Basally Osseointegrated Implants as a Viable Immediate Solution in Cases of Failed Implants in Atrophic Posterior Maxillary Region: A Case Report
Vaibhav Nagaraj3*, Sudhakara Reddy K1, Thokala Dhamodaran2 and Swarna Sudeeshna4
1 Department of Oral & Maxillofacial Surgery, Sri Rajiv Gandhi College of dental sciences, India
2 Department of Conservative & Endodotics, Raja Rajeswari Dental College, India
3 Department of Oral & Maxillofacial Surgery, India
4 D Private Practitioner, India
Submission: February 07, 2017; Published: February 19, 2018
*Corresponding author: Vaibhav N, Department of Oral & Maxillofacial Surgery, Sri Rajiv Gandhi College of Dental Sciences,India,Tel:+919844258076; Email:firstname.lastname@example.org
How to cite this article: Sudhakara Reddy K, Thokala Dhamodaran, Vaibhav Nagaraj, Swarna Sudeeshna. Basally Osseointegrated Implants as a Viable
Immediate Solution in Cases of Failed Implants in Atrophic Posterior Maxillary Region: A Case Report. Adv Dent & Oral Health. 2018; 7(5): 555722. DOI:10.19080/ADOH.2018.07.555722
Basal implants are gaining popularity at recent times and emerging as alternate option to avoid sinus lift and other grafting procedures. Due to their unique design of horizontal disc component which gets engaged in basal cortical bone, they can be installed even in those cases, where the vertical bone supply is reduced such as moderate to severe atrophic ridges.
This article describes the placement of basal implant in a case where conventional dental implant done along with indirect sinus lift was a failure. Since the possibility of mounting prosthesis does not depend on the presence of vertical/alveolar bone, they can be restored immediately. Two years follow up showed successful osseointigration of basal implant without any loss of bone
Posterior maxilla often presents with several challenging situations for placement of implants because of its anatomical limitations. Poor bone quality combined with inadequate bone volume because of position of the floor of the sinus as well as resorption of the alveolar bone make conditions for implant placement less favorable in the region . Sinus lift with bone augmentation , is one of the most predictable alternatives for increasing subantral bone height to place implants. Since the first description  of subantral augmentation by Tatum and modified by Boyne, there were several modifications published in the literature. However, Sinus lift procedure has its limitations. It is invasive surgical procedure with complications  like membrane perforation, bleeding, postoperative infection and also donor site morbidity in case of autogenous grafting. They also increase both cost and treatment time . Even survival rate of implant  placed in augmented sinus area has wide range from 36% -100%. Implant ologists are facing the increased demand for alternate options with fixed restoration in short term treatment protocols with affordable cost without additional surgeries.
Laterally inserted basal osseointigrated implants not only avoid any additional surgical procedures but also provide reliable
anchor in basal cortical bone even in less vertical bone height and can be loaded immediately without waiting period of 3-6 months. Masticatory load transmission  is confined to the horizontal implant segment sand essentially to the cortical bone Structures. This virtually eliminates the need for vertical bone augmentation procedures.
We present a case in which patient had been treated previously with indirect sinus lift simultaneous implant placement was a failure within 3 months. With residual bone height of 3mm after removing failed implant, we placed laterally inserted basal osseointigrated implant with immediate loading. Post two years follow up showed no bone loss and no signs of failure. This report highlights the indications and advantages of basalosseo integrated implants in cases with inadequate bone height in posterior maxillary region.
A 40 year old male patient has come with a chief complaint of missing upper left first molar tooth and wanted to get it replaced. A cone beam computed tomography (CBCT) image of that region revealed that the available bone height was 6 mm (Figure 1).
Subsequently an ‘indirect’ sinus lift procedure was planned and
executed. A bone height of 9 mm was achieved by using calcium-
Phosphosilicate bone graft material (Nova Bone Dental Putty®)
for augmentation. Simultaneously a 4.2 x 8 mm crestal type
cylindrical implant (Hitech®, Herzlia, Israel) was placed. After a
period of 3 months follow up, implant failure was noticed by an
intraoral peri-apical (IOPA) radiograph that showed bone loss
around the implant (Figure 2). The failed implant was retrieved
and the area was curetted and cleaned. Radiographs after 2 months
of implant retrieval revealed a residual bone height of only 4mm.
The situation and prognosis was then explained to the patient.
The patient refused to undergo further surgical augmentation
procedures and wasn’t too keen on waiting longer to get the
final prosthesis. So, a decision was taken to place a Basal
Osseointegrated Implant’ BOI in the upper left first molar region
with immediate loading. A crestal incision was given along with
mesial and distal release incisions. Buccalmucoperiosteal flap
was reflected. A vertical cut was given on the buccal aspect of the
bone below the imaginary line depicting the sinus lining extending
till the lower border of alveolar bone on the buccal aspect using
a VC 1.6 straight long bur attached to contra-angled hand-piece.
