REVIEW ARTICLE Zygomatic Implants - A Review Jude Sudhakar’, Seyed Asharaf Al’, Suma Karthikeyan’ "DrJude Sudhakar PG Student "Dr Seyed Asharat Ali Professor "Dr. Suma Karthikeyan HOD & Professor Division of Prosthodontics, Rajah Muthiah Dental College & Hospital, Annamalai University, E-mail: jsldental@ yahoo.co.in, juderas21@yahoo.com Abstract Dental implants have always been more sensitive inthe maxilla than in the mandible, The situation becomes undesirable when the maxilla is severely resorbed and atrophic various protocols have been recommended to provide a optimal solution fr this complex problem, ‘Studies highlight the zygomatic bone as a suitable anatomical structure for placement of dental implants as it cross four cortical bones 2ygomatic implants were described by Branemark in 1998 asa suitable alternative for atrophic maxilla, These are long screw shaped implants developed as an alternative to bone grating and sinus augmentation Though itis technique sensitive, many studies had shown promising results Keywords: 2ygoma, Imolants, zygomatic implants, Severely resorbed rmaxiliae Introduction Severely resorbed maxillae presents a complex problem. Lackofinternal (Osseous stimulation and non physiologic crestal bone loading results in continued resorption of an already atrophic edentulous maxilla. In such patients conventional implant treatment cannot be performed because ff (1) extensive bone resorption and (2) pneumatization of sinus Treatment options fr these patients has often been some type of bone augmentation procedure in order to increase the volume of load: bearingbone. ‘Traditional, the atrophic maxilla has been treated with large bone rafts from the liac crest. But the procedure is resource demanding, takes long time and may present risk or morbidity of the donor site (One alternative to bone grafting that has been considered in the atrophied maxilaisthe use ofygomatictixtures. Study by Sonica Galan Gill ta, (Table 1) via ibllographie searches in PubMed, Cochrane, and the manual review of various odontological journals from 1993 to 2006 gives the prognosis and success rate of 2ygomaticimplants Zygoma Applied Anatomy! ‘The zygomatic bone is small and quadrangular, and is situated at ‘the upper and lateral part ofthe face: it forms the prominence of the cheek, part of the lateral wall and floor of the orbit, ané parts of the ‘temporal and infratemporal fossa. It presents a malar and a temporal surface; four processes, the frontosphenoidal, orbital, maxllary, and ‘temporal; and four borders. The antero-superior or orbital border is smooth, concave, and forms. considerable partof the circumference of the orbit. The antero-inferior or maxillary border is rough, and beveled atthe expense ofits inner table, to articulate with the maxilla; near the orbital margin it gives origin to the Quadratus labii superiors. The postero-superior or temporal border, curved lke an italic letter, is continuous above wit 1¢ commencement of the temporal line, and below withthe upper border of the zygomatic arch; the temporal fascia, is attached to it.The postero-inferior or zygomatic border affords attachment by its rough edge to the Masseteer, According to cadaver study, the mean length of available bone in thisregionisabout 14 mm, Fig Review of literature! 1n1993, Aparicio etal mentioned the possibilty of inserting dental implants in the zygomatic bone. In 1997 Weischer etal cited the use of _ygoma asa support structure in ehablitation of patients subjected to maxillectomies. TIADS VOL-2 Issue 2 April-June, 203% [24]Zygomatic Implants A Review Jude Sudhakar, Seyed Asharaf Al, Suma Karthikeyan Patients N° Zseomatic N° Conventional Saccems Rate Success Rae and tidehenins Implants Implants bianmions Zygomatic L — Convencional L. Branemik — 81 164 - 1 10 yeas om 7 Badossian al san n “4 %0 24 months 10% 91.3586 Nala ; et ° 5 7 6 months 100% ememak ‘i 2004 28 2 106, S10 yeas 9486 Hirshot a it 16 14 2 12 months 979% : Malevez ta jeez 55 103 14 10% o1.1s%6 ALNavas etal amas 2 2” Z 12 months ome s Landes 3 2 moet " - ie n 28 x 14.53 month am Pefianocha a at ; = 5 10 16 12-18 months 100% - Table 1. Review of erature In 2001 Uchida etal, measured the mala and the 2ygoma in 12 cadavers observing thatthe apex of a 3.75 mm élameter implant requires a zygoma of atleast 5.75 mm in thickness. With respect to implant placement, they advised that @ angulation of 438 er less increased the sof perforating the infratemporal oss or the lateral ares ofthe mail if the angulation is vertical, 506 (or) more, this increases the risk of perforating the orbital floor. (Fig.1) 'Nkenke et sed computed tomography anc histoorphometry ta examine 20 human zygoma The study revealed thatthe romati bone consists of trabecular bone, an unfavourable factor for implant placement; however the success of implant place in aygomatic