Article_6_4_5-Montanaro
ORAL IMPLANTOLOGY
ROLE OF THE MAXILLARY TUBEROSITY IN PERIODONTOLOGY AND IMPLANT
Review Articles
DENTISTRY - A REVIEW
Nicholas Montanaro1a, José Carlos Martins da Rosa2b, Luis Antonio Violin Pereira3c, Georgios E. Romanos1d*
1
Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY, USA
2
Department of Implantology, São Leopoldo Mandic Dental Research Center, Campinas, São Paulo, Brazil
3
Department of Biochemistry and Tissue Biology, Institute of Biology, State University of Campinas, Campinas (SP), Brazil
a
DDS
b
DDS, MsC, PhD
c
MD, PhD
d
DDS, PhD, Prof Dr med dent
ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(4).art.5 OPEN ACCESS This is an Open Access article
under the CC BY-NC 4.0 license.
Background: The maxillary tuberosity in implant dentistry presents the clinical
location for clinicians with respect to the periodontal, surgical, prosthetic, Peer-Reviewed Article
implantological and mechanical aspects. Citation: Montanaro N, Martins da Rosa JC, Pereira
LAV, Romanos GE. Role of the maxillary tuberosity in
Objective: The aim of this paper was to evaluate the role of the maxillary periodontology and implant dentistry - a review. Stoma
tuberosity based on the literature and to enhance the role of tilted implants Edu J. 2019;6(4):249-259
placed in the maxillary tuberosity as an anchorage to the most posterior Received: November 11, 2019
Revised: November 23, 2019
end of prostheses in order to avoid biomechanical complications from distal Accepted: November 29, 2019
cantilevers. Published: December 16, 2019
Data Sources: Information was obtained mainly from the PubMed and *Corresponding author:
Georgios E. Romanos, DDS, PhD, Prof. Dr. med. dent.
MEDLINE databases, online books managed by the National Center for Department of Periodontology, School of Dental Medicine,
Biotechnology Information, and non-indexed sources. Previous studies have Stony Brook University
106 Rockland Hall, Stony Brook, NY 11794-8700, USA
demonstrated more than 94% survival rates of implants placed in the maxillary Phone: (631) 632-8755, Fax: (631) 632-8670,
e-mail: georgios.romanos@stonybrookmedicine.edu
tuberosity despite the usage of varied implant designs and surgical protocols.
Data Extraction and Synthesis: The web search included the following Copyright: © 2019
the Editorial Council for the Stomatology Edu Journal.
keywords: bone, dental implant, dental implantation, maxillary osteotomy,
osseointegration for period 1980 to 2017. Proper insertion of tapered implants
with adequate bone condensation of the local cancellous bone is effective
in generating the required primary stability and eventual osseointegration
required for long-term success. In cases where implant placement in the
maxillary tuberosity provides no immediate restorative benefit, various hard
and soft tissues of the region can be harvested for autogenous grafting to
address distant constraints. Usage of the maxillary tuberosity for implant
placement or as a grafting source can provide increased options for clinicians
to restore a patient’s dentition to a higher quality without the requirement of
more numerous, costlier and complicated surgical restorative procedures.
Keywords: Bone; Dental Implant; Dental Implantation; Maxillary Osteotomy;
Osseointegration.
