Int. J. Oral Maxillofac. Surg.

2015; 44: 229238

http://dx.doi.org/10.1016/j.ijom.2014.08.005, available online at http://www.sciencedirect.com

Systematic Review
Dental Implants

Placement of dental implants L. F. dT. P. Lopes1, V. F. da Silva2,

J. F. Santiago Jr.1, S. R. Panzarini2,
E. P. Pellizzer1

in the maxillary tuberosity:

1
Department of Dental Materials and
Prosthodontics, Aracatuba Dental School,
UNESP Universidade Estadual Paulista,
Aracatuba, Sao Paulo, Brazil; 2Department of

a systematic review Surgery and Integrated Clinics, Aracatuba

Dental School, UNESP Universidade
Estadual Paulista, Aracatuba, Sao Paulo,
Brazil

L.F.dT.P. Lopes, V.F. da Silva, J.F. Santiago Jr., S.R. Panzarini, E.P. Pellizzer:
Placement of dental implants in the maxillary tuberosity: a systematic review. Int. J.
Oral Maxillofac. Surg. 2015; 44: 229238. # 2014 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this systematic review was to identify clinical studies on
implants placed in the tuberosity region to determine the survival rate of these
implants when compared to implants placed in other regions of the maxilla. A
search for data published up until March 2014 was undertaken using the PubMed,
Cochrane Library, Embase, and ScienceDirect databases. Eligible studies were
selected according to inclusion and exclusion criteria. The first database search
revealed 310 titles. After inclusion and exclusion criteria were applied, five studies
remained for the detailed analysis. A total of 113 patients were followed for a period
of 6144 months; 289 implants were placed in the patients evaluated. There were
eight failures/losses of dental implants in the tuberosity region; the overall survival
rate was 94.63% for these implants. In controlled studies, the cumulative survival
rates for implants placed in the maxillary tuberosity and other maxillary regions
Key words: dental implants; maxilla; maxillary
were 96.1% and 95%, respectively. In conclusion, implants placed into the sinus; alveolar bone.
maxillary tuberosity are a predictable alternative for the treatment of patients with
insufficient bone volume in the maxillary region. However, randomized trials are Accepted for publication 14 August 2014
needed to assess the effectiveness of this treatment. Available online 26 September 2014

Oral rehabilitation with osseointegrated
implants is a viable option for the treat-
ment of patients with partial or total loss of
teeth,1 since the use of implants is consid-
ered a predictable and reliable treatment.2
Implant survival is directly related to
primary stability and osseointegration,
which are dependent on mechanical
aspects and the biological response of
tissues,35 such as bone quality and quan-
tity,6 anatomical conditions in the area
where the implant is to be installed, the
implant surface,7 immediate or delayed
loading, prosthesis design, and the occlu-
sal pattern during the healing phase, all of
which must be considered.8
However, failures in rehabilitation with
dental implants should be considered when
osseointegrated implants are installed in
areas of poor bone quality, such as in the
upper molar region, especially in cases of
severe bone resorption.7,912 According to
Lekholm and Zarb,13 bone quality in the
posterior maxillary region is usually type
III or IV, characterized by thin cortical bone
and low density trabecular bone. Further, in
many situations the bone height in this
region is insufficient for proper implant
placement because of the presence of the
maxillary sinus. These factors are detri-
mental to the achievement of high primary
stability.2,1416 This region tends to show
low success rates,2 not only due to inappro-
priate primary locking, but also because
short implants may present unfavourable
biomechanics. The rehabilitation of this

0901-5027/020229 + 010 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
230 Lopes et al.