bone was achieved the implant covering four portions of crtalbone. pian Attheridge crest ‘Thesinus floor Rootofthe maxillary sinus ‘Superiarborder of thezygoma Kato et al investigated the internal structure of edentulous _ygomatic bone in cadavers using miero-computed tomography, finding the presence of wider and thicker trabecular at the apical end the fixturespromotinginternalfixation. ‘Texture (Implant) design (Fig.2)"* ‘The original 2ygomatic fixture isa self tapping titanium implant with a machined surface and is available in & different lengths of 30:52.5, rmin.The threaded apical part has a diameter of 4mm and a crestal part, ‘f4.5mm.The implant head has an angulation of 45 and an inner thread for connection of abutments inorder to compensate forthe inclination ‘of implant insertion with respect to zygoma. The implants has an ‘oxidized rough surface, a smooth mic-implant body, wider neck at the alveolarcrest Biomechanical considerations™* Number of implants ‘When compared to a standard implants, the 2ygoma implant has, an increased tendency to bend under horizontal loads. Ths elated to twofactors 1. Thegreatly increased length ofthis implants (30—53mm) 2. The fact that, in some circumstances, there is limited bone support inthe maxillary alveolar crest. Consequently, implants should be rigidly connected to stable conventional fixtures in the anterior maxilla. Based on clinical experience and biomechanical theoretical calculations, a full arch restoration in the maxilla, supported by two zygoma implants (one on each side, should be assisted by atleast two stable, regular implant systemsintheanteriormaxilla, TADS VOL-2 Issue 2 April-June, 203% [25]Zygomatic Implants A Review dude Sudhakar, Seyed Asharaf Ali, Suma Karthikeyan Bendingmoments Forces that cause bending moments are_known to be the most unfavorable, This forces can potentially jeoparadize the long term stability of an implant supported restoration. In order to decrease bending moments, the distribution of forces should be optimized by ‘© crossarchstabilization + decreased buccalleverarms © deceased cantilevers © balanced occlusion ‘+ decreased cuspal inclination Prostheticdesign Prosthetic design when utilizing the 2ygoma implants should includeeffertsto ‘+ incorporate sufficient rigidity and precisionin the restoration 1+ decrease bending moments ‘+ balanced functional, esthetic, phoenitic and hygiene requirements ‘+ facilizatemaintenance the prosthesisisinsuffiiently rigid, deformation and deflection of the -zygoma implants an leadtoimplantloss or screw loosening. Position and angulation of implants Fig.3) The tooth positions forthe planned restoration should be decided preoperatively. This will alow selection ofthe most appropriate position ‘and angulation for each implant. The existing removable prosthesis will foften serve as a guide for these postions. In some instances, 2 diagnostic wax-up will be necessary. Its up to the prosthetic team to censure that the surgical team clearly understands the tooth positions required for the final prosthesis. One ofthe most appropriate means of doing this is by providing a surgical guide, A quick and simple way of fabricating a surgical guide isto make a replica in cleat acrylic resin, either of the existing denture of the waxed up try in except for 2 supporting posterior connection, the palatal area ofthe replica is then cutaway, leaving only the buccal contours fthe teeth Implant is placed in the second premolar region. Recommended protocol is placing two zygomatic implants one on each side of maxilla, ‘Then2-4 conventionalimplants ae placed in premaxillary region, Vrielinck etal presented a planning system for zygomatic implant insertion based on preoperative CT imaging, they calculated the position of the implants and fabricated a surgical guide, Using their system they obtained a success rate of 92% in 29 patients with zygomaticimplants (or) The existing removable prosthesis will often serve as a guide to position. A diagnostic waxup is also made and surgical guide is {abricatedin clear acrylicresin, Indications 1. Insufficient bone volume for placement of regular implants posterior tocanine (ie)<4mm bone height dstalto canines. 2. When there s contra indication for harvesting iliac crest bone graft. 3. $ystemic disease with atropy of posterior maxilalixe congenital ectodermal dysplasia, cleft palate 4. Reconstruction of maxillary defects following tumor resection, Nasal reconstruction Contraindleations 2) Sameasforconventionalimplants 2) Presencecflocalinfection surgical Evaluations ‘The same presurgcal routine is used as for any other intraoral surgical procedure requiting local or general anaesthesia. Prior to surgery, the patient, ‘+ musthave clinically symptom free sinuses ‘+ musthaveno pathology associated with bone and soft tissues ‘+ musthavecompletedall necessary dentaltreatment. General Radiographic Examination"* The radiographic examination of the resorbed frontal alveolar bone ofthe upper jawisrecommended. 