Implants

Enhanced CPD DO C

Pynadath George

A Novel Approach for the

Placement of Zygomatic Implants:
The Zygomatic Bone Zone Index

Abstract: This article explores the considerations and factors that implant dentists may use to decide whether the placement of zygomatic
implants is necessary, and if so, the potential considerations in planning for them within the zygomatic bone. A novel treatment planning
tool has been presented, the Zygomatic Bone Zone index, to improve the surgical placement of zygomatic implants, to help reduce
complications and to allow for further placement within the zygomatic bone in the future.
CPD/Clinical Relevance: It is important for clinicians to be aware of treatment modalities that might be of benefit to some patients.
Dent Update 2023; 50: 927–930

The minimum amount of bone required for
a dental implant is a relevant topic, not just
for implant dentists, but also for general
dentists, oral surgeons, prosthodontists,
periodontists and any other health
professional who provides treatment
planning advice to patients about implants.
The minimum height of vertical bone
required for the placement of dental
implants in the posterior maxilla was
originally defined by the Sinus Consensus
Conference in 1996.1 The consensus stated
that a residual bone height inferior to the
sinus floor of 3 mm or less is best treated
with a lateral sinus graft approach, with
a delay in implant placement. In 2008,
2011 and 2016, the International Team for
Pynadath George, BDS, MFDS, MSc Rest Dent, MSc Imp Dent, DClinDent Oral Surg,
Fellow CGDent, General Dental Surgeon with practice limited to advanced/complex
prosthodontic and surgical implantology.
email: georgedentsurgeon@hotmail.com
Implantology (ITI) clarified this position,
stating that a residual height of bone
inferior to the sinus of 4–6 mm justifies
the provision of a direct lateral sinus graft,
with simultaneous implant placement.2 In
2013, the ITI considered that a minimum
of 1 mm of bone circumferentially around
the planned implant was required before
considering bone grafts.3 This would
equate to a ridge width of 5 mm for an
implant that is 3 mm wide.
Therefore, a posterior maxilla with
less than 3 mm residual bone height
below the sinus and/or 4 mm or less
bucco-palatal width of bone prevents the
placement of conventional implants and
could be considered ‘extremely’ atrophic.
An edentulous ridge such as this would
require bone grafting to allow implant
placement, or alternatively the use of an
implant anchored in the bone outside the
maxilla, otherwise known as ‘extra-maxillary
implants’. Zygomatic implants are a type
of extra-maxillary implant that is used to
support teeth when there is an extremely
atrophic ridge.
Zygomatic implants
Brånemark first wrote about zygomatic
implants in 1998 after using them for 10
years.4 This implant is a longer titanium rod
that is apically installed into the zygomatic
bone, but emanates from the maxillary
crest (Figure 1). Primary stability of the
zygomatic implant is often excellent and
can allow for immediate placement of a
fixed prosthesis.5,6
Since the late 1990s zygomatic implants
have been used in cases with severe bony
atrophy or tissue loss. Soft and hard tissue
atrophy from tooth loss or previous implant