region is therefore a challenge to the den-

tist.17
Consequently, grafts utilizing the iliac
crest have been the most commonly used to
increase bone volume in this area. Grafts
with Le Fort I osteotomy, bone grafts for
sinus lifting, zygoma implants, and
implants in the pterygoid region have also
been suggested.1820 However, many of
these techniques have long operative times,
are surgically complex, and may be physi-
cally demanding for the patient, especially
the elderly. Furthermore, from an economic
standpoint, such procedures may be too
expensive for the patient and a burden on
health care resources.21 They may also be
impractical, such as for patients submitted
to severe maxillary surgical resection due
to a tumour or neoplasia.22,23
Implant placement in the maxillary tu-
berosity region, which is the most distal Fig. 1. Schematic diagram of a fixed partial denture supported by two dental implants, one
area in the maxillary alveolar process,24 installed prior to pneumatization of the maxillary sinus and the other in the region of the
posterior to the maxillary sinus,23 has been maxillary tuberosity (after pneumatization of the maxillary sinus).
suggested as an alternative by many
authors.2123,2530 In fact, bone tissue in IV,21,23,25 so firm primary stability should These two techniques have important
the tuberosity region should be less dense be obtained at the surgical stage.26 In anatomical differences (Table 1).20,21,23
than in other areas of the maxilla30; it is addition, appropriate reverse planning is 26,3235
A systematic review indicated a
unclear whether very spongy bone quality very important. 92% survival rate (first year) for implants
provides predictable osseointegration.31 Another recommended technique for placed in the pterygoid region20; however,
However, this alternative relies on the implant placement in the posterior maxilla evidence-based reviews addressing
placement of these implants on an incline, is related to the use of a pterygoid im- implants placed in the tuberosity region
without the use of bone grafts, with the plant.20,32 Pterygoid implant placement are scarce.
implant placed posterior to the maxillary requires passing through the pillar of bone Clinically, there is evidence that
sinus and not invading it (as shown in composed of the maxilla, pyramidal pro- implants positioned in the tuberosity re-
Fig. 1).1,21,22,26,28,29 cess of the palatine bone, and the ptery- gion show suitable outcomes in patients
All procedures in the tuberosity region goid process of the sphenoid.15,20,32,33 with atrophied jaws21,2628,36 and in
should be evaluated carefully, since the Bidra and Huynh-Ba20 stated that implant patients with severe maxillary defects.22
tuberosity region may not always be avail- placement in the pterygoid region involves In addition, easy access and visibility of
able or may have a low amount of bone the tuberosity region; however, implants the site of the tuberosity36 facilitate the
available for implant placement. In this placed in the tuberosity region are not surgical procedure. However, little is
region, the bone is mainly types III and necessarily fixed in the pterygoid plates. known about the long-term results.

Table 1. The concept of implants placed in the tuberosity and in the pterygoid region.a
Points addressed Tuberosity implant
Definition Region most distal to the maxillary alveolar
process.20,24 Bahat23 indicated that the real posterior
structure of the maxillary tuberosity is the pyramidal
process of the palatine bone.26 Therefore, these
implants may involve the pyramidal process of the
palatine bone.20 Finally, Venturelli25 stated that the
posterior border of the maxillary tuberosity is defined
by the pyramidal process of the palatal bone and the
anteriorinferior surface of the pterygoid laminae of
the lamellae.
Bone type Bahat23 stated that the bone in this area is very
cancellous. Different bone types have been reported:
III and IV,21,25,35 II, III, and IV.23
Vital structures The posterior wall of the maxillary sinus.20,21 Ridell
et al.21 stated that: Attention must be paid to the
region posteriorly and medially to the tuberosity
considering the maxillary artery and its branches
specifically the greater palatine artery.
Angulation of implants 10208,23 <308,25 and 1535826
a 20
Adapted from Bidra and Huynh-Ba.
Pterygoid implant
This implant passes through a pillar of bone
composed of the maxilla, pyramidal process of the
palatine bone, and the pterygoid process of the
sphenoid.32,33 Furthermore, it is conceived as implant
insertion through the maxillary tuberosity and
pterygoid Plate.20,24 Vrielinck et al.34 stated that
The pterygoid implant enters in the region of the
former second molar, follows an intrasinusal
trajectory in a dorsal and mesio-cranial direction,
where it subsequently perforates the posterior sinusal
wall and the pterygoid plates.
The pyramidal process of the palatine bone and the
pterygoid process of the sphenoid are dense cortical
bone.20,32,35
Internal maxillary artery, posterior or superior
alveolar nerve, pterygoid muscles,32 infratemporal
fossa, pterygopalatine fossa, nasopharynx, and
sphenoid sinus.20
45508 angulations32