1. Introduction ber region also functions as an attachment point for
The maxillary tuberosity (MT) is a bony region locat- the medial pterygoid muscles. In the past, soft and
ed bilaterally on the upper jaw that is posterior to the hard tissues of the MT served as excellent donor sites
most distal molar roots. It is often characterized by its when these tissues were deficient elsewhere in the
prominent rounded appearance that bulges outward maxilla. It has been shown that gingival connective
from the face of the maxillary bones around the max- tissues can be harvested and grafted successfully at
illary sinus. The tuber region is comprised primarily recipient sites for cosmetic and functional root cov-
of spongy cancellous osseous tissue – specifically erage in the anterior maxilla [3,4]. The MT can also
categorized as a combination of type III and IV bone function as a bone source as there is frequently an
with abundant marrow [1,2]. It is situated along the abundance of untapped usable bone mass, even in
medial side of the pyramidal process of the palatine patients with bone recession throughout the remain-
bone and forms an articular surface at this site. The der of the maxilla. Bone harvested from the maxillary
posterior superior alveolar nerves and vessels pierce tuberosity has been used in the reconstruction of
through the posterior surface of the MT, and this tu- compromised sockets for immediate implantation,
Stomatology Edu Journal 249
ROLE OF THE MAXILLARY TUBEROSITY IN PERIODONTOLOGY
AND IMPLANT DENTISTRY- A REVIEW
implant-supported prostheses to avoid distal canti-
Review Articles levers and control bending moments in the posterior
segments. Implant placement in the MT is a much
more conservative option in treatment when there
is insufficient bone mass throughout the rest of the
maxilla. This allows for the circumvention of exten-
sive surgical grafting or sinus lifting procedures that
entail greater risk of complications. Implant place-
ment in the MT becomes a more sensible choice for
elderly patients, those with healing deficiencies, or
those where cost for treatment is restricted.
2. Materials and methods
This literature review was carried out through the
Figure 1. Maxillary tuberosity providing support for an implant-sup- utilization of PubMed.gov, an online database com-
ported fixed prosthesis (courtesy: Dr. E. El-Haddad, Torino, Italy).
prised of biomedical literature from MEDLINE, life
as well as effectively in the management of intrabo- science journals, and online books managed by the
ny defects in mandibular molars [4,5]. Varying defects National Center for Biotechnology Information.
covering trauma, infection, or bone recession often Search criteria for scientific papers in this review
result in structure changes of alveolar processes that were confined to the role of the maxillary tube-
cannot be candidates for implantation without addi- rosity and pterygoid in implant dentistry. This includ-
tional grafting procedures. The usage of bone grafts ed anatomy, implant placement, removal of tissues,
harvested from the MT can provide a superb alterna- and surgical outcomes.
tive source of autogenous bone to augment the alve-
olar ridges and sockets without the need for more in- 3. Results
vasive surgical harvesting procedures, such as when The tuberosity currently serves as an underutilized
bone tissues are taken from the chin or the ramus [6]. region of the maxilla that has the potential to be a
Although the maxillary tuberosity does not naturally critical area for implant placement in patients with
support teeth nor is it a traditional site for dental im- bone deficiencies throughout the mouth. Despite its
plants, it can provide support for some restorations advantages, implant placement in this region is often
in particular cases. hindered by its own anatomy; primarily the spongy
The MT is a more permanent structure, and even with bone of the maxilla is softer and more cancellous
the extraction of all maxillary teeth, the MT remains than that of the mandible, and bone density decre-
with only minor resorption. It is speculated that the ases posteriorly.
pterygoid medialis muscle provides loading forces The bone of the tuberosity presents a high volume
during mastication which counteract disuse atrophy of bone marrow with increased vascularization
[1,2]. Bone resorption in the palatal direction and nar- [1,2,12,22,23]. As such, any clinician planning for the
rowing of the MT is generally only seen when tooth placement of implants in this location must first take
loss is secondary to pronounced periodontal disease. into consideration the relative lower density and
As such, the convex anatomy of MT should always properties of this osseous tissue to best avoid im-
be taken into consideration in traditional denture plant failure [8,9,11,18,24]. Generally, implants must
design as the medial and lateral walls resist the hori- be angulated to properly fit the tuberosity bone
zontal and torqueing forces which would move the structure with sufficient length.
denture base in the lateral or palatal directions [7-11]. Angled (tilted) implants were seen as unfavorable to
In more recent times, the MT has been deemed as an support large restorations in the past as they were
acceptable site for implant placement, especially in thought to increase risk of bone resorption and im-
cases where there is a need to avoid sinus grafting, plant failure, but more current studies have shown
thus providing increased stability for fixed (Fig. 1) or that angulated implants offer the same, if not better,
removable prostheses (Fig. 2). long-term results when compared to their non-angu-
Implant placement in this posterior region is lated counterparts – especially with implant lengths
quite comparable to that of conventional im- exceeding 13mm, regardless of angulation [25-27].
plant placement elsewhere in the maxilla with This may likely be due to greater primary stability im-
only slight alterations of drilling, bone conden- parted by the additional threads of longer implants,
sation procedures, and instruments in order to leading to more successful long-term outcomes.
protect the weaker bone in the area. Several pre- This primary stability may have been a more critical
vious studies have demonstrated excellent sur- factor to implant success than the spongy bone’s
vival rates comparable to that of implants placed lesser density support.
throughout the remainder of the maxilla [12-21]. Additional considerations for implant placement in
Successfully placed and osseointegrated implants the MT include the amount of bone available and
in the tuber region can be used as abutments for bone height issues.
