The Internotionai Jourr-iol of Periodontics & Resforotive Dentistry

513

The Pterygoid Plate Implant:

A Solution for Restoring the
Posterior Maxiiia

Stuart L Groves, DDS. PviS' Restoring fhe dentition in fhe

posterior maxilla can be very
challenging.'"-* Firsf and sec-
ond molars tend to be the
feeth initially lost to pathoses."
Often implants are not placed
in this region because of the
poor quality of bone or pneu-
Ttie sinus cavity ond ttie rarefied posterior maxillary bone make it difficult matlzafion of fhe sinus.^''
to place Impiants posterior ta the first premoiar. Placement of an implant Piacemenf of a cantilevered
into ttie pterygaid plate area has been used to overcome these anatomic resforafion or augmentation
aOstacies. allawing successtui restoration at the area. Sixty-four implants wifh a sinus liff has become
were pioced in 49 patients. Forty-three impiants are in function. There have convenfional freatment for the
been 7 foiiures. The technique is described and a typical case is iilustrated.
maxilla.'"^" Placement of a
(Int J Periodont Rest Denf 1994:14:513-523.)
pterygoid plate fixture is an
alfernafive fhaf may be used
with predictable success," This
implant passes through a pillar
of bone composed of the max-
illa, pyramidal process of fhe
palafine bone, and the ptery-
goid process of fhe sphenoid'^
(Figs l a to lc).

Anatomy

The tuberosity of the maxilla is

Private practice in oiai surgery, Bri<e. Virginia. composed of type III and type
Reprint requests: Dr Stuart L. Graves, 5206 Lyngate CoLfrt. Burke, IV cancellous bone. The pyra-
Virginia 22015. midal process of fhe polafine

Volume 14, Number , 1994

514

Mandibular f.

StTloiiI aro'

Fig la (abave) Three separate bohes are cined together in the pferygoid region-
the posterior moxillo, the pyramidal process of the palafine. and the pterygoid
process of the sphenoid.

Fig lb (top right) The ptetygoid fossd is bordered Oy the mediah and lateral ptery-
goid piafes. Branches of fhe posferiot superior aiveoior nerve pass through this
region. There are no ma/or arteries or veins The thickesf Puffress of bone s medial fo
the alveolar ridge.

Fig Ic (bottom right) The ideol piocement of fhe impianf is from midfuberosity info
the pterygoid fossa The hamuiar process is just medidi to fhe apex.

and fhe pterygoid process of nal maxillary artery crosses 1

the sphenoid ore dense corfi-
coi bone. An ideally ploced
impionf will pass completely
through the pterygoid process
into the pferygoid fossa (Figs 2a
to 2c).
No anotomicolly significant
sfrucfures are found in this
region. A branch of fhe posteri-
or superior aiveoior nerve pass-
es befween fhe pferygoid
piates.'^ The pterygoid muscles
occupy the majority of spoce
befween fhe plates. The inter-
cm superior to fhe pterygo-
moxiliary suture as it enters fhe
pterygopolatine tossa. The
mean disfance from fhe inferior
pterygomaxillary suture to this
artery is 25 mm."* In a Le Fort I
osfeotomy, the pferygoid
plotes are sectioned trom the
palafine bane at the pterygo-
maxillary sufure (Figs 3a ond
3b). This is considered a safe
areo becouse of fhe lack of
vital structures (Figs 4a and 4b).