Therefore, the aim of this systematic
review was to analyze relevant clinical
studies on implants placed in the tuberosi-
ty region of the maxilla regarding the
survival rate and recommendations for this
technique. The following hypothesis was
tested: the survival rate of dental implants
placed in the tuberosity region of the
maxilla is similar to that for other regions
of the maxilla.
Materials and methods
Procedure
This systematic review was executed in
accordance with the PRISMA statement37
and followed models proposed in the lit-
erature.7,18,20 The selection of articles was
done individually by two of the authors
(LFTPL and VFS), and there was no dis-
agreement in the selection of articles.
Search strategy
A search for relevant studies published in
the English language was conducted using
the following databases: PubMed/MED-
LINE, Embase, ScienceDirect, and the
Cochrane Library. The period covered
was 1967 to 23 March 2014. Two pairs
of keywords were employed in the search:
dental implants AND maxillary tu-
berosity and dental implants AND
maxillary tuber. The studies were se-
lected by title and abstract and according
to the inclusion and exclusion criteria. The
full-text articles were evaluated by readers
using a pilot test form.7 There was no
discord in the selection of articles made
by the independent researchers (kap-
pa = 1). The preparation and discussion
of data were performed by JFSJR, SRP,
and EPP. In addition, a manual search was
conducted during the period February
2013 to 23 March 2014 in the following
periodicals: Journal of Periodontology,
Clinical Implant Dentistry and Related
Research, Clinical Oral Implants Re-
search, International Journal of Oral &
Maxillofacial Surgery, The Journal of
Prosthetic Dentistry, Journal of Prostho-
dontics, International Journal of Oral &
Maxillofacial Implants, and Journal of
Craniofacial Surgery. The authors of the
articles were not contacted.
Study selection
Clinical studies were chosen based on
their titles and abstracts. Prospective and
retrospective studies were included. The
selected studies reported the clinical mon-
itoring of implants placed in the maxillary
Implants in the maxillary tuberosity
tuberosity region. Furthermore, in accor-
dance with the PRISMA statement,7,37
participants, interventions, comparisons,
and outcomes (PICO) were determined
to organize a specific clinical question.
Participants were patients who had been
rehabilitated with dental implants in the
posterior maxilla. The intervention was
dental implants placed in the maxillary
tuberosity region (without considering im-
plant placement in the pterygoid plate
Table 1). Comparisons were dental
implants placed in other maxillary
regions. The outcomes studied were
the survival rate and recommendations
for the effective use of this technique.
Inclusion/exclusion criteria
Inclusion criteria for the studies were as
follows: English language; studies report-
ing clinical series of dental implants
installed in the maxillary tuberosity re-
gion; minimum of five patients. Moreover,
retrospective and prospective studies were
included. Implants installed in the tuber-
osity region were defined as follows:
implants involving the most distal aspect
of the maxillary alveolar process, behind
the maxillary sinus,26 occasionally engag-
ing the pyramidal process of the palatine
bone,20,23,25 and located between the pos-
The studies collected were compared ex-
teriorinferior surface of the maxillary
tensively (n = 5). The data were summa-
bone and the anteriorinferior surface of
rized for qualitative and quantitative
the pterygoid laminae of the sphenoid
bone.23,25
Exclusion criteria were the following:
duplicated studies, animal studies, cadaver
studies, computer simulation and bio-
mechanical studies, in vitro studies, mini-
implants, orthodontic studies, morpho-
metric studies, studies analyzing the max-
illary tuberosity as a bone graft donor site,
anatomical and radiological studies, clini-
cal studies of implants on humans involv-
ing the pterygoid and pterygomaxillary
regions, clinical cases with small sample
sizes (fewer than five patients), clinical
monitoring for less than 6 months, theo-
retical studies, implants not placed in the
region of the maxillary tuberosity, and
missing data. Systematic reviews were
also excluded.
Reliability and quality assessment
A group of researchers conducted the de-
velopment of this systematic review. The
studies were analyzed systematically in
order to identify possible biases in the
results and conclusions. The studies were
classified by category: prospective or ret-
rospective. The assessment of the quality of
the methodology was conducted following
231
the requirements of the PRISMA state-
ment.7,37 The studies were classified into
different levels of evidence. The National
Health and Medical Research Council
(NHMRC, Australia) hierarchy of evidence
was utilized to assess the reliability and
quality of the selected studies.38,39
Data analysis
The following data were identified for
each article: first author, year, study type,
level of evidence, number of patients,
number of implants, number of implants
in the tuberosity region, implant geometry
(length/width), implant placement in other
maxillary regions, follow-up, the survival
rate in the tuberosity and other regions,
and marginal bone resorption in the tuber-
osity bone and other maxillary regions.
Furthermore, qualitative data were ana-
lyzed for each article: mean age, imaging
examinations, bone quality, implant man-
ufacturer, type of edentulous arch,
osseointegration period, and type of pros-
thesis and opposite arch. The data collect-
ed were organized for qualitative and
quantitative analysis.
Data synthesis
analysis. The survival rates of implants
placed in the tuberosity and other regions
were calculated. Failure and survival data
were analyzed using tables and graphs. The
failure rate was determined as the percent-
age of implants lost relative to the number
of implants inserted for each study.18 Fail-
ures included implants removed regardless
of the osseointegration period. Survival
represented stable implants without signs
of pathology, mobility, resistance to re-
moval torque, pain, or peri-implantitis.18
Results
General outcomes
The electronic search of the four databases
