ORIGINAL ARTICLE

From maxilla to zygoma: A review on zygomatic implants

DR Prithviraj, Richa Vashisht, Harleen Kaur Bhalla

ABSTRACT

Purpose: Patients with moderate to severe atrophy challenge the surgeon to discover alternative ways
to use existing bone or resort to augmenting the patient with autogenous or alloplastic bone materials.
The objective of the following study was to review the published literature to evaluate treatment
success with zygomatic implants in patients with atrophic posterior maxilla.
Study Selection: Medline/PubMed searches were conducted using the terms atrophic maxilla,
zygomatic implant, zygomatic bone, grafts, maxillary sinus, as well as combinations of these and
related terms. The few articles judged to be relevant were reviewed.
Results: Based on the current literature review, zygomatic implants show excellent survival rates (>90%)
and a low incidence of complications.
Conclusion: With proper case selection, correct indication and knowledge of the surgical technique, the
use of zygomatic implants associated with standard implants offers advantages in the rehabilitation
of severely resorbed maxillae, especially in areas with inadequate bone quality and volume, without
needing an additional bone grafting surgery, wherefore shortening or avoiding hospital stay and
reducing surgical morbidity.

KEY WORDS: Atrophic maxilla, grafts, maxillary sinus, zygomatic bone, zygomatic implant

INTRODUCTION deficient anatomical regions, including total/segmental

Dental implants are now commonly used for replacing
missing teeth in various clinical situations. Dental
implants are surgically inserted in the jawbones.
Unfortunately, restrictions have appeared in the use of
oral implants. One of them is the lack of sufficient bone
volume, especially in the posterior maxilla.[1]
During the last three decades, several surgical procedures
have been developed to increase local bone volume in
Department of Prosthodontics, Government Dental College and
Research Institute, Victoria Hospital Campus, Fort, Bengaluru,
Karnataka, India
Address for correspondence: Dr. Richa Vashisht,
Government Dental College and Research Institute, Victoria Hospital Campus,
Fort, Bengaluru - 560 002, Karnataka, India.
E-mail: dr.richavashisht@gmail.com
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DOI:
10.4103/0974-6781.130973
bone on lays, Le Forte1 osteotomy with interpositional
bone grafts and grafting of the maxillary sinus with
autogenous bone and/or bone substitute.[2]
These techniques pose a series of inconveniences, such
as the need for multiple surgical interventions, the use of
extraoral bone donor sites (e.g., iliac crest or skull) - with
the morbidity involved in surgery of these zones - and
the long duration during which patients remain without
rehabilitation during the graft consolidation and healing
interval. These factors complicate patient acceptance
of the restorative treatment and limit the number of
procedures carried out.
In order to overcome such limitations, different
therapeutic alternatives have been proposed, such as,
implants placed in specific anatomical areas like the
pterygoid region, the tuber or the zygoma [Figure 1].
Any of these procedures requires considerable surgical
expertise and has its own advantages, limits, surgical
risks and complications involving biological and financial
costs. The placement of implants in the zygomatic bone
as an alternative to maxillary reconstruction with
autogenous bone grafts has been considered a viable
option in the rehabilitation of atrophic maxillae.

44 Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

 Prithviraj, et al.: Zygomatic implants: A review
ANATOMY OF ZYGOMATIC BONE
The zygoma bone can be compared to a pyramid, offering
an interesting anatomy for the insertion of implants. In
an article in 1993, Aparicio et al. mentioned the possibility
of inserting dental implants in the zygomatic bone.[3]
In 1997, Weischer et al. cited the use of the zygoma as
a support structure in the rehabilitation of patients
subjected to maxillectomies.[4] Following Branemark’s
description, Uchida et al. in 2001, measured the maxilla
and zygoma in 12 cadavers, observing that the apex
of a 3.75 mm- diameter implant requires a zygoma of
at least 5.75 mm in thickness. With respect to implant
placement, they advised that an angulation of 43.8° or
less increases the risk of perforating the infratemporal
fossa or the lateral area of the maxilla; if the angulation
is more vertical, 50.6° or more, this increases the risk of
perforating the orbital floor.[5]
Nkenke et al. in their study used computed tomography
and histomorphometry to examine 30 human zygoma,
the study revealed that the zygomatic bone consists of
trabecular bone, an unfavorable parameter for implant
placement; however, the success of implants placed in
the zygomatic bone was achieved by the implant crossing
four portions of cortical bone.[6]
In a study done by Kato et al. investigated the internal
structure of the edentulous zygomatic bone in cadavers
using micro-computed tomography, finding that the
presence of wider and thicker trabeculae at the apical
end of the fixture promotes initial fixation.[7]
DESCRIPTION OF THE ZYGOMATIC IMPLANT
The zygomatic implants are self-tapping screws in c.p.
titanium with a well-defined machined surface. They are
Figure 1: Anatomical buttresses of the midface.
(1) Frontomaxillary buttress. (2) Frontozygomatic buttress.
(3) Pterygomaxillary buttress
Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1
available in eight different lengths ranging from 30 to
52.5 mm. They present a unique 45° angulated head to
compensate for the angulation between the zygoma and
the maxilla [Figure 2]. The portion that engages the zygoma
has a diameter of 4.0 mm and the portion that engages the
residual maxillary alveolar process a diameter of 4.5 mm.[8,9]
PRESURGICAL EVALUATION
Clinical examination is not sufficient for this evaluation
and radiologic assessment has to be considered. Bedrossian
et al. in their study on zygomatic and premaxillary implants
used panoramic radiographs, which generally depict the
size and configuration of the maxillary sinuses, the height
of the residual ridge and the position of the nasal floor. The
body of the zygoma can usually be visualized.[9] However,
orthopantomography can give distorted information
and therefore, the examination of choice is the spiral
or helicoid computed tomography (CT) scan, which
makes two- and three-dimensional imaging possible
with axial cuts every 2 mm parallel to the palatal arch
and conventional tomography with frontal tomograms
perpendicular to the hard palate every 3-4 mm. The CT
scan also gives the opportunity to visualize the health
of the maxilla and the sinus. Sinusitis, polyps or any
sinusal pathology can be excluded. The density, length
and volume of the zygoma can be evaluated and special
templates for inserting the zygomatic implants can be
constructed on stereolithographic models to facilitate
the orientation of the zygomatic implants during the
surgery with minimal errors in angulation and position.[10]
Vrielinck et al., presented a planning system for zygomatic
implant insertion based on the pre-operative CT imaging;
they calculated the position of the implants and fabricated
a surgical guide. Using this system they obtained a success
rate of 92% in 29 patients with zygomatic implants (two
implants did not reach the zygomatic arch when using
this surgical guide).[11]
Figure 2: Radiologic aspect of a patient restored with two
zygomatic implants
45
 Prithviraj, et al.: Zygomatic implants: A review