The internotionai Journal of Periodanfics & Restorafive Dentistry


Fig 2a Tfie ideal placement of the
pterygoid plate fixture is showing. The
anguiotion and position are deter-
mined by the size at tne sinus cavity.
Fig 4a The average height of the
pterygoid maxillary suture IS 15 mm
Superior to this level, the sphenopala-
tine fassa cantains fhe maxiilary nerve
and ferminal branches ot the internai
maxiliary artery.
Fig 2b The typical position ot 20-mm
impiant is shown on o modei witti the
laterol tuberasity and iat&ial pterygoid
plate remaved. Tfie fixture extends from
the second molar region through the
pterygoid buttress of bone inta the
fossa.
Fig 4b The distance from the second
moiar area to the pterygoid buttress is
15 mm The distance fram the same
orea at the tuberosity to the cranial
base is mare than 40 mm.
515
Fig 2c The cephaiomerric radiograph
Shaws the relotionship of the implant ta
the facial skeleton. The ape*- extends
past the pterygoid buttress of bone.
Fig 3o (left) The internal maxiliary
artery courses superior and lateral ta
the pterygomaxiliary suture and termi-
nates in the sphenopalafine tosso.
Fig 3b (rignt) tn the Le Fort I osteoto-
my, the separating chisel is moved
through the pterygomaxiliary suture. As
long as the chisel is kept below the
sphenapalatine fossa, no yitol struc-
tures are threatened.
Voiume 14, Number 6,
516

The thici<est orea of sup-

porfing bone is iaoafed in fhe
middie parf ot the pterygoid
process between the piates.
Thiis is 3 to 4 mm medial fo tfie
aiveoiar ridge; an implant must
therefore be angied siightly
medially to bisect this dense
juncture ot bone In the pfery- Fig 5a (above) An implant with o 45-
goid region. Thie fiamular degree angle thot posses through the
pterygaid buttress engages 8 mm of
process on the mediai ptery- dense cortical bone. The apex pra-
goid plate is easily palpable in trudes 2 mm Into the fossa.
ti^e oropharynx. The impiant is
placed just iateral to this i<ey
iandmark. The average vi/idffi
of dense bone at the juncture Fig 5b (right) The thickness of the
of the palatine and sphenoid pferygoid buttress is 6 mm.
processes is mm (Figs 5a and
5b). It an implant is passed
through this pillar of bone at an
angie of 45 degrees, it incorpo-
rates 8 to 9 mm of dense corti-
cal bone. Frequently the screw
access hoie w\\\ be tound in tine
centrol fossa ot the first molar
(Figo),

Fig Ttie amounf ot bone surround-

ing a !O-mm implant is compared to
that surrounding a 20-mm pterygoid
plate implant. The screw access area
for both IS the ocdusal aspect of the
first molar

The Interhationai Journai ot Periodanfics S Restordfive Dentistry


Preoperatlve evaluation
A high-quality panoramic radi-
ograph is usually all that is nec-
essary to evalute the area
radiographically. Consideration
should be given to the degree
of pneumatization of the sinus,
the shape of the tuberosity,
and the relative density of the
bone of the pterygoid plates.
Knife-edged maxiilory ridges
are rarely o problem in this
517
Fig lu Radiograph lowing typical
pterygoid piate implont.
Fig 7b (left) The impiant is incorporat-
ed info o four-unit fixed prosfhesis. The
view of fhe sfonddrd dbutmenf exiting
gingiva reveots healthy tissue around
I ne obutment.
Fig 7c (right) Tiie buccal view of fhe
four-unit prosfhesis is shown.
area, becouse the maxiila
tends to increase in width as it
approaches the second ond
third molars. Computerized
tomography provides a clearer
picture, but has been used by
the outhor only in patients with
severe maxillary atrophy. The
size of the sinus determines
both the angle ond anteropos-
terior placement of the implant
(Figs 7a to 7c).
Volume 14, Number . 1994
 518
f i g Sa Preoperatively, the sinus is
moderately pneumatized in ft\e left
moxillo, The ieft second premolar ana
first molar were extracted 1 mantn prior
to implont placement.
Surgical technique
The surgical fechnique is shown
in Figs 8a fo 8h, Locol anesthesia
is achieved with lidocoine 2%
with epinephrine 1:100,000, Infil-
trations are made in the
greater polafine area of fhe
soff palate and the lateral buc-
cal vestibule, and posterolater-
al to the tuberosity,
A full-thickness incision is
made a few millimeters medial
to the crest of fhe tuberosify
from fhe pterygomaxillary
fissure to t h e p r e m o l a r
region, A relaxing incision is
placed anteriorly, A m u c o -
periosteol flap is elevafed
buccally, exposing fhe fuber-
osify in ifs enfirefy. A "labial
veneer" sfenf is preferred
for the flexibility if affords the
Ttie intemationai Journai ot Periodontios & Restorotive Dentistry
surgeon in location and angle
of the fixture. Because of the
45- fo 50-degree angulation of
the fixfure, the crew access
area will be in the central fosso
of the firsf molar. The implant
angle is determined by fhe tloor
of the sinus and fhe vertical
height of bone in the tuberosi-
ty. The normal tendency when
this procedure is attempted for
the firsf fime is to place the Hxfure
too far anteriorly wifh foo little
horizontal angulation.
A guide hole 3 to 4 mm
deep is placed in the second
molar area of the tuberosity
with a No, 4 or 6 round bur. To
establish the final depth and
angle of the fixture placement,
a long-shaft 2-mm twist drill on
a bur extension is used. The
hamular process is palpated
and the drill is directed 5 mm
laterally at approximately 45
degrees to the occlusol plane.
This process is the primary
guide used to determine the
thickest part ot fhe pterygoid
pillar of bone. It the correct
path is followed, the twist drill
will encounter dense cortical
bone of fhe pferygomaxillary
sufure area at 10 to 14 mm
deep. The drill will slow down
noticeobly, then speed up
again affer it passes through
the pteiygoid process. The drill
is removed and a probe is
p l a c e d in fhe hole in an
attempf fo feel fhe sinus cavity.
If the floor of fhe sinus has been
perforafed, a new site must be
lacated at least 3 mm posterior
to the previous one. The long-
shaft pilot and twist drills are