1), Panoramicimage~toidentify anatomic structures and detect pathological changes within the jaw 2) _ Intraoral radiographs —in te frontal area as a supplement to ‘the Panoramic image to exclude pathology. 3) Lateral cephalogram (Profile radiograph) to evaluate jaw Width in the midline to determine saggital relationship between|aws, 4) Tomography, conventional (or) computed tomography to determine available bone volume in the frontal 3s wellin the posterior area. Presurgcal prosthetic considerations There are many factors that contribute tothe long term success of this technique. In order to achieve proper treatment planning anc securelong term success, aneffectiveapproach must beestablshed. The presurgical prosthetic examination and evaluation should include: . facial profileandcontours . parafunctional habits . horizontaland vertcaljaw relations . ‘occlusal plane orient . ‘occlusal relationships . statusofthe opposingdentition Surgical technique™ (ne advantage with this technique is that it can be performed as an outpatient procedure under local anesthesia and conscious sedation, TIADS VOL-2 Issue 2 April-June, 203% [26]Zygomatic Implants - A Review Jude Sudhakar, Seyed Asharaf Ali, Suma Karthikeyan However, for better comfort of the patient, the routine procedure is usually performedunder generalanesthesia, ‘The original procedure defined by Brane markin1998 consisted of the insertion of @ 33-55 mm long implant anchored in the zygomatic bone following an intra-sinusal trajectory. Since this description many author came with different technique. Stella and Wagner described a variant of the technique in which the implant is positioned through the sinus via a narrow slt, folowing the contour of the malar bone and introducing the implant in the zygomatic process. n of the ‘maxillary sinus is avoided and implant is caused to emerge over the alveolar crest. first molar level at more vertical angulation Surgical procedures Patient is premecicated with 2 gms of amoxicilin 1 hour prior to the surgery. The patient is sedated and draped, and the administration of a local anesthetic agent is carried out circum vestibular infiltration and greater palatine blocks are administered In this way, the need for fenestat It Is essential that bilateral inferior alveolar nerve blacks be administered significant retraction of the tongue, lower lip, mandible is necessary during the procedure, since Using 3 smallguage needle, bilateral transcutaneous infiltration of the temporal areas over the zygomatic body and zygomaticnotehis also administered. Incision is standard Le-fort | incision, to obtain coverage of the Implant by the Periosteur and a wide wound area to minimize the risk lof dehiscence during healing, Alternatively the incision can be made on the crest (or) 10mm palatally to rest to reflect the soft tssue and the periosteum upto the level of zygoma. This will expose the lateral surface ofthe maxilla and allow identification ofthe infraorbital foramen for anatomicorientation ofthe area priortoinstallation, ‘Then using extra oral bimanual contol, the Periosteal elevator is {guided over the lateral aspect ofthe zygomatic body in a superior and lateral dissection towards the 2ygomaticnotch careful upward tentingof the issue's performed toallow the placement ofa toe-outretractorin the zygomatic notch. The index finger ofthe hand holding the retractor Is always placed at the lateral canthus to ensure that instrumentation is notdirected towards the eye, ‘A fine fissure bur Is used to create a vertical triangular sinus ‘opening. The Schneideran membrane is completely elevated, since iit 's picked up by the implant during movement through the sinus, the achievement of Osseointegration could be compromised. At this point direc visualization of the path ofthe implant from the Premolar area to the base of the zygoma is possible. A series of long zygoma drill are sed to preparetthe Osteotomy. ‘To begin Osteotomy, the round bur is used followed by 22.9 mm A.29 mm to 35 mm plot dril is then used to allow stabilization of the 3.5 mm twist dri, which completes 2ygoma twist del osteotomy. The alveolar portion of the implant Osteotomyis completed by introduction of 4.0 mm twist drill, which prepares the crestal Bone to its final diameter. Prior to implant placement and at all times during preparation ofthe Osteotomy, the entire surgical paths of the drills are visualize. To facilitate implant placement, Premounted implant carriers allow for easy handling the implant with the hand piece. The implant placed into the Osteotomy with copious irrigation. portion of the implant engage 1 to 2mm of the dense zygomatic bone, ‘once the apical the handpiece stalls remaining portion