Atrophic maxilla: Recommendations?

I just received this panoramic  X ray and I would like to hear your opinion. I don’t perform zygomatic implants and the patient does not want this kind of procedure. How would you approach this case? Bilateral sinus lift and 6 implants- 3 on the right and 3 on the left?  What do you recommend?

38 thoughts on: Atrophic maxilla: Recommendations?

  1. NYOMS says:


    I am not sure how you can counsel the patient on the procedure that you do not perform. How does the patient know that they don’t want zygomatic implants if they have not been truly informed about it.

    Lack of informed consent…

  2. Howard Abrahams says:

    Hi there. Very important to consider available bone in anterior maxilla before deciding on treatment plan. CBCT.
    Don’t forget to look for combination syndrome as this patient looks like a long time denture wearer, i.e. pre-prosthetic surgery. Good luck

  3. TH20 says:

    For the sinus part, you can perform the bone-ring-technique in which you lock the implant in between a special coffer screw and a bone ring. It is an alternative for zygomatic implants

  4. Patrick E Walker DDS MSC says:

    I have treated patients from Kaiser that had Zygomatic Implants that were already mobile when I saw them. The implants were 57 mm long and pathetic. I believe the Doctors were experimenting on these poorly informed individuals. after 40 years i would rather have sinus lifts but only if implants could be placed in the areas of 6 and 11. If the six are placed to far posteriorly the cantelever will be too great and you and the patient will be very disappointed in the function. even if you do cast bars with attachments the function will be poor!

  5. scott berdelle says:

    The patient only has second bicuspid occlusion in the mandible and the second bicuspids
    are cantilevers. I can’t determine where his sinuses start but maybe you could consider
    Implants anterior to the sinuses and upper occlusion only to the lower bicuspids. Considering
    that all the lower crowns are on endodontically treated teeth I would be careful of the load I placed on the lower dentition and the cantilevers.

  6. Tem says:

    Very interesting case as i already have a similar one right now. Did you consider subperiosteal implants, also combination of screw and plate implants as an alternative to zygomatic and pterygoid implants??

    • Matt Helm DDS says:

      Subperiosteal implants, while they can be a lifesaver for a case like this, are much more difficult to do than implants or even than mini implants (which are also tougher to do than implants). They require a very adept surgeon with experience in subperiosteals, excellent patient cooperation, and very skilled dental techs. The casting must be of the utmost accuracy. Subperiosteals have been around since the late 50’s, but they lost favor due to the large number of soft tissue dehiscences they’ve suffered. I highly doubt that anyone is still practicing them in the US any more. I’ve seen a couple of cases of subperiosteals, but the dehiscences were a constant cause for concern and a constant OH nuisance. Still, I must say that surprisingly they did hold up long-term even with those unsightly dehiscences. It’s a real testament of the resiliency of the oral tissues and the oral environment overall.

  7. Sajjad A.Khan says:

    Follow the time tested simple treatment plan>
    B/L sinus lift with #4,#5#6 and #11,#12 ,#13 implants with OD (Locater type) attachments .
    Pre maxilla will be paper thin F P width
    Patient is long term denture wearer will be very pleased with the out come . If you are not well experienced in sinus lift procedure this case you should avoid doing yourself . Get your favorite specialist or fellow GP with sinus lift experienced and create a team of doctors and provide the best care for this patient .

  8. scott says:

    I agree with this last comment. Depending on the distal bone available with or without sinus lift I would place 2 to 4 Implants and create an Overdenture with locator attachments. Since the patient already wears a denture adapting to one without the palate would be easy. Also it would create less force on the lower cantilevers.

