Maxillary Arch Rehabilitation: A Case Report

A treatment plan that involves minimal time loss is greatly appreciated by today's dental patients, because it satisfies a great need for business and socially active persons.¹  If nontraumatic surgery without flaps and sutures can be performed, minimal inflammation and discomfort will result. If patients are never without teeth during the surgical and restorative procedures, changes in appearance and disruption of nutritional needs would be minimized. Being without teeth for even a short period of time can cause patients to withdraw further and further from society.²  A technique that can fulfill these requirements and deal with severe maxillary resorption is presented.

The first stage involves the insertion of screw implants in the tuberosity regions (Figure 1). The remaining compromised teeth (and failing implants if present) are extracted at the second stage (4–6 months later). Usually local anesthesia is adequate, although sedative agents should be available for the apprehensive patient. Bony spicules and sharp edges of bone are carefully removed. Conservative surgery is preferred to preserve as much alveolar bone as possible. The use of flaps and suturing should be avoided. If sutures are necessary, as few as possible should be used.

The selected implants are then inserted in the extraction sockets and connected by intraoral welding to a titanium bar with the integrated implants in the posterior tuberosity areas (Figure 2). Insertion of the temporary fixed prosthesis occurs the day of the second surgery (Figure 3). No temporary removable prosthesis is inserted, and patients are never without teeth.

An 82-year-old healthy white woman presented to the office of 1 of the coauthors (LDC) complaining of a 30-year-old ill-fitting complete upper denture. The lower jaw had a stable implant supported prosthesis. Thick, mobile fibrous tissue covered the anterior maxillary ridge. Radiographs indicated sufficient bone for implants to be placed bilaterally in the maxillary tuberosities. The treatment plan called for a new implant-supported maxillary complete prosthesis (Figure 4). Implants were placed in the posterior tuberosities (Figure 5, left).

The patient returned in 5 months for continuation of treatment. The anterior maxillary area exhibited a narrow alveolar ridge. To avoid bone augmentation, 3 narrow ridge blade implants (BioMicron Bioblade type 1) were selected to be placed along with 1 thin root form implant (Acerboni).

After exposing the implants and inserting abutments in the tuberosity regions, the 3 blade implants and 1 root-form implant were placed in the anterior maxillary alveolar process (Figure 5, right). The abutments were adjusted to obtain a satisfactory path of insertion.

A custom-made flat titanium bar (Acerboni) with attached screw retentive elements (A-Z Implant) was adapted, tried in, and welded to the implants. The patient's interim prosthesis was relined, and parts of the screw-retentive connectors were transferred to the prosthesis. A new screw-retained prosthesis was used for interim and permanent fixation, and the provisional prosthesis was screwed into position (Figure 6).

The definitive prosthesis seats on the bar and abutments, whereas the engaged screws maintain the prosthesis in position (Figure 7). If there is need to remove the prosthesis, it can be easily done by removing the retentive screws.

Final occlusal adjustments were made and verified. The patient returned in 30 days for a follow-up examination and minor occlusal adjustments. She was extremely happy with her new maxillary prosthesis. Once a stable occlusion was achieved, the patient was scheduled for routine recall examinations.

The maxillary tuberosities are rounded eminences on the posterior–inferior surface of the maxilla that enlarge with the development and eruption of the third molars. They articulate medially with the palatine bone and laterally with the lateral pterygoid processes of the sphenoid bone and are the most distal parts of the maxillary residual alveolar ridge.

A detailed analysis by Lopes et al³  from 5 studies of 289 implants placed in 113 patients, followed for a period of 6–144 months, revealed a 94.63% overall survival rate in tuberosity regions in controlled studies.

Venturelli⁴  reported the loss of only 1 of 42 implants placed in the maxillary posterior areas of 29 partially edentulous patients after 36 months. The patients ranged in age from 38 to 62 years (17 men and 12 women). All implants were checked radiographically every 12 months with a customized film holder.

Utilization of the tuberosity region must be carefully evaluated, as an adequate amount of bone may not always be available for implant placement as a result of tooth loss and/or sinus expansion.

The technique described involves the use of submerged screw implants and the Mondani intraoral welding machine.⁵  The intraoral welding machine was designed to permanently connect 1-piece implants or abutments to a titanium wire or bar by means of an electric current for a short period of time (4 ms). The titanium wire or bar is bent and aligned passively by the clinician or dental laboratory technician to the contour of the labial and lingual surfaces of the implants before the electric current is applied to permanently weld the bar to the implants.⁶ 

An adequate dentition, either natural or artificial, is not essential for sufficient food intake for maintaining a good nutritional balance during normal health. However, an adequate dentition, either natural or artificial, may be necessary to support the extra demands of illness and is definitely needed as an aid to the enjoyment of food.⁷ 

There are many options to keep patients from being without teeth, some simple and others complex. It is the obligation of dentists to select a satisfactory treatment plan, depending on patient age, general health, financial situation, occupation, oral condition, and other existing circumstances. Dentists must remember that patients do not want to be without teeth, even for the shortest period of time.

The technique used is an expensive procedure. If finances and/or complexity present a problem, perhaps an interim denture¹  that has several of the advantages of this procedure or another technique can be used to satisfy the esthetic and nutritional needs of patients.

Maxillary sinus lift surgery is not performed with this procedure.

The technique presented allows rehabilitation of the maxillary arch with the placement of an immediate fixed prosthesis in 2 stages. The first stage involves the insertion of implants in the posterior tuberosity regions. The remaining compromised teeth are extracted at the second stage 4–6 months later, and implants are inserted into the anterior extraction sockets. All newly inserted implants are connected by intraoral welding to a titanium bar with the integrated implants in the posterior tuberosity regions. No temporary removable prosthesis is inserted, and patients are never without teeth. Sinus lift surgery is not performed with this procedure.

The authors declare no conflicts of interest.