Journal of Oral Rehabilitation 2001 28; 125132

Anatomical study of the pyramidal process of the palatine bone in relation to implant placement in the posterior maxilla
S. P. LEE, K. S. PAIK & M. K. KIM
South Korea Department of Oral Anatomy, College of Dentistry, Seoul National University, Seoul,

SUMMARY

The placement of dental implants in the molar region of the maxilla is often difcult because of insufcient bone volume and the inferior bone quality. In order to avoid these limitations, the pillar of bone, which is composed of the maxillary tuberosity, the pyramidal process of the palatine bone and the pterygoid process of the sphenoid bone, was introduced for implant placement. In fact, the pyramidal process is the posterior structure where implants are placed but until now, there is no available data of the size or shape of the pyramidal process. Therefore, we measured the height, anteroposterior distance and mediolateral distance of the pyramidal process and observed the shape of lateral and posterior surfaces of the pyramidal process of 54 Korean edentulous dry skulls in this

study. The height was 131 mm (male: 136 mm, female: 124 mm). The anteroposterior distance was 65 mm (male: 67 mm, female: 61 mm). The mediolateral distance was 95 mm (male: 99 mm, female: 90 mm). The most common type was the rightangled triangle in the lateral surface (444%) and in the posterior surface (667%). There was no statistical signicance between the male and the female in all items (P > 005). These results provide anatomical features in relation to placement of dental implants in the molar region of the maxilla and would be useful in treatment planning of partially or completely edentulous patients.
KEYWORDS :

anatomical study, dental implant, posterior maxilla, pyramidal process

Introduction
Since the report of the successful implantation of nemark et al., titanium prostheses in dog jaws (Bra 1969), endosseous implants have been widely used in dentistry for the reconstruction of completely or partially edentulous patients and many successful results have been reported. However, the placement of endosseous implants in the molar region of the maxilla is often difcult because of insufcient bone volume due to the presence of the maxillary sinus and the reduction of alveolar bone following loss of teeth and the inferior bone quality (Krogh, 1991; Yamaura et al., 1998; Kim, 1999). Therefore, the majority of implants in the maxilla were commonly placed anteriorly to the rst molar region (Adell et al., 1981). This could result in a shorter bridge or cantilever bridge, which causes aesthetic and
2001 Blackwell Science Ltd

functional problems. In order to avoid these complications, several alternative methods have been proposed. To increase the amount of bone-to-titanium surface contact, one option is the use of wider implants (Langer et al., 1993; Bahat & Handelsman, 1996), and the other is using an increased number of implants (Reiger, 1991; Bahat & Handelsman, 1996). Many studies regarding sinus lift procedures have been reported (Boyne & James, 1980; Kent & Block, 1989; Fugazzotto, 1999), however, these procedures have disadvantages and may cause other complications (Nique et al., 1992; Schliephake et al., 1994). The pillar of bone, which is composed of the maxillary tuberosity, the pyramidal process of the palatine bone and the pterygoid process of the sphenoid bone (Graves, 1994; Khayat & Nader, 1994), was introduced by some authors for the implant placement

125

126

S . P . L E E et al.

Fig. 1. Picture showing a pillar of bone composed of the maxillary tuberosity (a), the pyramidal process of the palatine bone (arrow) and the pterygoid process of the sphenoid bone (b).

Fig. 4. Radiograph showing a pillar of bone composed of the maxillary tuberosity (a), the pyramidal process of the palatine bone (arrow) and the pterygoid process of the sphenoid bone (b).

Fig. 2. Pillar of bone. (Arrow) pyramidal process, (a) maxillary tuberosity, (b) pterygoid process, (c) maxillary sinus.

Fig. 5. Radiograph showing placement of dental implant in the pillar of bone.