Fig 8b A depfh prabe is piaced on
the tiamular process to fielp ih the ori-
entation Ttie ideal impiaht placement
is 5 mm iaterol fo this process. This struc-
ture is frequently palpated during the
drilling phase.
Fig 6c The standard incision is made
from the posterior tuberosify, stighfiy
medial fo the alveolar crest ta ffie pre-
molar area.
519
Fig 8d A guide hole is placed with the
aid of a lobioi veneer sfenf.
Fig Be (ieft) A long-shaft 2-mm twist
drill on a bur extension is sunk through
the pterygoid buttress.
FigSf (right) An 18-mm implant is
piaced without counfersini<ing.
FigBg (leff) Final placement of the
irriplani with cover screw is shown. The
implant heod is flush wifh fhe corlicol
bone of the tuberosity.
Fig 8ti (right) The implahf is parallel fo
the flaor af the sinus and protrudes
through fhe pferygoid process of sphe-
noid bohe.
Volume 14, Number 6. 1994
 520
used similarly. It is imporfanf fo Soft tissue piasty or tuberosi-
pass compietely through the fy reduction is often performed
pterygoid plate buttress of at ciosure. The incision is closed
bone. There is no oounfersink- wifh 3-0 resorbabie suture on a
ing. No. cutting needle with con-
After fhe impianf site has tinuous suturing,
been completely prepared, a The patient is allowed to
depth probe with an eniarged wear the prosthesis immediate-
tip is used to explore fhe site ly affer surgery. The denfure is
and determine the length of relieved in fhe tuberosity to pre-
the impiant fo be used. Care is vent premoture loading. The
taken to check that the sinus patient is placed on antibiotics
has not been perforated. The for 1 week. Penicillin 500 mg
impianf shouid pass compiete- four times per day is preferred.
ly through the pterygoid if the patient is sensitive to peni-
process fo esfablish bicorfioal ciliin, cephaiosporin or clin-
stabiiizafion, damycin can be substituted.
A fixture that wiil extend 3 At reentry in 6 months, the
fo 4 mm past the pferygoid impiant is reverse torque tested
process and into the fossa is (10 Ncm) fo ensure osseoinfe-
selected. This is usually a seif- gration. A standard abutment
fapping 15- to 20-mm thread- is usually placed. Where the
ed implant, if is easiiy placed angulation has exceeded O
with a long fixture mount. The degrees, an angled abufrmenf
implant should be seated so has been used.
that the hex head is buried in
the cortex of fhe fuberosity. A
cover screvi/ is then piaced. Discussion
To date, 64 pterygoid plate
fixtures have been piaced in 49
patients. Forty-three are
presently loaded and in func-
tion. There have been 7 faii-
ures, All failures were obvious
at fhe second stage, when
their mobility was tested, None
of fhe impianfs has f a i l e d
under function. This wouid indi-
cate that implants, uniike
teeth, respond weii to nonaxiai
loading. The occiusai plane, in
relation fo fhe impiant axis,
seems to exert no significant
The interhotionoi Journai of Periodohtics & Restorative Dentistry
influence on the peri-implant
heaifh or stabiiity.'^
Advantages of pferygoid plate
impianfs
1. No bone graft is necessary.
2. integrity of fhe sinus is pre-
setved,
3. The architecture of the
sinus (eg, septafed sinus) is
rareiy a technical probiem,
4. The outcome is predicfabiy
successful (of 5 fixtures
piaced, six have been
unsuccessful).
5. The anterior-posterior spread
is maximized; fhere is no
need for cantilevering.
6. The fixture is pioced at an
easy angle to restore.
7. There is iittie morbidity.
8. Tuberosify reduction or
other tissue plasfy can be
done simultaneously.
9. Treatment fime is shorter
than wifh sinus grafting.
Disadvantages ot pterygoid
plate impianfs
1. The procedure is technique
sensitiveit is a semiblind
procedure through 15 fo 20
mm of bone.
2. Adequafe bone supporf is
necessary in fhe tuberosity
and pterygoid piafe region.
 521