250 Stoma Edu J. 2019;6(4): 249-259 www.stomaeduj.com
Number of
Length of Width of Number of Survival Rate Survival Rate
Number Implants in Implant Follow-ups
Author Implants Implants Implants in Other In Tuberosity in other regions
of Patients Tuberosity Manufacturer (months)
(mm) (mm) Maxillary Regions (failures) (failures)
Region
Shirota et
1 2 10.0 4.0 4 N/A 24 100% 100%
Stomatology Edu Journal
al.
Leles et al. 1 2 11.0 & 13.0 3.75 3 N/A 24 100% 66.6% (1)
Alves and
1 2 14.0 4.1 & 4.8 6 N/A 36 100% 100%
Neves
Markt 1 4 10.0 & 13.0 3.75 2 N/A 18 75% (1) 50% (1)
Nocini et
1 2 N/A N/A 6 N/A N/A 100% 100%
al.
Park and
7 7 11.5-15 3.75-4.0 10 CSM 12 to 84 100% N/A
Cho
Nobel Biocare,
Ridell et al. 20 22 13.0-20.0 3.75-4.0 64 12 to 144 100% 96.87% (2)
Brånemark
Implant
Venturelli 29 29 10.0-20.0 3.75-4.0 13 36 to 48 100% 92.3% (1)
Innovations
Nobel Biocare,
Bahat 45 72 N/A N/A 0 21.4 93% (5) N/A
Brånemark
Krämer et Cylindrica1 IMZ
11 19 N/A N/A 53 6 to 60 84.21% (2) 92.45% (4)
al. type
52.08
TOTAL 117 161 161 95.03 (8) 94.41% (9)
(mean)
Table 1. Survival rates of implants placed in the maxillary tuberosity across published studies[12-21].
AND IMPLANT DENTISTRY- A REVIEW
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A B
Figure 2. Clinical (A) and radiologic (B) conditions demonstrating the maxillary tuberosity providing support of tuberosity-embedded implants
10 years after functional loading of a removable implant-supported prosthesis.
A B
Figure 3. Representative photomicrographs of a biopsy specimens visualized by hematoxylin and eosin staining retrieved 3-months after grafting of
maxillary tuberosity bone to the alveolar ridge. (A) Panoramic view (microscopic objective 10x) of well-vascularized and cell-rich marrow (), newly
formed trabecular bone (*) with bone lining and/or osteoblast-like cells (), and areas of non-vital bone () with empty lacunae. A large number of
exuberant osteocytes in lacunae are associated with non-lamellar arrangement typical of newly remodeled bone. (B) At higher magnification
(microscopic objective 20x), details of marrow (), newly formed trabecular bone (*), bone-lining cells or osteoblast-like cells (), osteoblasts (), and
osteoclasts () resorbing non-vital bone are evident. No signs of inflammatory reaction were observed.