Fig. 3. Picture showing placement of dental implant in the pillar of bone.

in the posterior maxillary region (Figs 15). They presented high success rate and satisfactory results using that region (Tulasne, 1989, 1992; Bahat, 1992; ndez Balshi, 1992; Balshi et al., 1995, 1999; Ferna n & Ferna ndez Vela zquez, 1997). The maxillary Valero tuberosity is mainly composed of type III and type IV bone quality according to the classication of Lekhorm and Zarb (1985), while the pyramidal process of the palatine bone and the pterygoid process of the sphenoid bone are dense cortical bone (Balshi, 1992; Graves, 1994). Although some authors stated that the pterygoid process is the posterior boundary of the maxillary tuberosity (Graves, 1994; Balshi et al., 1995), in fact the pyramidal process was the posterior structure where ndez Valero n implants are placed (Bahat, 1992). Ferna ndez Vela zquez (1997) took great interest and Ferna
2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

ANATOMICAL STUDY OF THE PYRAMIDAL PROCESS IN RELATION TO IMPLANT

about the pyramidal process as it is a structure of thick compact bone, providing sufcient bone volume for implant placement, however, they did not present any measurements about the pyramidal process. To the best of our knowledge, there is no available data of the size or shape of the pyramidal process. Therefore, we measured the height, anteroposterior distance and mediolateral distance of the pyramidal process and observed the shape of lateral and posterior surfaces of the pyramidal process in this study. midsagittal and the coronal planes were cut by an electrical saw. Items of measurement Measurements were recorded in millimetres and carried to the rst decimal point using a pair of Nonius (1/10 mm). (i) Height of the pyramidal process of the palatine bone The distance from the highest point to the lowest point of the pyramidal process was measured on the skulls set parallel to the Frankfurt horizontal plane. (ii) Anteroposterior distance of the pyramidal process of the palatine bone The highest width of the anteroposterior distance in the midsagittal section of the pyramidal process was measured. (iii) Mediolateral distance of the pyramidal process of the palatine bone

127

Materials and methods

Fifty-four Korean edentulous dry skulls (male: 34, female: 20), were obtained from the Department of Oral Anatomy, College of Dentistry. The ages of the subjects ranged from 50 to 80 years. All measurements and observations were undertaken on the right side except the measurement of the anteroposterior distance, which was undertaken on the left side. The

Fig. 6. Shape of the lateral surface of the pyramidal process (black area) of the palatine bone. Type I: Regular triangle in shape; Type II: Rightangled triangle in shape; Type III: Right-angled triangle with narrow width in shape; Type IV: No appearance.
2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

128

S . P . L E E et al.

Fig. 7. Shape of the posterior surface of the pyramidal process (black area) of the palatine bone. Type I: Regular triangle in shape; Type II: Rightangled triangle in shape; Type III: Right-angled triangle with narrow width in shape.

The highest width of the mediolateral distance in the coronal section of the pyramidal process was measured. Items of observation (i) Shape of the lateral surface of the pyramidal process of the palatine bone (Fig. 6) The shape of the lateral surface of the pyramidal process was observed as follows: Type I: Regular triangle in shape Type II: Right-angled triangle in shape Type III: Right-angled triangle with narrow width in shape Type IV: No appearance

(ii) Shape of the posterior surface of the pyramidal process of the palatine bone (Fig. 7) The shape of the posterior surface of the pyramidal process was observed as follows: Type I: Regular triangle in shape Type II: Right-angled triangle in shape Type III: Right-angled triangle with narrow width in shape Analysis For items of measurement, mean values and standard deviation (s.d.) were calculated and the signicance of sex differences has been carried out by means of the t-test. For items of observation, percentage frequency was determined and the signicance of
2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

ANATOMICAL STUDY OF THE PYRAMIDAL PROCESS IN RELATION TO IMPLANT

sex differences has been carried out by means of the chi-square test.
Table 4. Shape of the lateral surface of the pyramidal process of the palatine bone n (%) Total Type Type Type Type I II III IV 6 24 21 3 54 (111) (444) (389) (56) (1000) Male 3 16 13 2 34 (88) (471) (382) (59) (1000) Female 3 8 8 1 20 (150) (400) (400) (50) (1000)