December 2023 DentalUpdate 927

pg927-930 George.indd 927 07/12/2023 09:13

 Implants
Figure 1. Two zygomatic implants in situ.
Figure 2. Post-operative cone beam CT scan
demonstrating zygomatic implants to the
posterior maxilla and conventional implants in
the anterior maxilla. If the anterior conventional
implants were to fail in the future, there
would be inadequate space to place a further
zygomatic implant from the anterior maxilla
because the current zygomatic implant would
interfere with the trajectory of any potential new
zygomatic implant.
failure can lead to an unsuccessful complete
denture owing to a lack of retention
and support being provided from the
surrounding tissues. Zygomatic implants are
often installed to support and retain a fixed
or removable prosthesis. Although this is a
common reason for zygomatic implants to
be installed, it is not the only one. Genetic
syndromes such as ectodermal dysplasia,
where teeth are naturally missing, leads
to a poorly developed maxilla with similar
issues for complete denture construction
and often, zygomatic implants are used
in these cases. Other reasons for maxillary
bone to be missing or poorly developed can
be trauma, abnormal development, such as
cleft palate, or from sinister developments,
such malignant tumours that require bony
resections of the maxilla and other facial
bones.7 Once zygomatic implants are placed
in these types of cases, they will commonly
928 DentalUpdate
pg927-930 George.indd 928
Figure 3. Diagram of sections in the right
zygomatic bone described by Rigolizzo et al.16 The
sections outlined in red (5–10) were all feasible
for engaging and placing zygomatic implants.
support various types of conventional
implant prosthetics, such as fixed bridges
or removable overdentures, but will
occasionally aid facial and oral obturators
and prosthetics.8
Zygomatic implant surgery is not
without its complications. The surgery
is invasive and can cause trauma to
surrounding vital structures. Oral antral
fistulas and sinusitis are not uncommon,
and can develop owing to the zygomatic
implant’s trajectory through the maxillary
sinus cavity. Some of the more severe
complications described within the
literature relate to significant trauma of
the orbit9 or damage to the neurovascular
vessels, leading to bleeding and nerve
damage.10 Complications are often due to a
lack of good visual and surgical access and
misjudgement of the drilling trajectory.11
The current literature and
the problem
Although zygomatic implants have
been used clinically since the 1990s,
and high survival rates of over 96% have
been reported,12 there are limited data
for understanding the anatomy of the
zygomatic bone and the ideal apical
placement of the implant. Currently, there is
little guidance on where to place the apex
of the implant in the zygomatic bone in
relation to the area of prosthetic support
required in the maxilla. Aparicio et al’s
zygoma anatomy-guided approach (ZAGA)
relates the apical position to ‘complement
the implant path’ while maintaining 3 mm
Figure 4. Diagrammatic view of the zygomatic
bone separated into four simplified zones (A–D)
for the placement of implants.
of bone over the apical threads.5 They also
found that the choice of apical positioning
is dependent on the curvature of the
zygomatic process and the number of
zygomatic implants to be placed on the day
of surgery.
Background
3D radiography is required to consider
and assess whether it is possible to install
implants in areas such as the zygomatic
bone region. It is essential to visualize the
anatomy of the zygoma, and to assess
whether there is adequate space for one or
two implants to be installed and whether
any vital structures lie in the path of the
implant trajectory. The 3D radiological view
of the zygoma would then determines
whether zygomatic implants are an option,
or if grafting may be more appropriate
owing to potential risks, or lack of
zygomatic bone.
Current literature shows differences in
the original technique taught by Brånemark
et al,13 and there have been reports of cases
with one, two and even three implants
installed into each zygoma.14
Regardless of what surgical technique
may be used, proper planning of
apical positioning is essential to avoid
any significant complication, such as
inadvertent trauma to the orbit, or
entrance into the infratemporal fossa,
caused by a lack of space and improper
drilling technique.15
Chrcanovic and Abreu raised an
important point in 2013.11 If one zygomatic
implant is to be installed in the zygomatic
December 2023
07/12/2023 09:13

