Modified Surgical Protocol for Placing

Implants in the Pterygomaxillary Region:

Clinical and Radiologic Study of 454 Implants
Xavier Rodrguez, MD, PhD1/Victor Mndez, DDS2/Xavier Vela, MD, DDS3/Maribel Segal, MD, DDS3
Purpose: To review a series of 454 pterygoid implants placed more vertically than the previous standard
angle (45 degrees) over a functional loading period ranging from 2 months to 14 years with a mean follow-up
period of 6 years. Materials and Methods: A retrospective study was made. The sample was composed of
patients rehabilitated with pterygoid implants between January 1997 and December 2010. Patient selection
criteria included: edentulism on the posterior area of an atrophic maxilla, with less than 8 mm remaining
from the sinus floor to the alveolar crest, and the presence of an anterior implant or tooth to ensure mesial
support for a partial denture. After a healing period between 2 and 7 months, panoramic x-rays were taken
at the time of loading. The implant length, implant diameter, implant success, and the angulation of the
pterygoid implants were measured. Results: Three hundred ninety-two patients (206 women and 186 men)
ranging in age from 34 to 75 years were fitted with 454 pterygoid implants and followed up. The 18-mm
implant length was the most favored implant to fit in the pterygoid area. Implant diameter was 3.75 mm
in 448 cases (98.6%). The mean mesiodistal angulation of the pterygoid implants was 70.4 degrees 7.2.
After a mean follow-up period of 6 years, 96.5% of the implants placed were successfully osseointegrated.
Conclusions: The findings indicate that a mesiodistal inclination of the pterygoid implant at 70 degrees
relative to the Frankfort plane following the bony column of the pterygoid region decreases the non-axial
loads of the rehabilitations and exhibits good long-term survival; however, further studies are needed to
assess the long-term survival of implants in the pterygomaxillary region. Int J Oral Maxillofac Iimplants
2012;27:15471553
Key words: atrophic maxilla, follow-up period, pterygoid buttress, pterygoid implant

he posterior area of the maxilla presents many

limitations to implant placement. These anatomical factors include bone quality, quantity, location
of the antrum, and physical accessibility to operate.1
Pterygoid implant technique is a treatment option
for the atrophic edentulous posterior maxilla, as first
described by Tulasne.2 The pterygoid implant passes
through the maxillary tuberosity, pyramidal process of
palatine bone, and then engages the pterygoid process of the sphenoid bone. 3,4 Anchored in the pterigomaxillary area, such implants avoid the need for bone
grafting and/or prosthetic cantilevering (Fig 1).

1Private

practice, Barcelona-Madrid, Spain.

practice, Madrid-Lleida, Spain.
3 Private practice, Barcelona, Spain.
2Private

Correspondence to: Dr Xavier Rodrguez, C/ Ganduxer 122,

08022 Barcelona, BCN Spain. Email: headquarters@
borgroup.net

To simplify this technique, several authors advise

the clinician to place the implant(s) with an inclination
of 45 degrees relative to the Frankfort plane.59
However, there is no publication showing any pterygoid implant inclination series. It has been shown that
the angle of the maxillary-pterygoideal column in the
edentulous maxilla is 67.3 degrees 5.0 in an anteroposterior direction relative to the Frankfort plane, and
also has been shown that the buccopalatal angle is
14.1 degrees 2.1.10 This bony corridor differs slightly
from the 45 degrees described by several authors.57
Despite having a high rate of success, most studies
about pterygoid implants present a mean follow-up
period of less than 3 years.3,5,1113 There is insufficient
data about pterygoid implant failures beyond 3 years
of loading, which makes it difficult to draw any conclusion about their long-term survival.
The purpose of this study was to assess the effect
of placing pterygoid implants more vertically than has
heretofore been the standard (45 degrees), following
previous anatomical series and presenting a follow-up
period over 14 years.
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Rodrguez et al

Fig 1 CT scan Image of pterygoid implant after 4 years of loading.