Fig 9a (\ef) in the ideal placement,

the anterior-posterior spread is maxi-
mized. (Courtesy of Dr Daniei Sullivan.)

Fig 9b (right) A spark erosion frame-

work is fitted an standard aPutments for
an overdenture. (Courtesy of Dr Daniel
Sullivan.)

Fig Wa (ieft) Typically, the fixture is

placed at a 45- to 50-degree angie.
(Courtesy of Dr Abraham ingber.)

Fig 10b (nghf) The fixture is placed at

an easy-access ongle for placing
restorative components. (Courtesy of
Dr Abraham ingber.)

Conclusion

Long-term evaluafion is need-

ed fo assess fhe viobility of
implant placement in tfie pfery-
goid piate regicn. The ptery-
goid plate fixture has been
used successfuliy vi/ith fixed
prostfieses, spari< erosion pros-
theses, and framework-supporf-
ed overdentures (Figs 9a fo
10b). iVlany of the impianfs
fiave been in function for more
than 4 years. To date none has
been iosf after loading.

Volume 14, Number , 1994

 522

Figllo ' ,. . ..'-.-.' \iOS previously

scheduled to receive bitoterdi sinus lifts.
Because sinuses are septafed bilateral-
ly and because the patient suffers from
chronic sinusitis (evidenced by
increased density in the Sinus), the
pianned procedure was cancelled
and pterygoid pidle fixtures will be
plooed instead. Note the dense bone
present biiaterolly in the pterygoid but-
tress areo.

Fig l i b Piocemenf of the pterygoid plate fixtures has been successful. A spork ero-
sion overdenture is in place.

Fig 12 A pferygoid plate tixfure has

been piaced after a sinus groft faiied
The prosthesis has been in function for
mote than 4 yeors.

The Internationol Journal of Periodohtics & Restorative Dentistry


The sinus cavity (Figs 11a
and l i b ) and rarified posterior
maxillary bone create a diffi-
cult problem for implanf piace-
menf posterior to the first pre-
molar. The pterygoid plate
fixture has proved to be a pre-
dictably successtui solution with
low morbidity (Fig 12).
Acknowledgements
Special ttianks to Ms Cindy C, Blaiack
ond Ms Jen Eimare for assistanoe in tiiis
study and to Dr Gary Reiser for assis-
tance in preparation ot this artioie.
523
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the maxiiiary sinus fioor for
Brnemark implants: A preliminary
1, Jattin RA, Berman CL, The excessive
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loss ot Brnemark tixtures in type IV
North Am 1991(Nov):3C4).
b o n e : A 3-yeai anoiysis, J
Periodontoi 1991:2:2-4, 11. Krogh PHJ. Anatomic and surgioai
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Voiume 14, Number , 1994