As the MT is predominately lower density bone, the surgical access [14]. More confined openings may
insufficiency of the bone tissue may inhibit a patient’s negatively influence implant angulation or the abil-
candidacy for placement as ample bone volume is re- ity for the surgeon to manipulate instruments. The
quired for lasting results. use of a radiopaque marker integrated on a surgical
guide or other acrylic guide can be employed along
3.1. Implants in the Tuber Region the edentulous ridge to assist in proper implant site
Pre-operative planning, implant design, superb oste- location [12]. Several operatory procedures for im-
otomy preparation using an optimal drilling proce- plant placement in the MT have been suggested with
dure, and bone condensation are important factors mutual attributes yielding very similar results, and
to take into account in order to achieve long-term several studies have suggested that the utilization of
implant success. Detailed planning and bone map- an adapted drilling technique in sites of poor bone
ping is advised on a per-patient basis to avoid sur- density is vastly advantageous in improving initial
gical complications. Bone volume should be evalu- endosseous stability [9,14,15,25,28-33]. The highest
ated through the utilization of cone beam computed success rates and greatest primary stability were ob-
tomography (CBCT), but a combination of typical served after procedures that extensively employed
panoramic and periapical radiographs can provide under-sizing of the osteotomy, local bone condensa-
adequate pre-operative bone information to substi- tion, osseodensification (Versah drills), or a combina-
tute when CBCT is unavailable [28]. It has been sug- tion of these methods as compared to that of tradi-
gested that a lateral window in the maxillary sinus tional bone drilling techniques. By first under-drilling
can be made to further verify correct placement [18]. the bone with minimal countersinking and then min-
Once these considerations are taken into account, it imizing the site preparation, the implant can obtain
is advised to choose a location more palatal as bone a constricted fit into the osteotomy once the fixture
resorption is most commonly observed in the pala- is eventually placed. This allows for a stronger thread
tal direction, and distances of 35mm or greater from engagement into the surrounding bone walls.
opposing dentition are recommended to allow for Additionally, angulation of the implant site is criti-
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A B
Figure 4. Representative scanning electron micrographs of a bony fragment retrieved from the maxillary tuberosity with associated particulate
harvested via rongeur forcep. (A) Panoramic view of a particle with structure larger than 1mm to facilitate the osseoconduction process (30x). (B) At
higher magnification, details of bone matrix and fibrin network within cells are observed, which remain intact even after the particulate procedure
(1,700x).
proper blood flow and slow the healing process, and
intimate wound approximation is required for opti-
mal results. Complications at this site are minimal as
there are no major vital structures in the immediate
surgical area. Excess soft tissue over the surgical site
should be trimmed to be no more than 3mm, allow-
ing for adequate space for proper hygiene once the
initial wound has healed [12]. Any implants placed
in the tuber region should be allowed to heal for 6
months or more without loading in most cases. Pre-
mature loading would cause unwarranted stress on
the surrounding low-density bone, increasing risk of
failure before proper osseointegration [37]. In cases of
severely weakened bone, progressive or early moder-
Figure 5. The bone graft was harvested from maxillary tuberosity in ate loading protocols of the bone with implant pros-
close proximity to the receptor site using IDR chisels. The graft was
reshaped in relation to the defect configuration, and the remaining bone theses may be used to strengthen the bone over the
was crushed for use as particulate graft. healing period [38,39]. Posterior occlusal forces can
reach nearly ten times that of those in the anterior
cal, as the implant should maintain a 10-20o mesial jaw, and these forces must be eliminated or adjusted
slant to mimic the natural angulation of the third mo- to reach the desired load [12]. Loading forces can be
lar [12,34]. A special emphasis is also placed on the decreased through the reduction of prosthesis occlu-
bone condensation of the low quality bone. Bone sive contacts or through the adjustment of opposing
condensation is obligatory in areas of reduced bone dentition in contact with the prosthesis.
density in the posterior maxilla to attain sufficient im- Shorter healing times (4-6 months) and more prompt
plant stability [35]. To accomplish this condensation integration may be plausible with implant surface
properly, an osteotome or modified osteotome tech- modification [40]. Upon adequate healing of the im-
nique or the method of osseodensification should plant site, fixed permanent prostheses can be fabri-
be implemented over a conventional drilling tech- cated and placed in a similar fashion as fixed dentures
nique [15,31,36]. Blunt surgical osteotomes are rec- supported by implants placed in traditional maxillary
ommended as the lack of sharpened edges, such as positions. In fully or partially edentulous patients,
those found on drills, reduces the chance of cutting posterior implants can be splinted together with an-
palatine and other maxillary arteries and nerves[15]. terior implants to reduce stresses in the supporting
After bone condensation, significantly higher im- bone, as well as provide the framework for bridge or
plant stability has been recorded immediately after hybrid restorations that span larger proportions of
surgery, as well as during the following observation the maxillary arch [41]. High survival rates of implants
periods compared to solely bone drilling techniques placed in the tuber region have been consistently
[33]. Procedures with the highest success rates and shown in multiple studies [12-21,28]. Across these
greatest implant stabilities consistently placed ta- studies, 161 implants were placed in the maxillary tu-
pered implants in bone once implant sites were berosity with a 95.03% survival rate over an average
drilled and condensed [12-21]. The soft tissues of the follow-up period of 52.08 months (Table 1). All stud-
maxillary tuberosity should be treated with care dur- ies demonstrated high success rates. Comparatively,
ing surgery to avoid periosteal tears that will hinder 161 implants were placed in traditional regions in the
Stomatology Edu Journal 253
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A B
C D
Figure 6. (A) Maxillary alveolar ridge deficiency prior to site grafting. Adequate graft material was obtained through the harvest of tuberosity bone (B)
in combination with bovine osseous particulate as a composite graft (C). (D) The surgical site presented with excellent ridge contour after 3-months of
healing post-operatively.