identified 310 articles. After an analysis of
the titles according to the inclusion and
exclusion criteria and the elimination of
duplicate references, 25 full-text articles
were assessed for eligibility. Finally, five
studies were included in the qualitative and
quantitative synthesis21,23,2527 (Fig. 2).
Twenty full-texts were excluded for
the following reasons: clinical case stud-
ies,22,2830,36,40,41 biomechanical study,42
orthodontic study,43,44 data not local-
ized,45 morphometric study,46 in vitro
232 Lopes et al.
Fig. 2. Flow diagram of the literature search strategy.
study,47 anatomical and radiological
study,35,48 and implants not placed in
the region of the tuberosity or missing
data.4953 Since there are few studies
addressing the topic, relevant excluded
clinical studies are summarized in
Table 2.22,28,29,36,41 These studies indicate
a high predictability of implants placed in
the tuberosity region; the survival rate was
100%.22,28,29
The inter-reviewer agreement for all
studies (kappa = 1.0) and the abstract (kap-
pa = 1.0) indicated no disagreement. The
five studies included in this systematic
review were published from 1992 to
2010. Tables 3 and 4 summarize the
main data collected in the systematic re-
view.21,23,2527
Qualitative analyses
The selected studies were classified as
retrospective21,26 and prospective.23,25,27
Non-randomized studies were located in
the sample. The levels of evidence for
these studies were III-2 and III-3. A total
of 113 patients were followed for a period
of 6144 months (mean 52.08 months)
(Table 3). The mean age of patients was
55.1 years.21,25,26 All studies presented
elderly patients in the sample (Table 4).
A total of 289 implants were placed in
the patients evaluated (Table 3); 149
implants were placed in the region of
the tuberosity21,23,2527 and 140 implants
were installed in other regions of the
maxilla.21,2527 The studies predominantly
indicated the placement of long implants
in the region of the tuberosity.21,23,25,26
An important surgical detail observed
was the need for angulations of the
implants placed in the tuberosity region.
However, this inclination was reduced as
much as possible.25 The degrees of angu-
lation were variable: 10208,23 <308,25
and 15358.26
In relation to the diameter, only three
studies detailed the use of implants with a
regular diameter (3.754 mm).21,25,26
Venturelli25 emphasized that when mini-
mal instability in dental implants was
observed during the surgical procedure,
the implant was removed (3.75 mm)
and replaced immediately with a larger
diameter implant (4 mm) (eight cases)
without any new drilling.
The region of the tuberosity was cate-
gorized predominantly as bone type III
and IV.21,23,25 Adequate primary stability
of the implants was indicated as an impor-
tant condition.21,25,26 The minimum peri-
od of osseointegration was 4 months.
In relation to the type of prosthesis,
there was a prevalence of fixed prosthe-
ses21,23,26; one study suggested the use of a
reinforced acrylic resin provisional resto-
ration initially (6 months), and after this,
fixed partial dentures were made for the
patients.25 The rehabilitation treatment
was acceptable to the patients. Kramer
et al.27 reported that the prosthesis could
equalize soft tissue and bony defects,
resulting in an aesthetically and function-
ally satisfactory restoration. Riddell
et al.21 asserted that there were no reported
complications with the prostheses, no pro-
blems related to the components of the
implant system, and no inflammatory
reactions of the oral soft tissues; other
studies did not provide specific informa-
tion.
Regarding the opposite arch, there was a
prevalence of natural teeth and fixed pros-
theses.21,23,25 Venturelli25 indicated that
no significant difference was related to
the type of opposing arch. However, the
authors showed that no direct contact was
allowed between the distal implant and the
opposing arch.
None of the studies analyzed reported
implant mobility, a radiolucent area at the
implant apex, or prosthetic mobility. The
marginal bone loss of implants placed in
the maxillary tuberosity remained within
acceptable limits.21,26,27 All data above
are given in Tables 2 and 3.
Quantitative analyses
A total of 289 dental implants were placed
in the 113 patients, and the mean follow-up
was 52.08 months (range 6144 months).
From this sample, a total of 149 implants
were placed in the tuberosity region and
140 implants were placed in other regions
of the maxilla. There were eight failures/
losses of dental implants in the tuberosity
region and the survival rate was 94.63%
(Fig. 3 and Table 5). The lowest interval
survival rate was 97.26% due to the loss of
four implants during the third period (12
24 months) (Table 5). The main factor
related to the failure/loss of these dental
implants was a lack of osseointegration
(three implants); Kramer et al.27 related
that the reason for these failures was pene-
tration of the maxillary sinus during im-
plantation. In the study of Bahat23,
Table 2. Clinical cases of implant placement in the maxillary tuberosity: excluded studies.
Survival Marginal
rate in the bone
Number of Length of the Width of the Implants Length of Width of the tuberosity/ resorption in
implants in implants in implants in in others the implants implants in other regions tuberosity
Number of the tuberosity the tuberosity the tuberosity regions in others the tuberosity Follow-up (number of implant/other
Author Year patients region region (mm) region (mm) (maxilla) regions (mm) region (mm) (months) failures) regions
Shirota et al.29 2011 1 2 10 4.0 4 35; 40a Not reported 24 100% Zygomatic implants showed
a marginal bone loss of 3 to 4
threads. Two conventional
implants demonstrated a
marginal bone shift of one
thread or less
Leles et al.22 2010 1 2 11; 13 3.75 3 9; 11; 13 3.75 24 100%/66.6% (1) No radiographic signs of
significant bone loss around
implants
Alves and 2009 1 2 14 4.1; 4.8 6 12 4.1 36 100% Follow-up appointment
Neves28 showed acceptable bone
levels
Markt41 2003 1 4 10; 13 3.75 2 18 50% None reported. The patient
has worn the prostheses
without complications for 18
months
Nocini et al.36 2000 1 2 6 100% Radiographic evaluation was
obtained pre- and post-
implant placement
a
Zygomatic implant.