ofthe implant is seated to ensure proper orientation ofthe angulated implant head, a screw driver's placed onto the implant ‘Then with the manual driver ("the onion”) the cartierscrowhead. Thelongaxisof the screw driver shaft must angles to the edentulous ridge to ensure proper orientation of implant platform, Then 2-4 regula platform implant are placed in the premaxilary region. Zygoma Prosthodontics" ‘Z2ygomaticimplants canbe recommended for both completelyand partial edentulous maxilla. The factors that has to be considered are yearight the type of opposing dentition ~ natural, fied or removable prosthesis and parafunction habits. The type of prosthesis depends upon the ‘number and location of zygomatic implants and additional conventional Implants. The type of prosthesis can be either a screw ~ retained fixed prosthesis orabaretained over denture depending upon the number of implant Implant ~ abutment connection is usually a external hex connection. Two types of abutment are used. They are the straight ‘multiunitabutment and 17 multiunit abutment. Provisional prosthesis is made of Acrylic whereas definitive prothesis may be of acrylic, metal-arylc, metal-ceramic or all ceramic (high strength) prosthesis Prosthetic Procedures, ‘The prosthetic clinical procedure follows the same sequence as 2 conventional regular platform implant cases. Elastomeric impression ‘material and open tray is recommended. Adjustment of the patients existing denture is imperative during the course of the Prosthetic treatment. Acrylic record base with a wax occlusal rim s recommended. preliminary tooth set upistried for est tics, phonetics and occlusion. Final restoration and the retaining prosthetic screws are tightened to 15NCM. The occlusionischecked andif necessary adjusted, Postinsertion visit ‘The patient should be seen one to two weeks after delivery fora checkup, The stability of the restoration is checked and a general evaluation of function, phonetics, estheticsis made. The stability ofthe bridge retaining screws are also tested and f necessary, the screws are restightened Conclusion 2ygomatic implants are very useful in Prosthetic rehabilitation of the severely resorbed maxila, regardless of whether it is totally edentulous (or) partially edentulous individuals. literature surveysshows that good clinical outcome can be achieved. The 2ygoraticimplant technique should be regarded as major surgical JIADS VOL-2 Issue 2 April-June, 2033 [27]Zygomatic Implants A Review procedure and proper training is, of course, needed. However, in ‘comparison with bone grafting procedures, the technique is less Invasive and complicated and has @ lower risk of morbidity because of| the fact that harvesting of bone gratis usually note needed, References 4. Galan Gi 5, Petarocha Diago M, Balaguer Martinez J, Mart Bowen € Rehabiltation of severely resorbed maxilae with zygomatic impants: an update, Wed OralPatl Oral cir Buca. 2007;12(3) 216-2 2. Twahlen RA, Grite KW, Ovenslin CK, Studer SP. Survival rate of 1yg0matie Implantsin trophic or partially resectea maxlie prior tofunctionalloading “retrospective circa report, Int Oral Mailofalrnplants. 2006;21(3}13 2o. 3. Rossi M, Duarte LR, Mendonga R, Fernandes A, Anatomical bases for the inserton of zygomatic implants. Cin Implant Dent Relat Res. 2008, sojg}2715, 4 Ween L, Politi , Schepers S, Pauwels M,Neert |. image-based planning ‘and clinical validation of zygoma and pterygoid implant placement in patients with severebone atopy using customized dillguides. Preliminary results roma prospective clinia!olow-up stay. Int Ora Maxlloae Sur 2003;3210}7-14 Jude Sudhakar, Seyed Asharaf Al, Suma Karthikeyan Defarrocha M, Uribe R, Garcia 8, Mart. 2ygomsticimpants using the sinus slot technique: clinical report of a patient series. Int J Oral Maxlofae Implants. 2005 2015):788-92 prostneticrehabiltation of the severely resorbed manila Periodonto 2000, Malever C, Abarce M, Durdu F, Daelemans P. Clinical outcome of 103 Consecutive zygomatic implants: a 648 months folow-up study. Cin Oral Implants es. 2004;25(1;18-22. ‘Bedrossianf,Stumpel 3rd, Beckely Mt, IntesanoT The2ygomate implant: preliminary data on treatment of severely resoroed maxilae. A cna! Feport.ntJ Oral Maxilofac implants. 2002;17(6) 861-5. Pefarrocha M, Cail, Boronat A, Mart Level of satiation inpatients wth maxillary fullarch fed prostheses: somatic versus conventional implants. Int Oral Manilofaclmplants.2007;22(5). 769-73, Friberg 8. The posterior maxi: clinical considerations and current concepts Using remark System implants, Periodonto 2000. 2008;47:67-78. i Urgell, Revila Guiére V, Gay Escoda CG. Rehabilitation of atrophic ‘maxi: a Feview of 201 zygomatic implants. Med Oral Patol Oral Cr Buca 2008;1315}:363-70. ico €, Ouazzani W, Hatano N. The use of zygomatic implants for TIADS VOL-2 Issue 2 April-June, 203% [28]