Fig1a Axial view: the pterygoid
implant is located between the
posterior wall of the maxillary sinus, the palatine bone, and the
pterygoid process of sphenoid.
Fig1b Coronal view: the implant body runs parallel to the
palatine bone.

Fig1c Sagittal view: the implant body and apex is located

between the posterior wall of
the maxillary sinus and the
pterygoid process of sphenoid.

Fig2a Panoramic radiographs after 6 years of loading.

Fig2b Teleradiography after 6 years of loading.
Fig 2c Radiographs after 3 months of surgery, before
stage-two surgery.

Materials and Methods

This study included all patients who had implants
placed in the pterygoid-maxillary region between January 1997 and December 2010 (range, 2 to 168 months).
Patient selection criteria included edentulism on the
posterior sector of an atrophic maxilla, with less than
8 mm remaining from the sinus floor to the alveolar
crest, as measured by orthopantomography, and the
presence of an anterior implant or tooth to ensure
the mesial support for a partial denture (see Fig 2). Exclusion criteria included metabolic bone disease, an
unstable systemic condition, such as uncontrolled diabetes or untreated hypothyroidism, or the discovery of
a malignancy.
All patients received a preoperative orthopan
tomography (Planmeca Proline, Planmeca OY). In the
panoramic radiograph, the patient should be positioned through the guides lights along three major
axes (anterior-posterior, vertically (Frankfort plane),
and midsagittal alignment) to standardized the radiologic measures.

To prevent infection and reduce inflammation,

preoperative medication was prescribed for every patient to be taken 24 hours before the operation. This
medication included amoxicillin (750 mg) or clindamycin (600 mg), one tablet every 8 hours; ibuprofen
(600 mg), one tablet every 8 hours; and metamizol
(75 mg), one tablet every 8 hours after surgery. A single
doctor placed all the implants in the pterygomaxillary
region between January 1997 and December 2010
(range 2 to 168 months).
Local anesthetic (articaine with epinephrine
40:0.005 mg/mL) was infiltrated into the maxillary nerve
and the palatine nerve, plus an anesthetic booster that
was infiltrated into the tuberosity. A posterior incision
was made in the alveolar crest of the maxillary tuberosity to expose it, and a straight contra-angle handpiece
was used on the drill, with a bur guide and long burs
2 and 3 mm in diameter and 13 to 20 mm long at
500 to 1,500 rpm, and external irrigation with saline
solution. Antero-posterior drilling angles were adapted to the patients anatomy, entering 10 to 15 degrees
medially.

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Rodrguez et al

Fig3 The handpiece moves in a posterior, medial direction.

Nasal
cavity
Maxillary
sinus

Palatine

Buccal

Pterygoid

Maxilla
Palatine

a
Fig3a Coronal view.

b
Fig3b Surgical view.

The mesiodistal angle of the implant was adjusted

continuously to fit each patients anatomy (Fig 3). In
this technique, it is extremely important to feel ones
way along while perforating and gradually going from
soft cancellous bone to hard cortical bone, without
a break that might indicate the bur was penetrating
the maxillary sinus or nasal cavity. In some cases, it
is advisable to perform the extraction of the wisdom
teeth to avoid direct contact between the molar and
the pterygoid abutment position.6 Following Tulasnes
recommendation to ensure anchorage in the pterygomaxillary region, all implants used in this series were at
least 13 mm long.2,3 All the implants were seated with
bicortical anchorage (Fig 4). The cover screw or the
abutment was positioned, and the flap was sutured.
In cases where the width of the gingiva reached more
than 4 mm, the soft tissues were removed in order to
fit an abutment of 4 to 6 mm in length.
Panoramic radiographs were taken before stagetwo surgery or while the prostheses were fabricated.
For this reason, a panoramic radiographic view was
used to measure the pterygoid implant inclination. An
accurate patient positioning was achieved while the
radiographs were taken: the vertebral column had to
be straight, the patient had to bite a plastic bite-block,
and an accurate position of the midsagittal plane
perpendicular to the floor had to fit by means of the
guide to avoid errors due to insufficient or incorrect
shape and size that would result in distorted images.
Lack of a peri-implant radiolucency on radiographs
and implant mobility and/or pain were the principal
factors for assessing osseointegration success.
The implant length, diameter, success, and the angulation of the pterygoid implants were measured.
Descriptive statistics was done using SPSS version 12.0
(IBM). The angulation of the pterygoid implants was