Table 3. Data summary for the five studies selected reporting dental implants inserted in the tuberosity region.

Implants in the maxillary tuberosity

Survival rate Marginal
Number tuberosity bone
implants Length/width Implants Length/width region/other resorption in
Level Number Number in the of the implants in other of the implants Follow-up regions tuberosity
of of of tuberosity in the tuberosity regions in other in months, (number region/other
Author Year Study type evidence patients implants region region (mm) (maxilla) regions (mm) mean (range) of failures) regions (mm)
Park and Cho26 2010 Retrospective III-2 7 17 7 11.515.0/3.754 10 1015.0/3.754 84 (1284) 100% 0.93
Ridell et al.21 2009 Retrospective III-2 20a 86 22 13.020/3.754 64 Not reported 96 (12144) 100%/96.87% (2) 1.6/1.9
Venturelli25 1996 Prospective III-2 29 42 29 1020/3.754 13 1020 40 (3648) 100%/92.3% (1) Not reported
Bahat23 1992 Prospective III-3 45 72 72 Not reported 0 Not reported 21.4 93% (5) Not reported
Kramer et al.27 1992 Prospective III-2 11 72b 19b Not reported 53b Not reported 19 (660) 84.21% (3)/92.45% (4) 2.5 (M)/2.4 (D)
2.4 (M)/2.5 (D)
M, mesial; D, distal.
a
One patient died (initial sample = 21).
b
The study began with 66 implants, but after an initial loss of six implants (three in the tuberosity region and three in other regions), there was further surgery for implant placement (according to

233
Table 1 of the article).
234 Lopes et al.

fixed partial denture (39),

osseointegration of five implants failed

occlusal surfaces) (8),

fixed plus implant (4)

during a follow-up of 12 months in different

lacked occlusion (8)

Opposite arch

fixed prosthesis (2),

types of bone (type II, 2; type III, 1; type IV,

dentures (ceramic

removable partial

Natural teeth (2),

Teeth (7), fixed
2). Four of these implants were placed in

partial dentures
(gold occlusal
Not specified

denture (10)b
surfaces) (4),

Not reported
patients with parafunction. Furthermore,

fixed partial
Teeth (11),
these patients used fixed partial dentures
or fixed partial dentures plus implants.23
The five studies did not indicate a rela-
tionship between the total number of
implants and an increased failure rate.
Screwed prosthesis

Reinforced acrylic

restoration; fixed
Figure 4 shows the studies arranged by

resin provisional
NiCr alloy fixed
Porcelain fused

partial denture

partial denture
prosthesis

Metal-ceramic
the number of implants placed in the
Type of

(29); O-ring

Removable
tuberosity region, the number of implant
failures, and failure rates. Only two studies
bridge

indicated implant failures in the tuberosity

region; Kramer et al.27 showed a higher
failure rate (15.78% surgical technique)
integration

when compared with Bahat23 (6.94%).

