1E: 1 NF - 5 NF - 7 PP

Situation 2: If anterior extent of sinus pneumatization and midline ranges between 21-25mm i.e SP2, with minimal or no PSP, segment 5 does not have the required RB, then segment 4 becomes the point of entry for implant B, segment 2 for implant A and implant C is the same as in situation 1. If RB is less for segment 2, the exit point can be changed to vomer through the same entry or segment 1 can be used to engage the nasal floor. The implants angulations are similar to situation 1. (Figure 4)

Situation 3: In the event of distance between the anterior extent of sinus pneumatization and midline ranging between 16-20 mm i.e SP3, with minimal or no PSP, implying no bone in segments 4 and 5, engagement of zygomatic cortical bone is necessary with point of entry being segment 5. The implants are angulated mesio-distally engaging the cortical zygoma which becomes the exit point of implant B. The anterior implant A and posterior implant C are placed similar to situations 1 and 2. (Figure 5)

Situation 4: When the distance between the extent of sinus pneumatisation and midline is less than 15mm, i.e. SP 4, with minimal or no PSP, for anterior implant A entry point segment will be 2, implant B will be zygomatic implant with entry point at segment 5 and implant C is the same as in previous situations. Implant A is directed disto-mesially and bucco-palatally with angulations ranging between 9-30⁰ exiting at the floor of nasal cavity. In some cases where RB is very less, a quad zygoma approach can be used with implants A and B and the angulation for implant A becomes similar to B. (Figure 6)

Situation 5: In the event of pneumatisation extending posteriorly, for implant C, the limiting structure is the junction between posterior wall and floor of maxillary sinus. Implying the 3mm bone height availability in the distal maxilla, implant C would enter through segment 7. In addition, trans-sinus pterygoid implant with segment 7 entry point is another feasible option for implant C. For implants A and B, the placement can be planned as per situation 1, since ASP is minimal. All implants are directed mesio-distally, bucco-palatally following an angulation ranging between 30-60⁰ degrees in sagittal section and 15–25⁰ in axial section to exit at pterygoid cortex depending on the degree of maxillary tuberosity resorption and sinus pneumatization. (Figure 7)

In the event of pneumatization extending posteriorly, segment 8 becomes the point of entry as long as Misch's rule of two pontics is followed whereby the adjacent implant could have entry point at segment 5.[24] If this possibility is limited by the absence of bone in segment 5, zygomatic implant has to be introduced.

Situation 6: With moderate ASP and extreme PSP, the preferred configuration for optimum implant and prosthetic support and stability is achieved through an additional trans-sinus implant in segment 7 exiting at medial pterygoid plate (MPP). The implants A, B and C are similar as in situation 5. (Figure 8)

Situations 7 and 8: ASP precludes anchorage from anterior anatomic landmarks and hence zygomatic anchorage is received from implant B in such situations. For implant A, segment 2 or 3 can be used as is available from the clinical situation. The implant C is similar as in situation 6. In the absence of available bone height in segments 1,2,3,4,5,6; use of pterygoid implants with entry points in segment 7 and two zygomatic implants with entry point in segment 3 and 5 on each side of maxilla can be used for complete fixed rehabilitation. For cases presenting with extreme sinus pneumatization from all three aspects of anterior, posterior and inferior, a quad zygoma approach may be utilized. (Figure 9,10)

Clinical application:

This classification has been devised for clinical decision making after assessing the sinus pneumatization. Below are cases where the anterior pneumatization of sinus is at different levels and corresponding situations have been used. (Figures 11-13)

Presurgical treatment planning is imperative for the successful outcome of implant therapy. A classification that embraces all forms of atrophy with immediate function in mind is intended throughout this study. All traditional classifications in implantology are circumscribed by morphology and availability of bone. They fail to focus on the implant placement areas that encompass the entry/fixation points. This retrospective study has helped devise a type of classification that holds ground as it can direct even an inexperienced implantologist in implant placement. With the rise of many full arch implant rehabilitations, a prompt classification on fixture entry/exit points can contribute to the ease of treatment planning and surgical technique. Even if maxillary sinus pneumatization is not same bilaterally in any patient, a combination of two different situations from this classification can be conveniently applied for each case.

