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A Retrospective Cohort Study

of the Survival Rate of 88
Zygomatic Implants Placed
Over an 18-year Period
Harpal Chana et.al
Int J oral maxillofac implants 2019;34:461–470

Bharath Simha Reddy Dalli

3rd Yr Postgraduate
• The placement of zygomatic implants is challenging due to the difficulty of navigating the complex

anatomy during site preparation and the placement of relatively long (30 to 52.5 mm) implants.

• postoperative complications are infrequent, Thus, zygomatic implants can be an attractive option for

patients who do not want to rely on bone augmentation procedures, which can fail and cause

considerable morbidity.
• Zygomatic implants can be placed as a single implant (unilateral), a single implant in each maxillary

process (bilateral), or two implants per maxillary process (quad). Quad zygomatic implants can be

used when both maxillae are severely resorbed.

• Bilateral zygomatic implants are not sufficient to absorb the full occlusal load of fixed or removable

dentures; therefore, it is essential to pair them with shorter implants placed anterior to the zygomatic

implant or to use a quad zygomatic configuration.

AIM

• This retrospective, observational study is to evaluate the survival rates of anodized and machined

surface zygomatic implants placed by three practitioners at a primary care setting and a secondary

care setting over a period of 18 years.

MATERIALS AND METHODS

• This study was conducted in accordance with STROBE guidelines.

• Surgeries were performed between June 1999 and November 2017 at Kingston Hospital NATIONAL

HEALTH SERVICE Foundation Trust.

Inclusion criteria

• Patients were included if they had zygomatic implants placed to support prosthesis following oral

cancer or maxillofacial trauma or to replace failing dentition or unstable removable prostheses.

Patient preparation

• After clinical examination, the maxilla and zygoma region of each patient was evaluated

radiographically with orthopantomograms, occipitomental radiographs, computed tomography (CT),

or cone beam computed tomography.

• The orientation and location of implants were planned using an anatomy-guided approach, and all

surgical planning in the primary care setting used digital treatment-planning software (Nobel

Clinician, Nobel Biocare). None of the implants were placed with CT-guided surgical stents.
• The placement of zygomatic implants in a secondary-care setting was performed under general

anesthesia with local infiltration of 2% lidocaine with 1:80,000 adrenaline (Septodont) to achieve

adequate mucosal vasoconstriction. In the primary-care setting.

• The procedure was performed either under intravenous sedation with midazolam (Hamelyn) and

fentanyl (Pfizer) administered by an anesthetist or with local anesthesia alone in non anxious patients

(determined using an in-house anxiety scale)

• Local anesthesia was achieved using 4% articaine with 1:100,000 adrenaline (Septodont) to

achieve adequate mucosal vasoconstriction. Dexamethasone (16 mg) and intravenous amoxicillin

(1.2 g; Alliance Healthcare) was administered perioperatively to prevent postoperative swelling

and potential infections, respectively, in all patients regardless of setting.

Surgical Protocol

• In patients receiving bilateral implants, a full-thickness flap was raised from the right to the left

maxillary tuberosity, and approximately 10-mm relieving incisions were made anterior to the

maxillary tuberosity into buccal tissues, keeping the incision as far away from the Stenson’s duct as

possible.

• For patients receiving a unilateral zygomatic implant, a full-thickness flap from the appropriate

maxillary tuberosity to the central incisors was raised to give adequate access and view during

surgery. A palatal flap was also raised and held in place with a suture.
• During osteotomy preparation:

• saline-cooled burs were used to avoid trauma

• Initial osteotomy preparation was performed with a round bur

• 2.9-mm and 3.5-mm twist- drill sequence with a steady in-and-out motion

• Copious saline irrigation

• Angled depth indicator

• 2,000 rpm was used during osteotomy preparation

• Implant placement was from the area of the second premolar/first molar, traversing the maxillary sinus

to reach the zygomatic bone.

• ZAGA concept from 2011.

• Implants were placed completely through the sinus (ZAGA 0),

• partially through the sinus (ZAGA 1, 2, and 3)

• completely extra-maxillary of the zygomatic arch (ZAGA 4).

• ZAGA 4 placement was used in cases of complete or partial maxillectomy.

• In cases where two implants were placed (placed near to orbit)

• Canine,lateral region

• 2nd premolar, first premolar region

• In cases of closing a potential communication in an oro-antral site, bone was harvested from the iliac

crest for grafting.

• Xenograft and collagen membrane were used to cover exposed threads

• 4-0 Vicryl Rapide absorbable sutures (Ethicon).

 Postoperative Care

• secondary- care setting was performed as a two-stage procedure in which the implants were left to

osseo integrate for up to 6 months before prosthetic loading.

• Implants placed in a primary-care setting were all immediately loaded under local anesthesia.

• Patients were instructed to consume only liquids and soft foods for 2 weeks and to rinse with

chlorhexidine mouthwash twice daily and with warm saltwater 4 to 5 times daily. Broad-spectrum

antibiotics were prescribed postoperatively for all patients for 7 days.

• immediate postoperative orthopantomogram and done for every 2yrs
Outcome Measures
• The primary outcome measure of this study was the survival rates of zygomatic implants
• Survival times were calculated as the interval between the date of surgery and the date of
failure.
RESULTS
Discussion

• Zygomatic implants placed using a variety of different approaches are successful in supporting fixed

or removable prostheses where there has been severe bone loss from extensive alveolar

resorption, maxillo- facial trauma, or cancer, and in cases of developmental defects.

• In cases where the emergence of the implant head was in a less-than-ideal position, the angulation

was corrected using an angulated 17-degree multiunit abutment. The use of angulated abutments

with tilted implants has been shown to yield good clinical outcomes long term.
Conclusion

• In this study, zygomatic implants placed over a period of up to 18 years had a high percentage

survival rate in managing severely atrophic or resected maxillae. While techniques for placing

zygomatic implants can be challenging, even for experienced surgeons, the high survival rates

reported here show that the use of these implants can yield predictable results when rehabilitating

patients with a broad range of indications.