bone, it is be prudent to consider future
planning and ensure that there is sufficient
space in the remaining zygomatic bone to
accommodate and install further zygomatic
implants. Strategic planning of the spatial
requirements for current and future
zygomatic implants is also required in case
of potential failure of the newly installed
zygomatic implant, or even failure of the
conventional implants that may have been
used in conjunction with the zygomatic
implants (Figure 2).
The planning of the apical zygomatic
points should follow the work by Rigolizzo
et al16 (Figure 3), Takamaru et al17 and Hung
et al,18 who all showed multiple appropriate
areas to engage the implants into the
zygomatic bone. Their research reveals that
in almost all cases, there is sufficient bone
to place implants into the central body of
the zygoma. Based on their findings,16–18
the body of the zygomatic bone to be used
for implant placement can be simplified
into four zygomatic bone zones, A, B, C and
D, for ease of surgical planning (Figure 4).
Quilez et al19 confirmed that for every
patient who presented to their team, there
was the possibility to install at least two
zygomatic implants into these four specific
zygomatic bone zones, which provided
each patient with a total of four zygomatic
implants (quad zygo).
The Zygomatic Bone
Zone index
This article introduces a treatment tool
to simplify the planning of the apical
positioning of the zygomatic implant in
relation to the required maxillary support:
the Zygomatic Bone Zone index.
With this simple index, support to
the posterior maxilla with the apex of the
implant engaging the inferior zygomatic
bone in sections C and D can be envisaged
and planned. Additionally, if there is a need
for a zygomatic implant to support the
anterior maxilla, the apex can be planned
to engage the superior aspect of the
zygomatic bone (zones A and B; Figures
5–7). Keeping to this index will help to
avoid situations where the superior part
of the zygomatic bone has been used for
a posterior zygomatic implant (Figure 2),
which would necessitate installation of
any further zygomatic implant even closer
to the orbit, or at worst, would prevent a
further zygomatic implant. Conversely, an
anterior zygomatic implant installed too
low on the zygomatic bone also prevents
December 2023
pg927-930 George.indd 929
Figure 5. Diagram to illustrate an example of planning using the Zygomatic Bone Zone index in a
quad zygomatic implant case.
Figure 6. Diagram to illustrate an example of
planning using the Zygomatic Bone Zone index
using the posterior zones. Zygomatic bone
(zone A) being used to support the anterior
maxilla. (Zone B could also have been chosen.)
Zone D is to be used to support the posterior
maxilla. (Zone C could also have been chosen.)
Figure 7. Diagram to illustrate an example
of planning using the Zygomatic Bone Zone
index using the anterior zones. Zygomatic bone
(zone B) has been used to support the anterior
maxilla. (Zone A could also have been chosen.)
Zone C is to be used to support the posterior
maxilla. (Zone D could also have been chosen).
further installation of zygomatic implants
in the posterior maxilla because the
existing anterior zygomatic implant
will be within the trajectory of any
potentially new zygomatic implant to be
installed posteriorly.
The apical position should also
ideally be kept within these four zones,
as posterior to this zygomatic area, the
bone is thinner and there is an increased
chance of damage to the infratemporal
region. To avoid trauma to the orbital rim,
the apex should be planned to be 3 mm
away from the orbital rim.
The Zygomatic Bone Zone index
can be used by both experienced
Implants
and inexperienced zygomatic implant
surgeons to future-plan implant positions
according to the available bone, prosthetic
position and most importantly, in case of
future implant failure, to ensure that there
is adequate zygomatic bone for further
implants. It can also help determine
which patients may be more challenging
to provide a ‘quad zygomatic’ implant
treatment in relation to their nearby
vital structures.20
Discussion
Although 3D imagery is a standard
requirement for the assessment of
zygomatic implants, the specific apical
positioning of these implants and future
planning for further implants are not.
Occasionally zygomatic implants are
placed directly through the full body of
the zygomatic bone preventing further
placement if another zygomatic implant
is required later. Standardization and
following a structured positioning plan
will help to avoid this conundrum, and
also prevent entrance into the orbit
and infratemporal fossa and avoid
other structures.21,22
Based on the existing available
literature, the present author proposes a
new simple assessment method for the
zygomatic bone to anchor implants for the
extremely atrophic maxilla. The aim is to
help surgeons form a safe and structured
approach to treatment planning. This
article sets forward that the ‘extremely’
resorbed maxilla may be defined as:
 4 mm or less bucco-palatal bone
width; and/or
 3 mm or less bone height below
the sinus
In scenarios with this degree of
atrophy, zygomatic implants may be an
appropriate treatment option rather than
bone grafting.
DentalUpdate 929
07/12/2023 09:13
 Implants
The zygomatic implant supporting
the posterior maxilla could be installed in
the inferior aspect of the zygoma in zones
C and D, while an anterior zygomatic
implant that is planned to support
anterior teeth could be installed in the
superior aspect of the zygomatic bone
in zones A and B. This planning avoids
spatial issues and encroachment into
the vital structures, but also prevents a
single zygomatic implant with a trajectory
through the full zygomatic body that
would prevent future zygomatic implants
should they be required.
The new simplified structured
planning, which separates the zygoma
into four distinct parts, will assist surgeons
in planning the appropriate apical position
for an implant, for the appropriate atrophic
