Use of zygomatic implants

to deal with resorbed posterior

maxillae
Chantal Malevez, Philippe Daelemans, Philippe Adriaenssens &
Francoise Durdu
For some 40 years, osseointegration has been
clinically applied in both the maxilla and the mand-
ible.
With a high predictability for some systems (19),
increased applications have been developed for com-
promised patients.
Unfortunately, restrictions have appeared in the
use of oral implants. One of them is the lack of
sufcient bone volume, especially in the posterior
maxilla. This insufcient bone volume can be due
to bone resorption as well as to pneumatization of
the sinus or to a combination of both. In any case,
insertion of implants in this region remains extre-
mely unpredictable.
According to some clinical reports, the minimal
bone height for a standard implant in the posterior
region should be at least 10 mm (33) to ensure
acceptable success rate. This is conrmed by a retro-
spective study of 660 implants using the Branemark
system in the posterior maxilla followed for 5
12 years showing a cumulative success rate of
94.4% but with a loss of 10 implants on 49 implants
with a length of 7 mm and a diameter of 3.75 mm
(22).
With the introduction of wide implants 5 and
6 mm in diameter (17, 18) the contact surface
between implant and bone is increased and assumes
a cortical anchorage with an initial stability in bone
type IV even if the bone height is no greater than
6 mm. Implants of wide diameter limit the biome-
chanical complications in the treatment of the pos-
terior maxillas.
Pterygomaxillary implants have also been pro-
posed for posterior anchorage in totally edentulous
patients (3).
Although wide implants could be a solution for
crestal heights up to 6 mm, many patients present
a maxillary height of 0.86 mm (39). For these cases,
several solutions have been proposed to augment the
volume of bone in this region, such as onlay/inlay
bone grafting (33).
Although autologous bone grafting remains the
gold standard, different types of grafting materials
have been proposed for these procedures: deminer-
alized bone from human cadavers, bovine bone and
synthetic materials. Although many have claimed
good clinical results, there is insufcient long-term
data from histologic and histomorphometric investi-
gations to provide real guidelines for these proce-
dures.
Contraindications for sinus lifting (33), such as
Caldwell Luc operations, Underwoods septae, severe
sinus oor convolutions and narrow sinuses, limit
the use of this clinical technique. Perforation of the
Schneidarian membrane could also jeopardize the
nal result.
The gold standard for sinus-lifting procedures
uses autogenous bone (25) but bone harvesting is
most often performed under general anesthesia
and, as in a majority of these cases these procedures
necessitate a two-stage since surgery, since the
implants are not inserted at the moment of the bone
grafting.
Complications like sinusitis or loss of grafts
have also been described with the sinus graft
technique. Final results (15) show a success rate of
up to 75% for the sinus-lifting procedure together
with simultaneous insertion of implants and it
is recommended to avoid this one-stage pro-
cedure.
82
Periodontology 2000, Vol. 33, 2003, 8289 Copyright
#
Blackwell Munksgaard 2003
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713
Vertical ridge augmentation using membrane has
also been proposed. In short series of prospective
and retrospective clinical studies histologically
documented (34, 35), it was proven that a ridge
augmentation of 4.95 mm could be obtained
around implants inserted and covered by barrier
membrane. In a retrospective multicenter study (29)
on 123 implants with a follow-up of up to 5 years, a
ridge augmentation of a maximum of 3 mm was
found.
However, in a histologic and histomorphometric
analysis of 30 patients (24) with provisional implants
inserted with threads only covered by bone chips,
membranes and soft tissue, there was a lower
(43.5%) bone density around the exposed threads
of the implants than around the threads (60.3 %) in
the nonexposed regions.
Surprisingly, in a recent animal study (26), no bone
growth appeared after 12 weeks of healing around
the noninserted part of the implants inserted in the
mandible of beagle dogs.
Distraction osteogenesis is a quite new procedure
for bone augmentation. However, although this new
procedure is in some areas well documented, no
publication concerning bone lengthening in the pos-
terior severely resorbed maxilla could be found.