c
Fig3c Mesiodistal view.

Fig4 CT scan: implants anchored in the palatine bone

and the pterygoid process.

measured relative to the Frankfort plane at the time of

stage-two surgery or when the prostheses were made
if the abutments had been previously inserted at the
first surgery. All radiographs were taken using Dimaxis
version 2.4.3, (Planmeca OY). Figure 5 shows in a clinical case how the measurements were done. The mean
time between implant placement and stage-two surgery, along with any complications were also reported.
Patients were scheduled for annual follow-up.

Results
Four hundred fifty-four pterygoid implants were placed
in 392 patients (206 women and 186 men, ranging
in age from 34 to 75 years). All implants had a rough
surface. Four hundred fifty-three implants showed a
dual acid-etched surface (Osseotite, 3i/Implant Innovations) and one implant showed a sandblasted and acidetched surface (Mis, Israel DVDent). With one exception,
all surgeries were performed under local anesthesia.
Three hundred one patients (66.3%) were smokers.
For all implants, the functional loading period ranged
between 2 months and 14 years (168 months) with a
mean follow-up period of nearly 6 years (71.1 44.2
months). It must be noted that 227 implants (50%)
were followed for longer than 5.7 years.
The 18 mm-length implant was the most chosen implant to fit in the pterygoid area. In 349 cases (76.9%),
the implant length was 18 mm. In 51 cases (11.2%), the
implant length was 20 mm. In 45 cases (9.9%), the implant length was 15 mm. In 9 cases (1.9%), the implant
length was 13 mm. Implant diameter was 3.75 mm
in 448 cases (98.6%). In 5 cases, a 4-mm-diameter implant was used, and in one case, a 4.2-mm-diameter
implant was chosen.
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Rodrguez et al

a
Fig5a Buccal and occlusal views before prosthesis placement.

70 degrees

b
Fig5b Orthopantomographic image of the restoration and angulation of the pterygoid implant on the left side.

c
Fig5c Buccal and occlusal views of a fixed prosthesis.

The following complications were encountered in

the present study:
Intraoperative: Four cases of hemorrhage that
stopped when the implants were seated, and three
cases of pain while inserting the implant, relieved
with booster anesthesia via the palatine and intraalveolar route (the surgical bed).
Postoperative: One case of transient hypoesthesia
of the palatine nerve lasting 4 weeks, and one case
of pterygomaxillary pain that needed the implant
removed.

Prosthetic: One patient that exhibited bruxism fractured two bilateral pterygoid implants after 5 years
of loading. It must be noted that this patient also
fractured the implants placed in the premolar region.
Three bruxism patients also fractured the hybrid
prosthesis.
Of the 454 pterygoid implants, 438 (96.5%) osseintegrated successfully and 16 (3.5%) failed. Thirteen of these
16 implants did not osseointegrate at the stage-two surgery. The mean time between implant placement and
stage-two surgery was 4.2 months 1.2 months with a

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Rodrguez et al

50

30
Maxillary
sinus

Pterygoid

Maxilla

10

47 53 55 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 89
ANG

Fig6 Graphic of the implant mesiodistal angulation (ANG) relative to the Frankfort
plane.