The proposed classification of situations is based on the key rules established by Misch. [25] The implants used for full arch rehabilitation are placed in all key zones of the arch including anteriors, premolars and molars. The entry points are such that no more than three adjacent pontics are designed between two implants thus eliminating the increased flexural strength that can cause increased screw loosening, prosthesis fracture or even implant failure in the long run. [25] The Canine-molar rule is followed as first preference in the anterior region for implant entry point is the canine on both sides. The posterior molars are used for implant placement for complete elimination of cantilever on the prosthesis while restoring the occlusion upto second molars. [26]

The TTPHIL: ALL TILT® protocol is aimed at simplifying the implant surgical procedure, making it prosthetically driven and minimally invasive, for achieving predictable primary stability for immediate loading, and all this while avoiding grafting procedures through bypassing of vital structures. [20, 26] These tilted implants permit the placement of longer fixtures in the residual bone, which increases the surface area of BIC and allows to achieve high torques by providing anchorage to more than one cortical plate. [27] The sharp implant apex engagement at the basal bone reduces micromovement, so even when trans-sinus implants are used, the implant apex does not protrude in the sinus cavity. Other benefits include the elimination of cantilever length and stress reduction in both cancellous and cortical bone; and better distribution of the occlusal forces. [27] This tilted implant configuration also provides better anterior-posterior stress distribution that prevents angulated torque moments on the implants, frequently resulting in resorption in the cortical bone around the distal implant neck. [28]

The TTPHIL: ALL TILT® technique recommends single drill osteotomy which decreases time and heat to the bone tissue and enables under preparation of the implant bedsite, thus, increasing implant stability. [29] The immediate loading with platform switched microgrooved abutments after the single-stage surgery reduces the horizontal bone remodeling around the subcrestally placed implants.[30] Baggi et al. [31] have found that the platform switching concept along with subcrestal positioning demonstrated better stress distribution in bone and a lower risk of bone overload.

With 6 tilted implants usage for severe atrophic jaw rehabilitations becoming the norm for its biological and biomechanical advantages, it is pertinent to give an implant entry/exit point classification acknowledging the anatomical limitations and anterio-posterior implant spread. Proper knowledge and prompt decision making for planning implants in atrophic arches can help the clinician minimize human error and achieve predictable results.

This functional surgical classification aids in placing all-6 tilted bicortcal implants for immediate function while being versatile enough to be used in delayed cases as well. The knowledge of this classification helps to visualise the entry/fixation points minimising unpredictable and morbid grafting surgical procedures. It aids in efficiently delivering patient-centric minimally invasive, predictably stable, biomechanically sound, fixed implant treatments without cantilever in complete edentulism.

CONFLICT OF INTEREST

No conflicts of interest.

ACKNOWLEDGEMENTS

None.

SOURCES OF FUNDING:

Not applicable.

HUMAN ETHICS AND CONSENT TO PARTICIPATE:

Consent to treatment and use of data was taken. However, since it is a retrospective study consent to participate is not applicable.

DATA AVAILABILITY:

All the data is in the radiographs taken by the authors and is with the authors.

Author Contribution

V.R. did the conceptualization, formal analysis, investigation, project administration, writing the original draft and reviewing and editing the final draft.S.P. conducted the formal analysis, investigation, and reviewing and editing the final draft.B.L. did the formal analysis, investigation, project administration, writing the original draft and reviewing and editing the final draft.M.R. conceptualized the study, formal analysis, project administration, and reviewing and editing the final draft.All authors reviewed and approved the manuscript.

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No competing interests reported.

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Decision making for rehabilitation of the atrophic maxillary arch with tilted implants through TTPHIL:ALL TILT® Protocol: A proposed classification of various situations

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Abstract

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INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

Declarations

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