maxilla with a 94.41% survival rate in the same pa- implants was first proposed as a means of anchoring
tients over the same time interval (Table 1). Survival the posterior ends of fixed prostheses into as dense
rates of implants in the MT and that of other maxillary bone as possible in the posterior maxilla with im-
implants were not significantly different from one plants longer than 15mm [42]. This involves drilling
another (p>0.05). Marginal bone resorption across through the pterygoid processes of the sphenoid,
all studies was analogous to that of conventional the pyramidal process of the palatine bone, as well
implants placed throughout the maxilla despite dif- within the MT in close proximity to the posterior wall
ferent surgical modalities [28]. Similarities in survival of the sinus at approximately 35-55° angulation [10].
rates amongst implants placed throughout the max- The occlusal forces generated in the posterior maxilla
illa suggest tuberosity-based implants can provide a far exceed those generated in anterior areas, and the
stable and predictable alternative to the traditional bone quality of the MT is often inadequate to sup-
major grafting procedures that would otherwise be port fixed prostheses alone [12]. In these situations,
required to stabilize implants in maxillary areas with compensation by means of fixture engagement of
bone deficiencies further anterior to the tuberosity. the pyramidal process of the cortical plate and associ-
This provides a much more conservative option for ated pterygomaxillary regions may be required [44].
patients restricted financially or by medical condi- Increased implant length in the pterygomaxillary re-
tions that hinder or delay healing processes. Sur- gion was found to lead to superior rates of osseoin-
vival rates over longer time intervals (>15 years) are tegration [46]. This may be a result of better implant
required to further validate this conclusion as an ef- apex engagement of the cortical bone between the
fective conservative alternative to major grafting or medial and lateral pterygoid plates, thereby increas-
lifting procedures and to make accurate comparisons ing stability after placement. It is important to note
to established long-term studies of fixed prostheses. that although pterygoid implants utilize parts of the
Often times, the bone volume of the maxillary tuber- MT, not all MT-implants engage the area encompass-
osity alone is insufficient for implant fixture place- ing the pterygoid region. In this way, pterygoid im-
ment. In these cases, implants have also been placed plants and the implant restorations associated with
into the pterygoid plate area to overcome anatomi- them most frequently involve or incorporate a com-
cal constraints similar to the way implants in the MT bination or direct connection of the pterygoid with
have been used in partially or completely edentulous the MT. Dental implants incorporating the pterygoid
patients [10,42-46]. The consideration of pterygoid plate and accompanying areas have been shown to
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A B
C D
Figure 7. Peri-implant dehiscence (A) before placement of a soft tissue graft harvested from the maxillary tuberosity (B). The graft was immobilized
within a pouch (C), and healing at the 2-years surgery demonstrated an outstanding soft tissue condition (D).
have high cumulative survival rates in edentulous al bone harvesting site to alleviate these deficiencies
maxillary arches ranging from 88.2% to 97.7% with in cases of subpar bone mass for implant support.