range of 2 to 7 months. The time until functional loading depended on the stability of the mesial implants
and their osseointegration status. In five cases, a sinus
bone graft was made in order to achieve good stability for the mesial implant; these patients had to wait
7 months before the implant loading.
The implant mesiodistal angulation relative to
the Frankfort plane ranged between 47 degrees and
90 degrees. The mean mesiodistal angulation of the
pterygoid implants was 70.4 degress 7.2 degrees.
Two hundred seventy-nine implants (61.4%) showed
an implant mesiodistal angulation between 65 and
75 degrees. Four hundred forty-four implants (94.7%)
showed an implant mesiodistal angulation between
60 and 90 degrees (Fig 6).
Tissue-integrated prosthesis forms included: 313
metal-ceramic multifixture partial-arch fixed prostheses, 38 metal-ceramic multifixture complete-arch fixed
prostheses, 17 hybrid multifixture complete-arch fixed
prostheses, 13 complete removable overdentures, and
11 partial fixed prostheses connected to the teeth.
Regarding the 16 failed implants, 7 took place in
men and 8 took place in women. Ten of these implants
failed due to a lack of osseointegration in smokers
(60%) and 4 implants in nonsmokers (40%). All 14 implants failed before loading at stage two. Two osseointegrated implants fractured after 5 years of loading in
a bruxism patient. No significant differences in success
index were found when considering smoking versus
nonsmoking patients (P > .05). Again, no significant
difference was found when considering sex, age, or
time of implant loading and failed implants (P > .05).

Pte
r yg
om
a

xill
ar y

20

co
lum
n

Count

40

Palatine

67.3 degrees
Fig 7Anthropometric representation of
the pterygomaxillary column angulation.
Sagittal view.

Discussion
According to Tulasne, 80% of atrophic maxillae retain a
bone corridor that is sufficient to enable seating of an
implant 13 to 20 mm long.2,3
This bony pillar consists of: (1) the maxillary tuberosity, (2) the pyramidal process of the palatine bone,
and (3) the pterygoid process. The position of this
bony pillar has been measured anthropometrically. Yamakura et al observed that the angle of the tuberositypyramid-pterygoid pillar in the edentulous maxilla is
67.3 degrees 5 degrees in an anteroposterior direction relative to the Frankfort plane, and the buccopalatal angle is 14.1 degrees 2.1 degrees10 (Fig 7).
This bony corridor inclination differs from the pterygoid implant inclination (45 degrees) described by
several authors.57 In the present study, the mean mesiodistal angulation of the pterygoid implants relative
to the Frankfort plane was 70.4 degrees 7.2 degrees.
Furthermore, 61.4% of cases showed an implant angulation between 65 and 75 degrees and 94.7% showed
an angulation between 60 and 90 degrees relative to
the Frankfort plane (Figs 5c and 6).
The results of the present study differ from the
45 degree pterygoid implant inclination described by
several authors but is consistent with the results of
the anatomical study by Yamakura et al.10 Placing the
implant more vertically than 45 degrees improves the
loading conditions because the non-axial forces are
diminished and the angle approximates that of natural molar teeth.6,14 Bahat recommends a mesial angle
of 10 to 20 degrees (70 to 80 degrees relative to the
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Rodrguez et al