129

Results
Items of measurement The height of the pyramidal process was 131 mm (range: 83214 mm). The height of the pyramidal process was 136 mm in the male and 124 mm in the female (Table 1). The anteroposterior distance in the midsagittal section was 65 mm (range: 3397 mm). The anteroposterior distance of the male and the female was 67 and 61 mm, respectively (Table 2). The mediolateral distance in the coronal section was 95 mm (range: 42118 mm). The mediolateral distance was 99 mm in the male and 90 mm in the female (Table 3). The widest area was near the base line of the pyramidal process. The male, in general, showed greater value in all items than the female, but there was no statistical signicance between the male and the female (t-test, P > 005).

Items of observation As shown in Table 4, the most common shape of the lateral surface of the pyramidal process was the rightangled triangle in 444% and the next was the rightangled triangle with narrow width in 389%. The prevalence of the right-angled triangle was 471% in the male and 400% in the female and the right-angled triangle with narrow width was shown in 382% of the male and 400% of the female (Fig. 8). The most common type in the posterior surface of the pyramidal process was the right-angled triangle in 667% and the next was also the right-angled triangle with narrow width in 185%. The prevalence of the right-angled triangle was 676% in the male and 650% in the female (Fig. 9, Table 5). No statistical signicance was found between the male and the female in all items of observation (chisquare test, P > 005).

Table 1. Height of the pyramidal process of the palatine bone (mm) Male Mean (s.d.) MinMax 136 (30) 87214 Female Mean (s.d.) MinMax 124 (24) 83172

Total Mean (s.d.) 131 (28)

Discussion
Occlusal forces in the posterior region of the maxilla are greater than those exerted in the anterior region and the bone quality of maxillary tuberosity is not sufcient to stand them. To compensate for these disadvantages, the cortical plate of the pyramidal process would be engaged. The pyramidal process arises from the junction of vertical and horizontal plates of the palatine bone at the posterolateral corner of the bony palate and it lls the pterygoid notch between the medial and lateral pterygoid plates of the sphenoid bone (DuBrul, 1980). Unfortunately, there are no available records with regard to the height of the pyramidal process, although some authors presented records about the height of the pterygomaxillary suture which connects the maxillary tuberosity to the pterygoid process. According to Graves

Table 2. Anteroposterior distance of the pyramidal process of the palatine bone (mm) Male Mean (s.d.) MinMax 67 (10) 4697 Female Mean (s.d.) MinMax 61 (12) 3385

Total Mean (s.d.) 65 (11)

Table 3. Mediolateral distance of the pyramidal process of the palatine bone (mm) Male Mean (s.d.) MinMax 99 (14) 51118 Female Mean (s.d.) MinMax 90 (19) 42112

Total Mean (s.d.) 95 (17)

2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

130

S . P . L E E et al.

Fig. 8. Photographs showing shape of the lateral surface of the pyramidal process (arrow) of the palatine bone. Type I: Regular triangle in shape; Type II: Right-angled triangle in shape; Type III: Right-angled triangle with narrow width in shape; Type IV: No appearance.

(1994), the height of the pterygomaxillary suture was 150 mm and Cheung et al. (1998) reported 121 mm, while the height of the pyramidal process was 131 mm in this study. Of the total 54 samples, 45 samples (833%) were over 100 mm, which would be enough height for standard-diameter implant (375 mm) placement. According to Balshi et al. (1999), standarddiameter implants were used more frequently in the pterygomaxillary region, while wider-diameter implants were placed in fewer patients. The anteroposterior distance in the midsagittal section was 65 mm in this study. Although, the distance of the female (61 mm) was smaller than that of the male (67 mm), it is larger than the approximate data (60 mm) of Graves (1994). The contact surface between implant and bone will be greater than the