similar expected bone loss as conventional implants This is particularly critical as the MT frequently fails
in reported studies [10,47-50]. Implant placement to be recognized as a bone graft source during im-
into the pterygoid region poses similar difficulties as plantation assessment. Typical CBCT scans and pan-
tuberosity implants: high operator learning curves, oramic imaging can provide enough pre-operative
limited surgical access, and high risk of complica- assessment of the MT to determine if bone volume is
tion if arteries or their major branches are disrupted appropriate for grafting [5,52]. Removal of bone from
[49,51]. Regardless of inclusion of pterygoid engage- the MT is the least invasive alternative for intraoral
ment, these posterior maxillary implants function to grafting and would not require any extensive repair
support distal ends of fixed prostheses to alleviate at the donor site while providing more than adequate
bending and cantilever forces, as well as to provide bone volume to be used anteriorly to correct ridge
overall denture stability. Their usage to restore miss- deficiencies. This site has become a strong candidate
ing dentition is highly viable as both a standalone as a grafting source in Immediate Dento-alveolar
procedure or in situations where they are combined Restoration (IDR) of compromised sockets, where the
with implants in the MT that serve to decrease non- cortico-cancellous graft can be shaped to the size of
axial loads of permanent restorations. the distant defect and inserted to bolster bone mass
[4,53]. Amongst autogenous bone sources, the great-
3.2 Bone Grafting and Harvesting from the Tuberosity est vertical gains are frequently seen from MT blocks
Loss of osseous tissue from trauma, infection, or ge- compared to composite grafts in localized bone defi-
netic resorption leads to low bone density that can- ciencies [7,54,55].
not support implants, and consequently, implant- The biological properties of a patient’s own bone are
supported restorations. Traditionally, intraoral sites of enhanced when used as a grafting material, as the
autogenous bone block grafts, such as the symphysis autogenous bone contains a wealth of bone mar-
and ramus have been used to supplement alveolar row with great potential for angiogenesis (Figs. 3,
ridges with deficiencies prior to implant placement 4). Autogenous bone is the optimal choice in larger
[6]. Although the tuberosity serves as a candidate for block grafts due to its osseoinductive and osteogenic
direct implant fixation, when bone volume is abun- properties compared to that of xenografts, alloge-
dant, this maxillary region can be manipulated with neic, or alloplastic (synthetic) options [6,56-58]. Bone
the use of various instruments to serve as an addition- harvested from the MT (Fig. 5) can also be combined
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with other grafting materials to form composite 3.3.Soft Tissue Grafting and Harvesting from the Tuber
Review Articles grafts. In situations where only minimal amounts of Region
hard tissue can be harvested from the MT, biomate- The palatal area most commonly serves as the pri-
rials may be used to supplement (Fig. 6). Bone sub- mary donor site for soft tissue grafts in cases of root
stitutes, when embedded in osteoprogenitor cells coverage. This is not always the case with patients
of the MT, provide adequate bone formation in vivo with diminished size, thickness, or rate of blood flow
[59]. Employment of composite grafts using bioma- of the greater palatal artery which can lead to limited
terials and autogenous tuber bone expands patient quantities of connective tissue available for harvest.
candidacy by reducing the total amount of patient The MT has been associated with connective tissue
bone required for grafting procedures, while still re- that can be used as an autogenous graft for soft tis-
taining the benefits of utilizing autogenous tissue. In sue augmentation around implants (Fig. 7) simulta-
this respect, the hard tissue of the MT can be manipu- neously or secondarily with implant placement [4].
lated in a plethora of ways to overcome the problems The gingival cuff of the MT has been shown as an
of bone deficiency throughout the maxilla. excellent source of soft tissue to provide full, lasting
Different surgical alternatives for bone augmentation coverage in more anterior regions of both the max-
in post-extraction compromised sockets have been illa and mandible [3]. Transplantation of tuberosity
described [60]. However, some of these techniques connective tissue onto the aesthetic anterior gingival
require longer periods for rehabilitation and are usu- cuff demonstrated an improvement of the tissue bio-
ally expensive [61]. The Immediate Dento-alveolar type over a healing period to match the surrounding
Restoration (IDR), a one-stage technique, allows den- gingival tissue in texture and color [3].