    • Howard Abrahams says:

      I am always a little weary of unsplinted implants in grafted sinuses with the in and out of a locator denture. Perhaps a safer idea would be heavy sinus grafting, at least 3 implants in each sinus and 2 bars (i.e. a bar in the UL and URQ’s). This gives you the advantage of splinted implants. Not ideal, as we like to have cross arch stabilization if possible, but I think splinting all of these implants (R and L side) would have negative cantilever effect. Fun case! (not for the patient :))

  9. JRPeriodontist says:

    A CBCT is definitely needed to access bone volume; an all-on-four approach (tiltled distal implants ) may be utilized if volume is sufficient, especially since pt. only has premolar occlusion to begin with.

  10. Robert Wolanski says:

    Lots of great comments on how to potentially treat this highly complex case but I feel the two most helpful posts are those from JRPERIO and Ron RECEVEUR
    This is as complex as cases get. If you have to ask questions as to how to do this case I would suggest you are experimenting. If you are only diagnosing from a PAN I would suggest you are experimenting. Don’t experiment on a case like this, you will potentially harm the patient, your pocketbook and esteem and lining of your gut. If you can do this case in concert with someone highly experienced you will serve everyone better including yourself.
    Also remember. Zygomatic implants do not have the same ability to load as do other implants. The patient must be on a soft diet for the rest of their lives. This is important to know.

  11. Matt Helm DDS says:

    You can’t, and shouldn’t evaluate a case like this only from a pano. This looks like a long time denture wearer so the bucco-lingual width of the maxilla may be very lacking.
    Some great suggestions here but, considering that the lower bridge is limited to the 2nd bicuspid and is a cantilever you must be careful not to overload it — specially since most crowns show recurrent decay under the margins and the endodontically treated teeth have no posts. In my view anything more complicated than locator ball-and-snap attachment implants would be overkill. I would stay away from a bar because it will overload the lower.
    An all-on-four would be suitable also, but the final denture must have acrylic or composite teeth to not overload the lower.
    One viable option no one has mentioned are mini-implants, which also work out very well, specially in a case like this. They are placed strictly in the anterior area and they don’t need a lot of bucco-lingual bone width. But unless you’ve done them, I suggest you don’t use them on this as your first case. They are more finicky and more difficult to insert — you must achieve minimum 30Ncm torque from the beginning, and if you don’t achieve that you need to remove it and place it in a new osteotomy, because the don’t osteo-integrate like regular implants.

  12. Ronald Receveur says:

    In a really atrophic maxilla, I think there should be splinting / cross arch stabilization…that’s why the CT Scan would make all of my decisions. I’m scared of individual abutments (locators / no splinting) unless there’s a great foundation. JMO.

    • Dr. Abrams says:

      I have a patient with severe atrophy max/md. Will work with oral surgeon. Implants 22/27 w locators. 6 implants on maxilla, sinus grafts will be done with locators. If lower was not over denture, splinting would be considered due to increased forces on maxillary implants. Full palate should help distribute forces. I would not use horse shoe maxillary denture. Your point is well taken . Btw are you a gp? How long have you been practicing? Respectfully, Dr.A

    • Dr. Abrams says:

      Saw your website thank you for your comments. What is your opinion all on four maxillary but the patient is a class 3 with natural dentition. Ty

  13. Ronald receveur says:

    I’m a GP. Been practicing 36 years. Restoring implants for 25 years. About 2 years ago, I decided I would never do a detachable again. I’m sure some would criticize that, but I have more unhappy patients with removables than fixed. I place over 500 implants a year. Been placing my own surgically since 2008. Never placed an implant without a ct scan. Do not do mini implants. Tell me about your practice. Ron …p.s. I’m not scared of a class 3

  14. Dr. Abrams says:

    Raul I am a gp w 39years of experience. Restoring implants since 1981. Also placed implants in every site except 2nd molars. Now refer to oral surgeon with Cat scan/ surgical guides as standard. Occ;lusion is a key factor to longevity . Also home care etc. Nite guards recommended.