From his own experience based on animal
research and human experiments, P. I. Branemark
(8) knowing that the introduction of an implant in
the sinus would not necessarily jeopardize sinus
health considered using the zygoma bone as an
anchorage for prosthetic rehabilitation in hemimax-
illectomy patients as well as for other defects. As
these reconstructions (23) were successful and
long-term stability of these implants was established,
in 1997, Branemark developed a specic implant
called the zygomaticus xture to provide xed solu-
tions even when the conditions for implant insertion
were poor in the posterior maxilla. This new techno-
logic development offers alternatives to bone grafting
or sinus-lifting procedures, which involve rather
invasive surgery.
Description of the zygomatic
implant
The zygomatic implants (Fig. 1) are self-tapping
screws in c.p. titanium with a well-dened machined
surface. They are available in eight different lengths
ranging from 30 to 52.5 mm. They present a unique
458 angulated head to compensate for the angulation
between the zygoma and the maxilla. 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. At the max-
illary level the angulated implant platform extremity
offers the possibility to screw any kind of abutment
from the Branemark system
1
. However, for the new-
est generation of abutments a separate slightly
shorter abutment screw must be utilized for the con-
struction of conventional screwed prosthesis.
Fig. 1. The zygomatic implant.
Fig. 2. Three-dimensional CT image and occlusal view
showing connection of the zygoma with the maxilla.
Zygomatic implants for resorbed posterior maxillae
83
Indications for the use of the
zygomatic implant
Resorption of the maxilla appears in two dimen-
sions height and width. Posterior resorption can
lead to a maxillary bone height of 0.8 mm in the
posterior region. In the anterior region, height and
width can also be dramatically reduced (39).
Zygomatic implants are indicated in cases of
severe resorption of the maxilla: free end situations
in the maxilla where insufcient bone height is
Fig. 4. Radiologic (a) two- dimensional and (b) three-
dimensional view of the virtual insertion and placement
of the zygomatic implant from the maxillary level up to the
zygoma.
Fig. 5. Left (a) and right (b) view of the virtual emergence
of the zygomatic implant as previewed on the 3D recon-
struction before surgery.
Fig. 3. Tridimensional CT image showing the supposed
sites of insertion and end of the zygomatic implant.
84
Malevez et al.
available for standard implant insertion and in total
edentulism, when together with reduced bone height
of the posterior region, pneumatization of the
sinuses decreases the anterior area of the maxilla,
allowing the placement of only 2, 3 or 4 implants.
Because of its insertion in the zygoma region, the
zygomatic implant can be used in all of these situa-
tions.
In cases of very severe resorption of the anterior
maxilla in totally edentulous patients, when bone
grafting cannot be avoided, the use of zygomatic
implants reduces the dimensions of the bone graft
and the surgery is made easier.
The zygoma as an anchorage
The zygoma (Fig. 2) bone can be compared to a
pyramid, offering an interesting anatomy for the
insertion of implants (16, 38). Histologic analysis
(12) of the zygoma shows regular trabeculae and
compact bone with an osseous density of up to
98%. Due to this high bone density, the zygoma bone
has also been used in the treatment of maxillofacial
fractures, for the insertion of miniplates (11) and
during orthodontic treatment, offering a xed ancho-
rage to allow dental arch retractions (21).
In an animal study (30) the zygoma bone provided
an anchorage place for implants to obtain protrac-
tion of the maxilla by means of distraction. In max-
illofacial prosthesis, the zygoma bone is also utilized
as an anchorage for the placement of extraoral
implants sustaining a facial prosthesis (22, 27, 36).
After maxillectomy, zygomatic implants were con-
nected with standard ones to anchor a screwed pros-
thesis (14, 23).
In a recent study on cadavers (31) it could be
established that the mean length of the zygoma
was 14.1 mm, allowing the insertion of zygomatic
implants as described above.
Fig. 7. Reection of the Schneidarian membrane with a
gauze mesh (a) and drilling with the rst bur (b).
Fig. 6. Reection of the soft tissue (a) with identication
of the zygoma and suborbital nerve and (b) achievement of
the sinusal window.
85
Zygomatic implants for resorbed posterior maxillae
For all these reasons, the zygoma should be con-
sidered as an extended anchorage in a region situ-
ated at an important distance from the occlusal level.
This can make a crucial difference to patients with
compromised maxillary anatomy.