tal extraction, implantation, and provisionalization Additionally, soft tissue grafting from the MT has
to occur in the same procedure as the flapless bone been shown to be easier than grafting from the pala-
reconstruction using cortico-cancellous bone graft tal masticatory mucosa [3,68]. Subepithelial connec-
harvested from the maxillary tuberosity [62]. tive tissue can simply be harvested from the MT and
The IDR technique, aside from presenting lower over- sutured within a pouch in areas of localized gingival
all costs and treatment time, has been shown clini- recession with little to no complications to treat buc-
cally and radiographically to be effective with respect cal soft tissue dehiscence around single implants
to soft and hard tissue stability in compromised sock- [69-70]. This can fully or partially alleviate aesthetic
ets [63]. exposure of implant threads due to bone loss around
The advantages of IDR include: ease of tuberosity har- the fixture. Soft tissues of the MT can be employed
vest, the malleability of bone fragment which allows throughout the oral cavity in a similar way as other
adequate adaptation to the receptor region, and the traditional gingival grafts with similar success rates.
biological membranous properties of the cortico-can-
cellous graft that promote effective bone and gingival 4. Conclusions
healing. Furthermore, the trabecular nature of grafts There are high success rates of dental implants
harvested from the maxillary tuberosity contribute placed in the MT, which can provide a stable and pre-
to increase revascularization capacity and to release dictable alternative to the traditional major grafting
growth factors to the receptor site [64]. Bone density procedures required to stabilize implants in bone-
at the buccal, palatal, and basal cortical maxillary deficient maxillary areas anterior to the tuberosity.
tuberosity is less compared to other maxillary and Proper placement of implants in this region with the
mandibular bone locations. correct surgical techniques, especially local bone
Due to the decreased thickness of its cortical bone, condensing, can provide support of the prostheses
maxillary tuberosity grafts are easily shaped, yet its in patients without complex grafting procedures.
cortical structure can act as a biological barrier sta- Bone and soft tissue harvested from the maxillary tu-
bilizing the soft tissue and particulate bone graft berosity provides many advantages and serves as an
around the implant [65]. The total porosity and po- outstanding reservoir of tissue with excellent rege-
rous volume of these grafts indicate that the cortico- neration capacity.
cancellous structure can act as a scaffold structure for
cellular and vascular growth. Author Contributions
Additionally, the maxillary tuberosity is a source of NM and GR: wrote and edited the manuscript.
osteoprogenitor cells and growth factors [66]. Taken JMR and LAP: provided the information about the
together, the cortical and cancellous bone from the Immediate Dento-alveolar Restoration (IDR) and
maxillary tuberosity can be considered as an ideal supported with photographic documentation.
structure for bone regeneration, as it is a natural scaf-
fold filled with osteoblastic cells and growth factors Acknowledgments
[67]. There is no conflict of interest.
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258 Stoma Edu J. 2019;6(4): 249-259 www.stomaeduj.com
ROLE OF THE MAXILLARY TUBEROSITY IN PERIODONTOLOGY
AND IMPLANT DENTISTRY- A REVIEW
Review Articles
Nicholas MONTANARO
DDS
Department of Periodontology
School of Dental Medicine
Stony Brook University
Stony Brook, NY, USA
CV
Nicholas Montanaro is an Oral and Maxillofacial Surgery resident within the Northwell Health System. He
completed his undergraduate studies in Cell and Molecular Biology at the Hofstra University, Long Island, New
York and later went on to earn his DDS degree from the Stony Brook University, Stony Brook, NY, USA. His current
research focuses on the advancement of innovative dental implant technologies, development of regenerative
biomaterials, and management of peri-implant disease.
Questions
1. Can maxillary tuberosity be used for implant placement?
qa. After panoramic radiographic evaluation?
qb. After occlusal radiograph?
qc. After CBCT?
qd. After periapical radiograph of the region?
2. Tilted implants are associated with more failures and crestal bone loss:
qa. The statement is not correct in case of supracrestal placement
qb. The statement is not correct in case of subcrestal placement
qc. The statement is not correct in bruxers
qd. The statement is not correct
3. An autogenous graft can be harvested from the
qa. Tuberosity
qb. Chin region
qc. Ramus
qd. All of the above
4. Soft tissue augmentation as a free gingival graft from the tuberosity is recommended
compared to the area of hard palate
qa. For improvement of aesthetics
qb. To eliminate risks of bleeding
qc. To increase thickness volume
qd. All of the above
Stomatology Edu Journal 259