SURGICAL PROCEDURE MULTIPLE ZYGOMATIC IMPLANTS

The original procedure, defined by Branemark in
1998, consisted of the insertion of a 35-55 mm-long
implant anchored in the zygomatic bone following
an intra-sinusal trajectory.[12] Since this description,
many authors have varied the technique slightly.
Stella and Wagner described a variant of the technique
(Sinus Slot Technique) in which the implant is positioned
through the sinus via a narrow slot, following the contour
of the malar bone and introducing the implant in the
zygomatic process. In this way, the need for fenestration
of the maxillary sinus is avoided and the implant is
caused to emerge over the alveolar crest at first molar
level, with a more vertical angulation [Figure 3].[13]
Peñarrocha et al. 12 published in 2007 a series of 21 cases
with the “Slot technique” with a 100% survival rate,
but the Schneiderian membrane was perforated in all
cases, even though the incidence of sinus pathology was
low (two cases).[14]
The use of multiple zygomatic implants (i.e., two to three
in each side) was suggested by Bothur et al.[15] In a recent
study, Duarte et al. used four zygomatic implants and
no premaxillary conventional implants in the prosthetic
rehabilitation of 12 patients with edentulous and severely
resorbed maxillas. A fixed bridge of a gold framework
and acrylic teeth was fabricated and delivered shortly
after implant surgery. The patients were evaluated after
6 and 30 months when the bridges were removed for
individual testing of implant stability. One zygomatic
implant was found to be loose at the 6-month follow-up
and another one was found to be loose at the 30-month
check-up. Thus, the overall survival rate was 95.8% after
30 months of follow-up. No severe complications relating
to the sinus or the soft-tissues were reported.[16]
COMPLICATIONS
The reported complications associated with zygomatic
implants include postoperative sinusitis, oroantral fistula
formation, periorbital and subconjunctival hematoma
or edema, lip lacerations, pain, facial edema, temporary
paresthesia, epistaxis, gingival inflammation and orbital
penetration/injury [Table 1]. Post-operative concerns
regarding difficulty with speech articulation and hygiene
caused by the palatal emergence of the zygomatic
implant and its effect on the prosthesis suprastructure
have been reported.

Figure 3: Right - trans-zygomatic implantation following an
intrasinusal path. Left - the extrasinus technique. Note the
implant emergence above the alveolar crest at first molar level,
with a more vertical angulation
CONCLUSION
The zygomatic implant is an alternative procedure to
bone augmentation, maxillary sinus lift and to bone

Table 1: Success rate of zygomatic implants

Study/year No. of No. of Follow-up Success Complication
patients zygomatic rate %
implants
Aparicio et al., 2006[17] 69 131 6 months-5 years 99 Sinusitis, loosening of the zygomatic implant
gold screws in nine patients, fracture of one gold
screw as well as the prosthesis in one patient
Bedrossian et al., 2006[18] 14 28 12 months 100 -
Peñarrocha et al., 2007[14] 21 40 29 months 100 Ecchymosis
Davó et al., 2008[19] 42 81 12-42 months 100 Oroantral fistula and sinusitis was found in one
patient
Pi Urgell et al. 2008[20] 54 101 1-72 months 96 Sinusitis
Balshi et al., 2009[21] 56 110 9 months-5 years 96 -
Aparicio et al., 2010[22] 25 47 2-5 years 100 -
Stiévenart and Malevez, 2010[23] 20 80 6-40 months 96 -
Migliorança et al., 2011[24] 75 150 12 months 98.7 Two zygomatic implants (1.3%) failed and were
removed
Davó et al., 2013[25] 42 81 5 years 98.5 One zygomatic implant was lost

46 Journal of Dental Implants | Jan - Jun 2014 | Vol 4 | Issue 1

 Prithviraj, et al.: Zygomatic implants: A review
grafts in patients with posterior atrophic maxillae.
The zygomatic implant technique should be regarded
as a major surgical procedure and proper training is
of course needed. However, in comparison with bone
grafting procedures, the technique is less invasive and
complicated and has a lower risk of morbidity due to the
fact that harvesting of bone graft is usually not needed.
Based on the current literature review, zygomatic
implants show excellent survival rates (>90%) and a low
incidence of complications, so this should be considered
a valid and safe treatment option when dealing with
patients with advanced maxillary atrophy.
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How to cite this article: Prithviraj DR, Vashisht R, Bhalla HK. From
maxilla to zygoma: A review on zygomatic implants. J Dent Implant
2014;4:44-7.
Source of Support: Nil, Conflict of Interest: None.
47
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