Supporting articles…
 Zygomatic implants placed in atrophic maxilla: an
overview of current systematic reviews and meta-analysis
Ramezanzade et al. Maxillofacial Plastic and Reconstructive Surgery (2021) 43:1

• ZIs appear to be a consolidated therapeutic option for significantly atrophic maxilla offering a promising

alternative to heavy bone grafting techniques with lower costs, fewer complications, shorter time for

rehabilitation, less prosthodontic work needed, and significantly higher survival rates.

• Complications were rare and usually easy to manage. However, the treatment should be directed by

appropriately trained clinicians with noticeable surgical experience.

TEN-YEAR follow-up of treatment with zygomatic implants
and replacement of hybrid dental prosthesis by ceramic
teeth: A case report.
Paulo H.T et.al, Annals of Medicine and Surgery 50 (2020) 1–5

• Therapy with zygomatic implants must be part of the treatment options presented to patients. Surgery

may occur in the private clinic with local anesthesia and oral sedation when performed by experienced

professionals. These treatments have shown high success and patient satisfaction rates, with

improvement in quality of life. All patients must participate in a maintenance and oral hygiene program.

• It was concluded that all patients with zygomatic implants must participate in a preventive maintenance

program to assure the predictability of this type of treatment.

Zygomatic Implants for the Rehabilitation of Atrophic Maxillae:
A Retrospective Study on Survival Rate and Biologic
Complications of 206 Implants with a Minimum Follow-up of 1
Year. Perla Della Nave, Int J Oral Maxillofac Implants 2020;35:1177–1186.

• In this study, the rehabilitation of atrophic maxillae through zygomatic implants was shown to be a

predictable treatment, which allows a graftless approach and makes it possible to carry out immediate

loading protocols, with enormous psychologic advantages for patients.

• Survival rates are high, and complication incidence is low. Thus, at present, zygomatic implants may

be considered a reliable treatment option in the case of severe atrophic maxillae.

A Retrospective Study of a Multi-Center Case Series of
452 Zygomatic Implants Placed Over Years for Treatment
of Severe Maxillary Atrophy.
Paul S.et.al, ZYGOMATIC IMPLANTS, COMPENDIUM April 2020 Volume 41, Number 4

• The use of zygomatic implants to aid in the support of immediate tooth replacement procedures in the

atrophic posterior maxilla has been shown to be a reliable option for patients choosing not to undergo

advanced bone-replacing protocols. Because the zygomatic arch provides a cortical bone volume and

quality similar to that of the anterior mandible.

• This study supports reports of zygomatic implants having a high success rate while allowing an array of

ancillary procedures to be avoided.

Immediate loading of zygomatic implants: A systematic
review of implant survival, prosthesis survival and potential
complications. Frank J Tuminelli et.al, Eur J Oral Implantol 2017;10(Suppl1):79–87

• Stated that immediately loading zygomatic implants for the restoration of the severely atrophic

maxilla presents a viable alternative for treatment of the atrophic maxilla.

• The complication rates are relatively few, rarely catastrophic, and easily managed. Further

randomised clinical trials should be conducted.

 Rehabilitation of Atrophic Posterior Maxilla With
Zygomatic Implants: Review. Eugenia Candel-Martı et.al, Journal of Oral
Implantology,2012.

• Zygomatic implants are a suitable alternative for the treatment of severe posterior maxillary atrophy.

• 3 techniques were used to place zygomatic implants: intrasinus implants with the classic sinus window

technique, the sinus slot technique, and extrasinus zygomatic implants.

• The most common restoration used was fixed prosthesis, with either delayed loading after 3–6 months (89%–

100% success) or immediate loading (96.37%–100% success).

• The weighted average success rate was 97.05%, and the most frequent complication was maxillary

sinusitis. The general level of patient satisfaction was high.

• Zygomatic implants have a high success rate and constitute a suitable alternative to treat severe

posterior maxillary atrophy.

Thank you…
 References:
• A Retrospective Cohort Study of the Survival Rate of 88 Zygomatic Implants Placed Over an 18-year Period, Harpal Chana et.alInt J oral maxillofac

implants 2019;34:461–470.

• Zygomatic implants placed in atrophic maxilla: an overview of current systematic reviews and meta-analysis, Ramezanzade et al. Maxillofacial Plastic

and Reconstructive Surgery (2021) 43:1

• TEN-YEAR follow-up of treatment with zygomatic implants and replacement of hybrid dental prosthesis by ceramic teeth: A case report,Paulo H.T

et.al, Annals of Medicine and Surgery 50 (2020) 1–5

• Zygomatic Implants for the Rehabilitation of Atrophic Maxillae: A Retrospective Study on Survival Rate and Biologic Complications of 206 Implants

with a Minimum Follow-up of 1 Year. Perla Della Nave, Int J Oral Maxillofac Implants 2020;35:1177–1186.

• A Retrospective Study of a Multi-Center Case Series of 452 Zygomatic Implants Placed Over Years for Treatment of Severe Maxillary Atrophy,Paul

S.et.al, ZYGOMATIC IMPLANTS, COMPENDIUM April 2020 Volume 41, Number 4

• Immediate loading of zygomatic implants: A systematic review of implant survival, prosthesis survival and potential complications. Frank J Tuminelli

et.al, Eur J Oral Implantol 2017;10(Suppl1):79–87

• Rehabilitation of Atrophic Posterior Maxilla With Zygomatic Implants: Review. Eugenia Candel-Martı et.al, Journal of Oral Implantology,2012.