Treatment of the edentulous maxilla

Dr. Tara Aghaloo explains why the Academy of Osseointegration took up the important topic of the edentulous maxilla at a recent Scientific Summit.

Why is treatment of the edentulous maxilla a current hot topic?

Treatment of the edentulous maxilla is such a hot topic today, because many things have changed, and many things have stayed the same.

A comprehensive diagnostic work-up followed by careful treatment planning is still the most important aspect of treating edentulous patients, no matter how complicated the surgery or restorative procedures are. We have patients who are able to receive fixed prostheses on implants in a number of hours; we have new digital tools to give us significantly improved views of our patients’ bone quality and quantity, vital structures, and potential pathology; and we have a tremendous selection of new prosthetic and surgical materials to aid in making almost every patient a candidate for dental implants.

What makes the clinical manage-ment of the edentulous maxilla so complex and controversial?

This topic is controversial because treatment is often seen as “one size fits all.” What I mean is that some clinicians want to give everyone immediately loaded fixed prostheses on tilted implants; other clinicians want to perform bone augmentation to place implants into a classically healed ridge; and still others are somewhere in between. The issue is that technology is advancing so rapidly that we don’t have time to evaluate the techniques and materials that we are utilizing in an objective way. In other words, by the time we have long-term studies on one technique or material, new and likely better ones have become available. However, this does not excuse the profession from researching these new technologies before we widely offer them to our patients. Herein lies the controversy.

Why are clinical practice guidelines so important for dentistry?

Clinical practice guidelines are so important for dentistry, especially for implant dentistry, because there are so many ways to manage specific clinical situations. Some treatment options require advanced training and skill, and should not be performed by less experienced clinicians, at least not without the proper training. At the Academy of Osseointegration (AO) Summit in August, AO brought together over 120 of the world’s leading scientists and clinicians in implant dentistry, including representatives from the American Association of Oral and Maxillofacial Surgeons, the American Academy of Periodontology, and the American College of Prosthodontists to propose up-to-date Clinical Practice Guidelines (CPGs) for management of the edentulous maxilla.

These guidelines, which are in progress, are based on a systematic review of the current dental literature, clinical information, and accepted approaches to the treatment of the edentulous atrophic maxilla. They are intended to provide practicing clinicians with current thoughts and recommendations for several topics, including the role of bone augmentation for implant site development, the role of implant design and surgical approaches, the role of advanced imaging for more minimally invasive procedures, the role of tissue engineering in hard and soft tissue reconstruction, and an interdisciplinary approach to prosthetic management of the edentulous maxilla. The guidelines can also be used as an educational tool to assist dentists in treatment choices, to improve the quality and efficiency of patient care, and to explain treatment options to patients.

What are some key diagnostic criteria to consider when weighing treatment options?

When evaluating different treatment options, we must consider maxillary/mandibular ridge relationship, quality and quantity of available hard and soft tissue, lip support, ability to maintain adequate oral hygiene, presence of pathology, and evidence of parafunctional habits.

How have advances in imaging/technology impacted the diagnosis/treatment of the edentulous maxilla?

Advanced imaging, mostly referring to cone-beam CT (CBCT) scans, is essential in both the diagnostic and treatment phase of treating patients with an edentulous maxilla. Not only can it help us determine if there is adequate bone for implant placement, visualize maxillary anatomy, and diagnose the degree of osseous atrophy, but it can help identify anatomic variations and the presence of pathology. Utilizing CBCT scans to digitally plan an implant case before it is actually performed on a patient is an extremely valuable tool, both for the novice and experienced clinician. Having a “test run” on each individual patient, where potential difficulties or challenges can be identified and overcome, cannot be overstated. This can help determine position or angulation of implants, number of implants, prefabricated surgical guides, or provisional and sometimes final prosthesis fabrication. The role of advanced imaging will only continue to increase in the future.

What are some treatment options that should be considered?

Treatment options that should be considered for the edentulous maxilla were covered very well in the recent AO Summit. After discussing the patient’s chief complaint, doing a complete history, physical exam, diagnostic casts, and appropriate radiographs, these options can be discussed. A complete maxillary denture is always an option, especially if it is well made and can meet the esthetic, phonetic, and functional requirements. If it cannot, a prosthesis utilizing implants should be considered. A removable implant-assisted overdenture is an option that has been shown to increase a patient’s satisfaction and quality of life. However, this treatment option requires surgery, increased cost, and must be evaluated regularly for maintenance, repair, and/or replacement. Another option is an implant-supported fixed prosthesis, which generally requires more complicated surgery and increased cost. Again, if this is the option that fits the esthetic, prosthetic, and functional requirements of an individual patient, and the clinician and patient are willing to undergo regular maintenance, repair, or replacement, then the fixed prosthesis should be chosen.

At this stage, it is extremely important to consider the training and skill of the treating clinician. If there is an option that may be considered for a patient, but the treating clinician is not comfortable with it, that patient should be referred to another clinician who can provide those options. Clinicians should not perform procedures or recommend treatment options that they have not had the training or skills to perform.

How important is patient commu-nication in treatment planning?

Patient communication is the most vital aspect involved in diagnosis and treatment planning. We have to remember why patients seek our consultation: They want teeth! It is up to us to inform them of their attributes and limitations to achieving their chief goal. Whether it is a complicated medical history, inadequate available bone, unrealistic expectations, or financial limitations, any treatment performed will fail without proper communication.

What does the future look like for the management of the edentulous maxilla?

The future is extremely bright in management of the edentulous maxilla, whether it is severely atrophic or not. It is apparent that technology will continue to improve to provide us with enhanced diagnostic tools, improved materials to augment deficient tissues via less invasive procedures, better prosthetic options for both provisional and final restorations, and implants can be loaded sooner and can be used in more compromised sites.