measured distance because of an implant being passed through the pyramidal process at an angle to the sagittal and coronal planes (Graves, 1994; Khayat & Nader, 1994). The sectioned surface showed thick compact plate on both sides, hence bicortical xation, which will enhance the likelihood of stability (Bahat, 1993), would be provided for an implant placement. The mediolateral distance in the coronal section of the left side was 95 mm. Even if the coronal section was to be triangular in shape, it would be also enough space for standard-diameter implant. In the majority of samples, the shape of the lateral surface of the pyramidal process was the right-angled triangle and the right-angled triangle with narrow width. As mentioned above, an implant is angled medially in an oblique buccopalatal direction (Graves,
2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

ANATOMICAL STUDY OF THE PYRAMIDAL PROCESS IN RELATION TO IMPLANT

131

Fig. 9. Photographs showing shape of the posterior surface of the pyramidal process (arrow) of the palatine bone. Type I: Regular triangle in shape; Type II: Right-angled triangle in shape; Type III: Right-angled triangle with narrow width in shape.

Table 5. Shape of the posterior surface of the pyramidal process of the palatine bone n (%) Total Type I Type II Type III 8 36 10 54 (148) (667) (185) (1000) Male 5 23 6 34 (147) (676) (176) (1000) Female 3 13 4 20 (150) (650) (200) (1000)

These results provide anatomical features in relation to placement of dental implants in the molar region of the maxilla and would be useful in treatment planning of partially or completely edentulous patients.

References
NEMARK , P.-I. (1981) ADELL , R., LEKHOLM , U., ROCKLER , B. & BRA RANEMARK A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. International Journal of Oral Surgery, 10, 387. BAHAT , O. (1992) Osseointegrated implants in the maxillary tuberosity: report on 45 consecutive patients. International Journal of Oral and Maxillofacial Implants, 7, 459. BAHAT , O. (1993) Treatment planning and placement of implants in the posterior maxillae: report of 732 consecutive Nobelpharma implants. International Journal of Oral and Maxillofacial Implants, 8, 151. BAHAT , O. & HANDELSMAN , M. (1996) Use of wide implants and double implants in the posterior jaw: a clinical report. International Journal of Oral and Maxillofacial Implants, 11, 379.

1994; Khayat & Nader, 1994), therefore this shape of lateral surface should be considered. All the posterior surfaces of the pyramidal process were triangular in shape and the right-angled triangle type was found most frequently in 667%. Hence, it would be advantageous to place implants in the lower half of the pyramidal process for obtaining the maximum area.
2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