edentulous maxillary zone that requires
support for a prosthesis. It will also ensure
that patients who have minimal zygomatic
bone regions will be highlighted during
the assessment.23
This tool, the Zygomatic Bone Zone
index, will help to standardize and
structure cases for the apical positioning
of this complex implant therapy. The
tool is designed to improve the safe
provision of at least one or two implants
in each zygomatic bone by accounting
for the current and future spatial bony
requirements. It will also provide a basis
for teaching the zygomatic implant
modality. To the author’s knowledge, this
is the first classification to separate the
zygomatic bone into zones according to
the support required from the anterior or
posterior maxilla.
Compliance with Ethical Standards
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Jensen OT, Shulman LB, Block MS, Iacono
VJ. Report of the Sinus Consensus
Conference of 1996. Int J Oral Maxillofac
Implants 1998; 13 Suppl: 11–45.
2. Katsuyama H, Jensen SS. Sinus Floor
Elevation Procedures. Berlin, Germany:
Quintessence, 2019.
3. Chen ST, Buser D. Esthetic outcomes
following immediate and early implant
placement in the anterior maxilla – a
systematic review. Int J Oral Maxillofac
Implants 2014; 29 Suppl: 186–215. https://
930 DentalUpdate
pg927-930 George.indd 930
doi.org/10.11607/jomi.2014suppl.g3.3
4. Brånemark PI. The Zygomaticus Fixture:
Clinical Procedures. Nobel Biocare AB,
1998.
5. Aparicio C, Ouazzani W, Garcia R et al. A
prospective clinical study on titanium
implants in the zygomatic arch for
prosthetic rehabilitation of the atrophic
edentulous maxilla with a follow-up of
6 months to 5 years. Clin Implant Dent
Relat Res 2006; 8: 114–122. https://doi.
org/10.1111/j.1708-8208.2006.00009.x
6. Tuminelli FJ, Walter LR, Neugarten J,
Bedrossian E. Immediate loading of
zygomatic implants: a systematic review
of implant survival, prosthesis survival
and potential complications. Eur J Oral
Implantol 2017; 10 Suppl 1: 79–87.
7. Polido WD, Machado-Fernandez A, Lin
WS, Aghaloo T. Indications for zygomatic
implants: a systematic review. Int J Implant
Dent 2023; 9: 17. https://doi.org/10.1186/
s40729-023-00480-4
8. Alfenas E, Silva I, Oliveira D et al. Intraoral
and facial rehabilitation retained with
zygomatic implants and magnets after
complete resection of the maxilla, lip and
nose: a clinical report. J Clin Exp Dent 2023;
15: e695–e699. https://doi.org/10.4317/
jced.60659
9. Topilow N, Chen Y, Capo H, Tse DT.
Extraocular muscle injury in zygomatic
implant placement: a case report, review
of the literature, and simple maneuver
for avoidance. J Oral Maxillofac Surg 2020;
78: 1328–1333. https://doi.org/10.1016/j.
joms.2020.04.027
10. Bedrossian E, Bedrossian EA. Prevention
and the management of complications
using the zygoma implant: a review and
clinical experiences. Int J Oral Maxillofac
Implants 2018; 33: e135–e145. https://doi.
org/10.11607/jomi.6539
11. Chrcanovic BR, Abreu MH. Survival and
complications of zygomatic implants: a
systematic review. Oral Maxillofac Surg
2013; 17: 81–93. https://doi.org/10.1007/
s10006-012-0331-z
12. Brennand Roper M, Vissink A, Dudding T
et al. Long-term treatment outcomes with
zygomatic implants: a systematic review
and meta-analysis. Int J Implant Dent 2023;
9: 21. https://doi.org/10.1186/s40729-023-
00479-x
13. Brånemark PI, Gröndahl K, Ohrnell
LO et al. Zygoma fixture in the
management of advanced atrophy of
the maxilla: technique and long-term
results. Scand J Plast Reconstr Surg
Hand Surg 2004; 38: 70–85. https://doi.
org/10.1080/02844310310023918
14. Bothur S, Jonsson G, Sandahl L. Modified
technique using multiple zygomatic
implants in reconstruction of the atrophic
maxilla: a technical note. Int J Oral
Maxillofac Implants 2003; 18: 902–904.
15. Wang F, Monje A, Lin GH et al. Reliability
of four zygomatic implant-supported
prostheses for the rehabilitation of the
atrophic maxilla: a systematic review. Int
J Oral Maxillofac Implants 2015; 30: 293–
298. https://doi.org/10.11607/jomi.3691
16. Rigolizzo MB, Camilli JA, Francischone CE
et al. Zygomatic bone: anatomic bases
for osseointegrated implant anchorage.
Int J Oral Maxillofac Implants 2005; 20:
441–447.
17. Takamaru N, Nagai H, Ohe G et al.
Measurement of the zygomatic bone and
pilot hole technique for safer insertion of
zygomaticus implants. Int J Oral Maxillofac
Surg 2016; 45: 104–109. https://doi.
org/10.1016/j.ijom.2015.07.015
18. Hung KF, Ai QY, Fan SC et al. Measurement
of the zygomatic region for the optimal
placement of quad zygomatic implants.
Clin Implant Dent Relat Res 2017; 19: 841–
848. https://doi.org/10.1111/cid.12524
19. Bertos Quílez J, Guijarro-Martínez R,
Aboul-Hosn Centenero S, Hernández-
Alfaro F. Virtual quad zygoma implant
placement using cone beam computed
tomography: sufficiency of malar bone
volume, intraosseous implant length, and
relationship to the sinus according to the
degree of alveolar bone atrophy. Int J Oral
Maxillofac Surg 2018; 47: 252–261. https://
doi.org/10.1016/j.ijom.2017.07.004
20. Wang H, Hung K, Zhao K et al. Anatomical
analysis of zygomatic bone in ectodermal
dysplasia patients with oligodontia. Clin
Implant Dent Relat Res 2019; 21: 310–316.
https://doi.org/10.1111/cid.12731
21. Duarte LR, Filho HN, Francischone CE et
al. The establishment of a protocol for the
total rehabilitation of atrophic maxillae
employing four zygomatic fixtures in an
immediate loading system – a 30-month
clinical and radiographic follow-up.
Clin Implant Dent Relat Res 2007; 9:
186–196. https://doi.org/10.1111/j.1708-
8208.2007.00046.x
22. Davo R, Pons O, Rojas J, Carpio E.
Immediate function of four zygomatic
implants: a 1-year report of a prospective
study. Eur J Oral Implantol 2010; 3:
323–334.
23. Wang H, Hung K, Zhao K et al. Anatomical
analysis of zygomatic bone in ectodermal
dysplasia patients with oligodontia. Clin
Implant Dent Relat Res 2019; 21: 310–316.
https://doi.org/10.1111/cid.12731
December 2023
07/12/2023 09:13