Presurgical evaluation of feasibility
Inserting implants (Fig. 3) from the maxillary level
through the sinus and up to the zygoma is a challen-
ging venture. Three levels have to be investigated :
the maxillary level, the sinus and the zygoma. Clin-
ical examination is not sufcient for this evaluation
and radiologic assessment has to be considered. The
OPG can give distorted information and therefore,
the examination of choice is the spiral or helico d
computed tomography (CT) scan, which makes
two- and three-dimensional imaging possible
(Fig. 4a,b) (40).
Oralim
1
(Medicim, Leuven) provides appropriate
software. The implants can be placed via virtual
images and the surgeon only has to convert
these images to the reality of the clinical situation
(Fig. 5).
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 stereo-
lithographic models to facilitate the orientation of
the zygomatic implants during the surgery with
minimal errors in angulation and position (31).
Surgical procedure
The zygomatic implant surgical procedure should
involve atraumatic surgery, avoiding overheating in
the zygoma bone as well as in the maxilla under
sterile circumstances with what is in reality still a
two-stage approach.
Although the operation can be carried out under
local anesthesia, for the patients comfort, it has been
done up to now under total anesthesia or neuroleptic
deconnection (13). After a palatal 458 incision of the
soft tissue along the entire maxillary crest, the soft
tissue is completely reected from maxillary crest to
zygomatic buttress and the suborbital nerve identi-
ed. A window is then made by drilling at the upper
limit between the zygoma and the sinus (Fig. 6b) to
determine the orientation of the zygoma and to
reect the Schneidarian membrane. This window
will also be helpful during the surgical procedure
for cooling the drills to avoid overheating (Fig. 7a,b).
Fig. 8. Insertion with a low speed motor of the zygomatic
implant. The head of the implant is seen at the top
of the zygoma.
86
Malevez et al.
Different drills are used with increasing dia-
meters, ending with the insertion at low speed of
the self-tapping zygomatic implant (Fig. 8). The
length of this is carefully chosen by means of a
special gauge.
After insertion of the implant, a cover screw is
placed on the top of the zygomatic implant and the
soft tissue closed. There are no evidence-based argu-
ments that advocate the use of a membrane to cover
the hole made in the sinus.
The other implants are placed during the same
surgical procedure. At the second stage surgery 6
months later, the abutments are screwed on the
implants and an immediate (same day) provisional
prosthesis is provided for the patient (Fig. 9).
Prosthetic procedure
The prosthesis is made of gold and acrylic or gold
and porcelain routinely like a standard screwed
reconstruction on standard implants (Figs 10 and
11). Although screwed bridges allow a better adjust-
ment of the occlusion, overdentures retained by rigid
bars are also considered sometimes because of the
important cantilever due to the palatal emergence of
the zygomatic implants and to the distance between
the two maxillas or simply the resorption of the
maxilla.
Considering the biomechanical aspects of the
prosthetic reconstructions on zygomatic implants,
it is well known that when masticatory load is
applied to a rigid semicircular arch connecting
four anterior implants and two zygomatic ones,
the masticatory load in the posterior region is trans-
ferred to the bony support situated in the zygoma
(Fig. 12).
Fig. 11. Occlusal view of a bridge
made of gold and porcelain on top
of two zygomatic implants and four
standard implants.
Fig. 10. Occlusal view of a screwed prosthesis placed on
four standard implants and two zygomatic ones.
Fig. 9. Placement of an acrylic screwed provisional pros-
thesis.
87
Zygomatic implants for resorbed posterior maxillae
Results
Although this new development of a specially
designed implant has been elaborated for more than
10 years in Sweden and has, since 1997, been the
subject of a worldwide multicenter prospective
study, so far, few data are available from the litera-
ture (46, 13, 37). Case reports as well as technical
reports show satisfactory results and a high success
rate.
In our own experience of 55 edentulous patients
involving 103 zygomatic implants, the survival rate is
100% with an observation period up to 48 months
(20).
Conclusions
The zygomatic implant the zygomaticus xture -
appears to be a promising development in implant
technology. It offers an interesting alternative solu-
tion to heavy bone grafting in the severely resorbed
posterior maxilla. It has been in use for more than
10 years and gives a predictable outcome in the reha-
bilitation of totally as well as partially edentulous
patients. More published reports are needed and
more follow-up has to be provided to assess its nal
goal and predictability.
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