        • Matt Helm DDS says:

          Dr Abrams, dentistry without surgery and implant surgery is no fun, man! I naturally did lots of oral surgery before implant surgery, but implant surgery just opened up this whole new challenging (and fascinating) world that goes beyond mere dentistry. All the advanced restorative and cosmetics I did became “mere” dentistry. Sure there are cases I refer to the OS occasionally, just as there are cases I occasionally refer to endo and perio, but there is no satisfaction like that of doing a challenging reconstructive implant case completely, from start to finish. None! And the smile of the patient when it’s done and they say “thanks Doc, I can finally eat normally”? Priceless!
          My fave saying: “an implant a day keeps burnout at bay”.

          • Raul says:

            We are in the same boat, I do all my implant surgery and all of the bone grafting, of course that include perio surgery.
            The only cases that I wouldn’t do are the medical compromised patients, that present a surgical risk, and in those cases why expose them to any surgery, so I don’t refer.
            Of course I am not critical of any doctor that does’t want to perform the surgical phase of implantology. By the way the surgical phase is the easiest one. Like you I enjoy being able to fully reconstruct my patients to full function, esthetics and phonetics.
            To each its own

    • Matt Helm DDS says:

      Dr. Ronald, please humor me. What exactly do you call large cases? Typically mini-implants are not large cases. Were these mini implants employed in other ways prosthetically besides stabilizing overdentures? Or for more than replacement of a single anterior tooth? Even more importantly, how exactly were they placed? Which dimensions and which type of threads have you seen fail? And in what type of bone? (They are all contraindicated in D4 bone.) Were you directly involved in at least overseeing their insertion? Do you know if proper protocol was followed? Not that there is actually one protocol that fits all, really — one must have a very good feel for the bone one is working in, much more so than with regular implants — but still, there is a protocol and it differs from that of implants in one key aspect, i.e. one must engage the opposing cortical plate with the tip of the mini implant. That is one of the keys to the stability of the mini implant. Success can be achieved even in the absence of that one criteria, but then the choice of size and thread of mini implant becomes critical, especially in D3 bone.
      Mini implants are actually much more finicky and harder to place than regular implants, and the margin for error is much much smaller. One important caveat is very slow insertion, due to more rapid overheating of the bone even in the presence of cooling. That can lead to premature failure even if all the other proper insertion criteria are met. But they can be a lifesaver for the patient with very resorbed bone who has neither the age, nor the financial means, nor the disposition for sinus lifts or substantial bone augmentation.
      I’ve placed more than double the cases than the 30+ failed cases you’ve seen, and I haven’t had one failure! Still going strong 8-9 years on. Also used them in atypical applications, such as stabilizing Kennedy Class II full quadrant maxillary cast partials that had no hope of stability otherwise. So how and why did these 30+ cases you’ve seen fail? How long were they in place before they failed? Because another key of mini implants is that if one doesn’t achieve at least 30 Ncm, and ideally 35-40 Ncm of initial stability upon insertion, the mini implant is a write off from the very start –it should be removed and placed in a new osteotomy. Also, they are not designed to sustain occlusal forces, only to retain the overdenture. I would be very curious as to your clinical findings. Many thanks.

  15. Matt Helm DDS says:

    @Raul, indeed the surgical phase is the easiest phase. But then garnering the laurels of a successful restoration is the real satisfaction. We are in agreement on just about every issue. The only place I differ is that I will let the OS decide how much of a surgical risk a medically-compromised patient is, so I will at least refer for a consultation. I’ve restored medically compromised patients after successful surgery. Each OS has his own experience and tolerance levels, so I do my best not to prejudge.

    • Raul R Mena says:

      The main reason that I don’t refer is that I evaluate the patient with and consult with their physician. I did a one year hospital training after graduating from dental school and years later a 3 year hospital base residency on Oral-Cranial and Maxillofacial implantology, under Anthony Wolf MD Reconstructive and Craniofacial Surgeon .
      If I evaluate that the patient should not go through the surgical risk I tell the patient that personally I don’t advice the surgical procedure, but that they are welcome to a second opinion.
      At the same time I think that the way you handle those cases is also the right way.
      Only different ways of handling the situation, and I think that both options are Ok.