Care should be taken not to perforate the palatal wall. Then, a
horizontal cut is made on the upper border of the vertical cut
using a ‘T’ shaped bur. During this process, the vertical component
of the ‘T’ shaped bur corresponds to the groove of the previously
created vertical cut. At this point, a BOI®- BS9 implant (IHDE
Dental®, Gommiswald Switzerland) was placed in the ‘T’ shaped
groove that was created (Figure 3). It was then gently tapped with
a mallet to ensure proper seating of the implant within the groove.
The stability of the implant was then checked, the flap was sutured
back in position and an impression was taken after a week (Figure
After 2 weeks of placement, the implant was loaded with
a metal ceramic crown (Figure 5). The patient was followed up
regularly. The patient had no specific complaints. Two years
follow-up findings showed (Figure 6) successful osseointegration
with no bone loss and no implant associated complications with
complete patient satisfaction.
Conventional ‘crestal’ implants require good bone height
and width. But resorption following the extraction of posterior
maxillary teeth sometimes results in severe loss of bone in vertical
and or horizontal dimensions which may compromise the use of
conventional dental implants . Various sinus augmentation
 procedures have been used with varying amounts of success.
But, the invasiveness of these procedures not only adds local
complications like mucosal perforation , acute sinusitis 
etc but also economical burden to the patient. In severely resorbed
cases, Grafting with sinus lift most often accomplished as part of
a 2-stage implant protocol which is followed by a 3- to 6-month
healing period to allow for maturation of the graft prior to the
placement of dental implants. The total time taken for completion
of treatment with prosthesis delivery can take up to a year.
Dental implants for insertion from the lateral aspects of the
jaw bone have been described repeatedly, since 1972 . The
term basal implant refers to the principles of utilizing basal bone
and cortical areas free of infection and resorption. This rationale
stems from orthopedic surgery and from the experience that
cortical areas are more resistant against resorption [13,14]
Usage of basal implants virtually precludes the need for
sinus lifts or other bone augmentation procedures. This reduces
morbidity as well as the duration of the rehabilitation procedure.
These basal osseointigrated implants offer several other
advantages. No masticatory forces need to be transmitted to
the bone via vertical aspects of the implant. It is confined to the
horizontal implant segments. The positive retention in the bone
is created in the cortical bone region. Implant failure due to
infections is pretty rare because the load transmission is supposed
to occur within the basal aspect of the implant, far away from the
site of bacterial infection from the oral cavity . They can also
be used where very little vertical bone is present, while the supply
of horizontal bone is still sufficient or can even use trans-sinusly.
Peri-implantitis  is a real issue around crestal implants.
Once a ‘crestal’ implant is inserted, it completely obturates
the osteotomy site. Any infection carried into the bone
intraoperatively or preoperatively can endanger the therapeutic
result considerably leading to an implant failure. Presumably,
the prognosis of BOI implants is considered better because the
blood supply to the bone remains undisturbed because of the
‘skeletalized’ enossal implant fixture . It is assumed that the
incidence of periimplantitis is very less compare to conventional
implants due to smooth surface vertical component (no surface
enlargement) of the implant which eliminates bacterial attraction.
With integrated basal implants, infection originating in the oral
cavity would not normally be expected to spread endosseously,
for as long as the implants are not mobile to the extent that they
can be intruded. In cases infections sets in because of improper
hygiene or food retention, it spreads submucosally which is easier
to treat rather than intra-osseously.
The concept of immediately loading implants  has been
well documented in the literature. The maxillary arch poses
difficulties for immediate loading than mandible. The presence
of type III and IV bone predominantly as well as the presence of
the maxillary sinus makes the prognosis of immediate loading
implants rather questionable in the posterior maxilla . Basal
implants which are inserted laterally, can be loaded immediately
which shows adequate anchorage and osseointegration in
completely edentulous maxilla [19-21].
The maximum stresses are always located near the baseplates.
So the stress distribution is more even in basal implants
than conventional implants .
Basal implants are gaining popularity in recent times due to
its advantages of managing atrophic cases, immediate loading,
lack of periimplantitis and no additional expensive grafting
procedures. This case report shows failed case of indirect sinus lift
with conventional implant was successfully treated with laterally
inserted basal implant along with immediate loading without any
grafting procedures even in 4 mm the residual bone below the
sinus. Two years follow up showed successful osseointigration
without any signs of failure with no marginal bone loss noted.
Conventional implants are the first choice in normal bone
conditions but single stage basal implants should be option in
cases where conventional implant failure and in cases where
residual bone height was very less as in moderately or severely
atrophied ridges. Still long term follow ups, larger group studies
and comparative studies are required further.