132

S . P . L E E et al.
BALSHI , T.J. (1992) Single, tuberosity-osseointegrated implant support for a tissue-integrated prosthesis. International Journal of Periodontics and Restorative Dentistry, 12, 345. BALSHI , T.J., LEE , H.Y. & HERNANDEZ , R.E. (1995) The use of pterygomaxillary implants in the partially edentulous patient: a preliminary report. International Journal of Oral and Maxillofacial Implants, 10, 89. BALSHI , T.J., WOLFINGER , G.J. & BALSHI , S.F.II (1999) Analysis of 356 pterygomaxillary implants in edentulous arches for xed prosthesis anchorage. International Journal of Oral and Maxillofacial Implants, 14, 398. BOYNE , P.J. & JAMES , R.A. (1980) Grafting of the maxillary sinus oor with autogenous marrow and bone. Journal of Oral Surgery, 38, 613. NEMARK , P.-I., BREINE , U., ADELL , R., HANSSON , B.O., LINDBRA RANEMARK . (1969) Intra-osseous anchorage of M , J. & OHLSSON , A STRO STROM dental prostheses I: experimental studies. Scandinavian Journal of Plastic and Reconstructive Surgery, 3, 81. CHEUNG , L.K., FUNG , S.C., LI , T. & SAMMAN , N. (1998) Posterior maxillary anatomy: implications for Le Fort I osteotomy. International Journal of Oral and Maxillofacial Surgery, 27, 346. DU BRUL , E.L. (1980) Sicher's Oral Anatomy, 7th edn, p. 42. Mosby, St. Louis. NDEZ VALERO N , J. & FERNA NDEZ VELA ZQUEZ , J. (1997) FERNA ERNANDEZ ALERON ERNANDEZ ELAZQUEZ Placement of screw-type implants in the pterygomaxillarypyramidal region: surgical procedure and preliminary results. International Journal of Oral and Maxillofacial Implants, 12, 814. FUGAZZOTTO , P.A. (1999) Sinus oor augmentation at the time of maxillary molar extraction: technique and report of preliminary results. International Journal of Oral and Maxillofacial Implants, 14, 536. GRAVES , S.L. (1994) The pterygoid plate implant: a solution for restoring the posterior maxilla. International Journal of Periodontics and Restorative Dentistry, 14, 512. KENT , J.N. & BLOCK , M.S. (1989) Simultaneous maxillary sinus oor bone grafting and placement of hydroxylapatitecoated implants. Journal of Oral and Maxillofacial Surgery, 47, 238. KHAYAT , P. & NADER , N. (1994) The use of osseointegrated implants in the maxillary tuberosity. Practical Periodontics and Aesthetic Dentistry, 6, 53. KIM , M.K. (1999) Clinical Anatomy of the Head and Neck, 3rd edn, p.49. Medical and Dental Publishers Company, Seoul. KROGH , P.H.J. (1991) Anatomic and surgical considerations in the use of osseointegrated implants in the posterior maxilla. Oral and Maxillofacial Surgery Clinics of North America, 3, 853. LANGER , B., LANGER , L., HERRMANN , I. & JORNEUS , L. (1993) The wide xture: a solution for special bone situations and a rescue for the compromised implant. Part 1. International Journal of Oral and Maxillofacial Implants, 8, 400. LEKHORM , U. & ZARB , G.A. (1985) Patient selection and preparation. In: Tissue Integrated Prostheses: Osseointegration in Clinical nemark, G.A. Zarb, & T. Albrektsson), p. Dentistry (eds P.-I .Bra 199. Quintessence, Chicago. NIQUE , T., FONSECA , R.J., UPTON , I.G. & SCOTT , R. (1992) Particulate allogenic bone grafts into maxillary alveolar clefts in humans: a preliminary report. International Journal of Oral and Maxillofacial Implants, 7, 176. REIGER , M.R. (1991) Loading considerations for implants. Oral and Maxillofacial Surgery Clinics of North America, 3, 795. SCHLIEPHAKE , H., NEUKAM , F.W., SCHELLER , H. & BOTHE , K.J. (1994) Local ridge augmentation using bone grafts and osseointegrated implants in the rehabilitation of partial edentulism: Preliminary results. International Journal of Oral and Maxillofacial Implants, 9, 557. TULASNE , J.F. (1989) Implant treatment of missing posterior nemark Osseointegrated Implant (eds T. dentition. In: The Bra Albrektsson & G.A. Zarb), p. 103. Quintessence, Chicago. TULASNE , J.F. (1992) Osseointegrated xtures in the pterygoid region. In: Advanced Osseointegration Surgery. Applications in the nemark), Maxillofacial Region (eds P. Worthington & P.-I. Bra p. 182. Quintessence, Chicago. YAMAURA , T., ABE , S., TAMATSU , Y., RHEE , S., HASHIMOTO , M. & IDE , Y. (1998) Anatomical study of the maxillary tuberosity in Japanese men. Bulletin of Tokyo Dental College, 39, 287.
Correspondence: Prof. Myung-Kook Kim, Department of Oral Anatomy, College of Dentistry, Seoul National University, 28-22 Yungun-Dong, Chongro-Ku, Seoul 110-749, South Korea. E-mail: anakim@plaza.snu.ac.kr

2001 Blackwell Science Ltd, Journal of Oral Rehabilitation 28; 125132

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.