      • Matt Helm DDS says:

        Raul, I commend you for taking the time to take the training!
        I also eval patients and discuss with their physicians before referring to OS. I also study their latest blood lab reports. And I also tell them in no uncertain terms when I don’t think they should undergo implant surgery. It’s my s.o.p. However, I found in all my years of practice that most physicians will very rarely be completely unequivocal about absolutely contraindicating implant surgery (except in the most dire cases) and, that patients insist on exploring the option even when their physicians, and I, clearly lean against it. So after clearly exposing the risks to the patient and restating my opinion that I’m against it, I let them make the decision of whether to consult the OS. I feel that the patient deserves the chance for that consult and, that it is also the OS’s decision if he can mitigate the risk. Many OS’s feel that they can mitigate the risks, and they have done so successfully quite often. I just feel that I should not be the final gate-keeper, because I may exclude someone’s chance from ever eating properly again, specially when I can see that the patient clearly is suffering (be it mentally, physically, or both) from not being able to eat adequately. I’m not there to make life or death decisions, and I also feel that quality of life is truly important. Because let’s face it: eating is not only life sustaining, it’s one of the only 3 real pleasures in life. Since most elderly and/or medically compromised people are down to only 2 real pleasures in life… Well, you get the idea.
        I also feel that implantology and bone augmentation (not to mention imaging) have come a really long way, and much more can be achieved today much easier than a mere 15-20 years ago. No longer do we have to harvest mental bone (or superior anterior iliac crest bone) with a hammer and chisel like we had to as recently as in the mid-late ’90’s. We have bone augmentation materials and techniques that surpass our wildest imaginations of back then. And although still not what one might call simple, implantology has become at least a bit more seamless and certainly less traumatic.
        Your way is quite fine also. We all have a set of principles we stand on when it comes to our patients’ welfare, and we must be true to those principles.

  16. wally hui says:

    if somebody go ahead of sinus lift why not graft the anterior as well any way to solve the biomechanic issue, and use the palatal implant ASSIST the upper denture retention while waiting for the graft ready.

    • Raul R Mena says:

      Dear Richard,
      I hate to contradict your opinion, but this is not a subperiosteal case. In my opinion this is the worst selection for a subperiosteal implant, and I have done many. The same goes for Mini Implants, without getting in to the discussion of their positive or negative outcome, they don’t belong in this case.
      Let me start by congratulating the doctor that took such a nice Panorex, that is a high quality Radiograph.
      There are a few things that need to be done before starting treating this case.
      Upper and Lower Impression
      Bite Registration
      Is this a class I or a class II case?
      Upper full temporary denture (well done)
      Lower temporary partial
      A CT including the mandible and the maxilla.
      Bilateral sinus elevation
      4 posterior implants on each sinus with the most mesial implant placed with a reverse all on 4 angulation. Meaning that the the incisal of the right and left mesial implants are going to be angled toward the mesial and the apical portion angled distally.
      2 short implants on either side of the mandible, that will help with the occlusion and prevent the trauma of a combination case.
      Once the implants have integrated construct an upper temporary fixed bridge with a high lingual bar so it will not interfere with the grafting.
      Proceed to graft the premaxilla with block graft either with an open technic or with the Mena Digital Tunnel Technic.
      Once the graft has mature place implants in the premaxilla wait for integration.
      Final step is to finish the upper splinted fixed bridge and the lower posterior bridges.
      Another alternative will be to skip the grafting of the premaxilla and use multi unit attachmets or QFit fix attachents.
      All this can be done in a private setting under Local Anesthesia.
      Duration time from 2.5 to 4 years.
      I am sure that many will disagree with this treatment, I will be more than happy to listen to other suggestions.

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