(months)
Osseo-

period

reported
Four studies involving 217 implants

660
placed in the tuberosity region (n = 77)
68

68

Not
6

and in other maxillary regions (n = 140)

were analyzed separately (control group).
Not reported

Not reported
2540 N cm

The cumulative survival rate for implants

Primary
locking

Adequate

Adequate
stability

stability
primary

primary

placed in the maxillary tuberosity was

96.1% and in the other maxillary regions
was 95% (Fig. 5). Therefore, these data
Table 4. Qualitative data from the five studies selected reporting dental implants inserted in the tuberosity region.

indicate that implants installed in the tu-

Edentulous arch
(partially/fully)

berosity region may be suitable for oral

Partially and

Partially and

Not reported

rehabilitation.
Regarding marginal bone resorption,
Partially

Partially

two studies did not indicate these data23,25

fully

fully

and two studies presented a mean bone

loss of <2 mm21,26 during 12144 months
of follow-up. Finally, Kramer et al.27
Nobel Biocare,

Nobel Biocare,
manufacturer

showed marginal bone resorption similar

Innovations
Implant

Cylindrical
Branemark

Branemark

IMZ type

for implants installed in the tuberosity and

Implant

in other regions of the maxilla (mean

CSM

2.45 mm) during 19 months of follow-

up (Table 3).
II (9), III (35),
Bone qualitya
Not reported

Not reported
and IV (28)
III (12) and

Discussion
III and IV

IV (16)a

The survival rate of implants installed in the

tuberosity region was high (94.63%). These
results are similar to those reported in other
systematic reviews that have evaluated
Serial parallel
examinations

Not specified

Not specified
conventional
tomography

implants placed in regions of low bone

radiographs
peri-apical,
Panoramic,
Imaging

panoramic

density7 and in the pterygoid region.20

Digital

The tested hypothesis was accepted: the

scans

survival rate of dental implants placed in

the tuberosity region of the maxilla (96.1%)
Lekholm and Zarb13 classification.

was found to be similar to that of other

age, years,

(range)
Patient

All >80

regions of the maxilla (95%)21,2527

mean

(4365)

(4279)

(3862)

4768

(Fig. 5). There are important considerations

52.3

63

50

to be noted in relation to the surgery and the

No statistical difference.

prosthesis as reported in the studies evalu-

2010

2009

1996

1992

1992
Year

ated (Table 6).15,21,23,25,26,28,29

This systematic review followed the
PRISMA statement in order to obtain
Park and Cho26