Frankfort plane) for posterior implants as a way to imitate the emergence of second molars.15
One of the drawbacks of the traditional pterygoid implant placement technique is the presence of nonaxial
forces and the possibility that they might compromise
the long-term restoration. A 45 degree angle in an implant reduces its axial load capacity by half6 when comparing the same implant at 90 degrees. The axial load
on a 20-mm implant angled at 45 degrees would thus
be equivalent to that of a 10-mm implant. In contrast,
if the angle is 75 degrees, the axial load capacity of a
20-mm implant is 72.2% (comparable with that on a
14.4-mm implant). By placing two implants in the premolar region and a pterygoid implant in the posterior
region, a plane in a tripod shape is created that protects
the entire framework from transverse force and load,
making it suitable for restoring the posterior sector.
Tulasne advised implants of 13 mm length, at least
in the pterygoid region.3 In the present study, the
18-mm implant length was the most chosen length
to fit in the pterygoid area. The use of 13- to 20-mmlength implants helps the clinician achieve good primary stability and avoid damaging fine structures as
the base of the skull or the maxillary artery.16
Maxillary implantsupported restorations are less
successful than those in the mandible. Olsson et al
found an osseointegration rate of 86% in the maxilla
versus 99% in the mandible.17 Widmark et al presented
a 74% success rate at 5 years in atrophic maxillae.18
The success rate for pterygoid implants is one of the
highest in the maxilla. Tulasne obtained 97% success,
Raspall and Rodrguez 98%, Graves 89%, Balshi et al
88%, Venturelli 97%, Fernndez and Fernndez 93%,
and Pi 97.2%.3,5,6,1113,19 The success rate of the present
study agrees with the previous studies (96.5%).
For most studies, the lower end of the range of
follow-up period is less than 3 years, signifying that
the 3-year survival of several implants is unknown.
Fernndez and Fernndez analyzed 152 implants with
a range of follow-up between 0.1 and 169 months.12
The implant survival rate reported by Fernndez and
Fernndezs study was a 93%.12 Pi reported a 97.2%
survival rate in 177 implants in a follow-up ranging between 1 and 10 years.13 Ridell et al reported 22 pterygoid implants with a range between 1 and 12 years, and
presented a 100% success rate.20 Balshi et al reported
356 pterygoid implants with a range between 0.06 and
9.2 years with a 88.2% rate of survival.19 Pearrocha et
al reported 68 pterygoid implants followed for 1 year
with a 97% survival rate.21 In the pterygomaxillary region, most failures occurred before implant loading.7
The present study showed a success rate of 96.5%, according to those long-term studies.

Taking into account those studies, it can be said that

pterygoid implant rehabilitations present good longterm survival. Rough-surfaced implants can reduce the
waiting time before functional loading.22 Balshi et al
achieved a success rate of 96.3% for osseointegration
with rough-surfaced pterygoid implants.23 These results were statistically significant when compared to his
previous series using machined pterygoid implants.23
In the present study, all implants had a rough surface and the implant survival rate (96.5%) was similar
to that obtained by Balshi et al.23 Pterygoid implants
have provided abutment support for a variety of
prosthetic rehabilitation forms that include partial or
complete-arch fixed prostheses, complete removable
overdenture, and terminal abutment for partial fixed
prostheses connected to the natural dentition.7,19,2325
Some complications related to the surgical procedure have been reported: venous bleeding, trismus, misplacement of implant, and a unique case of
a continuous episode of pain and discomfort.6,7,11,26
Reychler and Olszewski reported a unique intracerebral penetration of a zygomatic implant inserted in
the pterygoid region.26 In the present study, minor
hemorrhagic and neurologic complications have been
shown. The authors consider that the use of drills and
implants as much of 20 mm in length make this a safe
technique.
In the present study, although smokers had a higher
number of failures, no significant difference in success
index was found when considering smoking versus
nonsmoking patients (P > .05). Several authors note
the low morbidity associated with the pterygoid implant3,57,11,21 and, therefore, the use of pterygoid implants can be a prudent option in patients who are
smokers, diabetic, osteoporotic, or who have Crohns
disease or severe parafunctional habits.27 The main
drawback with this method is that it requires detailed
knowledge of the pterygomaxillary region and surgical skill to achieve adequate anchorage.

Conclusion
In conclusion, the findings of the present study about
pterygoid implants indicate that mesiodistal inclination of the pterygoid implant at 70 degrees to the
Frankfort plane following the bony column of the
pterygoid region decreases the non-axial loads of the
rehabilitations and exhibits good long-term survival;
however, further studies are needed to assess the
long-term survival of implants in the pterygomaxillary
region.

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Rodrguez et al

Acknowledgments
The authors reported no conflicts of interest related to this study.

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