Kramer et al.27

the best available evidence for the clinical

Ridell et al.21

Venturelli25

outcome of implants placed in the tuber-

osity region. The level of evidence pre-
Bahat23
Author

sented in the studies included in this

b
a

review was low; no randomized controlled

 Implants in the maxillary tuberosity 235

the maximum number of studies. Four

databases were searched by independent
researchers. Moreover, a manual search
was done. The excluded clinical cases
are presented in Table 2, adding further
information for the reader, since few stud-
ies were included in the qualitative and
quantitative analyses (n = 5).
The technique of implant placement in
the maxillary tuberosity region follows the
same basic principles as the installing of
conventional implants, through milling or
by using bone condensation through
osteotomes. All studies presented a
high success rate, reaching an average
of 100% in three studies.21,25,26 The mean
follow-up was 52.08 months, ranging
from 12 months21,26 to 12 years,21 show-
ing that this technique was viable in all
Fig. 3. Cumulative survival rate (%) of dental implants in the five studies selected.21,23,2527 studies.21,23,2527
This technique is a conservative choice
for restorations in the posterior maxilla
Table 5. Life-table survival analysis showing the cumulative survival rate of tuberosity implants with large bone loss, since it does not
for the five selected studies. require the bone grafting usually neces-
Number of Number of sary in the upper molar region, an area
implants in failures in with maxillary sinus pneumatization and
Follow-up each interval each interval high bone resorption. Despite the great
intervals of in the in the Survival rate Cumulative advantages offered by cone beam comput-
the study, tuberosity tuberosity within each survival ed tomography (CBCT), which is gaining
months region region interval (%) rate (%) headway in modern dentistry, implant
06 149 3 97.98 97.98 placement in the maxillary tuberosity
612 146 0 100 97.98 is a technique that can be performed
1224 146 4 97.26 95.30 with panoramic and peri-apical
2436 142 0 100 95.30
radiographs22,26; however, we encourage
3648 142 1 99.29 94.63
4860 141 0 100 94.63 the use of CT scans to improve reverse
planning.21,28,29
Rigorous planning for implant place-
trials (RCT) were included. The literature to assisting in the synthesis of data and ment in this tuberosity region is highly
indicates that certain clinical questions in performance of the treatment utilized. Fur- relevant, and adequate bone mapping
implant dentistry cause difficulty in the thermore, these studies indicate deficien- should be considered. CBCT should be
development of well-designed studies, for cies in certain areas of implantology and used whenever possible.23,30 Moreover,
example, type of treatment and limited can therefore direct the execution of new a radiopaque marker placed on a surgical
choice of randomization.20 However, these well-designed clinical trials.20 guide or provisional acrylic resin guide at
systematic reviews can provide a contem- The inclusion criteria for this systematic the level of the edentulous ridge will help
porary view of the topic studied, in addition review were organized in order to obtain locate the implantation site.23
Although this region is considered a
treatment option, other regions are avail-
able for the placement of endosseous
implants as an alternative: implants may
be placed in blocks of autogenous bone
grafts in other areas, as well as the floor of
the maxillary sinus, or implants may be
placed in the zygomatic and pterygoid
regions.18,20,21 Finally, the bone tissue
must be evaluated mesiodistally and buc-
colingually to determine if it can accom-
modate an implant. Bone defects in the
buccal and lingual aspects of the tissue
may result in dehiscence and fenestration
defects around an implant, increasing the
probability of failure.23
The studies included in this review
Fig. 4. Number of implants in the tuberosity at each follow-up interval according to implant reported a period of osseointegration rang-
failure for the five selected studies.21,23,2527 ing from 4 to 8 months (Table 4), probably
236 Lopes et al.
Fig. 5. Survival rates for implants placed in the maxillary tuberosity and in other maxillary areas
in the four studies reporting these data.21,2527
due to poor bone quality in the area, which
would hinder the primary locking and
osseointegration. However, Alves and
Neves,28 in a case report study, indicated
immediate loading for tapered implant
placement in the maxillary tuberosity
but emphasized that more studies should
be done to confirm this technique.
Although there was great divergence
among the types of opposing dentition
presented by the patients in the studies,
Ridell et al.21 stated that 75% of dentate
patients presented natural dentition in
their opposing arch, which does not atten-
uate the masticatory forces as for remov-
able prostheses, demonstrating that this
technique would also be viable under
these conditions. On the other hand, Ven-
turelli25 reported that no direct contact was
permitted between the distal implant and
the opposing arch. Thus, it is important to
emphasize that adequate planning should
be done in relation to the opposite arch for
implants placed in the tuberosity region,
presenting fixed prostheses with a larger
extent.
Table 6. Summary of the main points covered for implants placed in the bone of the tuberosity.
Phases Pre-surgical planning
Surgery Correction of pathoses and
periodontal lesions23,26
Radiography and CBCT21,23
Detailed study of anatomy/
potential site30
App. 35 mm opening: site/
opposing teeth23,25,30
Prosthesis Opposing arch/load23
Parafunction must be controlled23
Space availability for the implant
and crown23
Quality and dimensions of the soft
tissues23
CBCT, cone beam computed tomography.
Unlike other authors, Shirota et al.29 and
Leles et al.,22 in case reports (Table 2), used
the technique of implants placed in the
maxillary tuberosity associated with other
implants for the rehabilitation of patients
with severe bone loss caused by tumours;
this does not exhibit the best conditions for
prosthetic rehabilitation, thus showing the
effectiveness of this technique in rehabili-
tating such patients satisfactorily, both aes-
thetically and functionally.
In cases of partial fixed prostheses, the
splinting of these implants placed in the
maxillary tuberosity with another implant
installed in the area of the first molar was
often reported. Thus this treatment option
is suggested for rehabilitating first and
second molars adding the third molar
along the prosthesis (implant in tuberosi-
ty), instead of installing only one implant
in the first molar area and rehabilitating
the second in a cantilever situation due to
the lack of bone tissue for installing an
implant in that region; this would generate
a lever arm and might even result in failure
of the prosthesis over the medium term.
Surgical planning
Internally irrigated drills25
Reduced speed of instrument25
Minimal use of countersinking23,25
Bone compaction28, modified osteotomes36
Achievement of bicortical fixation23,25,30
Drilling sequence to maximize stabilization
Maximum primary stability21,25
Implant diameter larger and length longer26,30
Favourable geometry of implant28
Elimination of occlusal loading in
osseointegration23
Surgery for the placement of implants in
the region of the tuberosity should be
performed by experienced surgeons.
Moreover, knowledge of the anatomy of
the posterior maxilla is essential to the
success of this technique,21,23 in particular
knowledge of the region posterior and
medial to the tuberosity, with special con-
sideration given to the maxillary artery
and its branches, specifically the greater
palatine artery21 (as shown in Table 1).
Thus, Ridell et al.21 suggest that a possible
technique is the preparation of an inspec-
tion window in the maxillary sinus to
further ensure correct fixture placement.
Studies have indicated the prevalence of
types III and IV bone in the tuberosity
region.21,23,25 This warrants the use of a
more favourable geometry for a primary
lock.28 Furthermore, an appropriate surface
treatment is relevant for implants placed in
bone of low density.7 In this regard, the
studies did not provide a detailed analysis
of the surface type used in these implants.
Ridell et al.21 used turned Branemark
implants and no failures were reported.
However, a strict protocol was adopted;
the authors used adequate primary stability,
careful management of bone tissue, and a
minimum length of 13 mm for implants,
and finally all implants were fully sub-
merged and allowed to osseointegrate
unloaded for 68 months. On the other
hand, Nocini et al.,36 in a case report, stated
that corticalization of an implant with suit-
able surface treatment reduces the need for
bicortical anchorage in the pterygoid pro-
cesses, thus reducing the risk of tuberosity
fracture. Longitudinal clinical studies
should be performed in order to analyze
the geometry and surface treatment of
implants for the posterior maxillary region.
Reverse planning should be utilized in
surgery for the placement of an implant in
Post-surgery planning
Enough healing time for maturation of
host bone (68 months)21,26
Possible surgery in mucosal tissue29
Prevent non-axial loading23
Occlusal scheme, avoid
overloading23,30
Occlusion and oral hygiene
periodically23
Access to the posterior oral cavity23;
careful manipulation of instruments

the tuberosity region. The angulation of
the implant is a factor that increases
the stress concentration in bone tissue.54
Additionally, Kramer et al.27 stated that
because of the divergent positions of the
implants, it was sometimes necessary to
divide the bar in the anterior region with
an attachment.
Data related to the extension of the
prosthesis are of relevance. The studies
included in the sample predominantly
showed partially edentulous patients,25,26
or partially and fully edentulous
patients.21,23 Park and Cho26 reported that
this was a limitation of their study, stating
that it is necessary to compare unilateral
partially edentulous cases, with a short
span, to the long span of fully edentulous
cases using tuberosity implants.
Biomechanically, the cantilever situa-
tion should be avoided. Kramer et al.27
conducted an in vivo study with a strain
gauge and reported that deformation was
increased 3.5 times in implants with a
cantilever situation compared to the
values obtained with implant support
in the maxillary tuberosity without a
cantilever.
Regarding bias in the studies analyzed,
the concept of a randomized trial or allo-
cation of patients was not used in any of
the published studies included in this sys-
tematic review.21,23,2527 In relation to the
quality of evidence, studies showed a low
level of evidence (Table 3). No attempt
was made to blind or mask the process
used for the elaboration of these stud-
ies.21,23,2527 Measurements of bone loss
were incomplete26 or were not
reported.23,25 Two studies involved a
small sample of patients (n  12).26,27
Thus, more well-designed studies should
be conducted to elucidate possible biases.
Finally, in an analysis of all studies, it
was observed that these implants showed
bone loss within acceptable limits, which
is further evidence of the high success rate
of this technique.21,26,27 In conclusion,
implants placed in the maxillary tuberosi-
ty are a predictable alternative for the
treatment of patients with insufficient
bone volume in the maxillary region.
However, randomized trials are needed
to assess the effectiveness of this treat-
ment.
Funding
None.
Competing interests
None declared.
Implants in the maxillary tuberosity
Ethical approval
Not required.
Patient consent
Not required.
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Address:
Eduardo Piza Pellizzer
Department of Dental Materials and
Prosthodontics
Aracatuba Dental School
UNESP
Jose Bonifacio
1193
Aracatuba
Sao Paulo 16015-050
Brazil
Tel: +55 18 36363297; Fax: +55 18 36363245
E-mails: ed.pl@uol.com.br,
leonardo_tpiza@yahoo.com.br