Zygoma

Graftless treatment solution for the highly resorbed maxilla

Zygomatic implants have been an evidence-based surgical and prosthetic solution for nearly two decades (using the two-stage approach). When bone volume deficiencies are present, zygomatic implants should be considered as an alternative to conventional bone grafting. High long term success rates using the classical 2-stage protocol and immediate loading have been published. Since 2007 zygomatic implants have been proven to work in the immediate function protocol. For the totally atrophied maxilla (missing anterior bone), the concept has been expanded to anchoring 2 additional implants in each zygomatic bone: by means of 4 well-distributed zygomatic implants a fixed bridge is immediately loaded (Quad zygoma approach).

Expert insights

Starting at 6.05. Reviews the surgical options including short and zygomatic implant type options, tilted positioning of the implants with e.g. the All-on-4 technique, and the combinations thereof, and explains the restorative options with removable, fixed removable and fixed solutions including their prosthetic components. The possibilities are summarized and highlighted in a patient treatment case with a quad zygoma reconstruction in the maxilla and an All-on-4 solution in the mandible.
Starting at 3.58. Dr Malo highlights that bone density is more important than bone volume and presents different treatment solutions in the edentulous maxilla ranging from 6 straight implants to quad Zygoma solution. Interaction and combination of the All-on-4 concept and zygomatic implants.
Dr Bedrossian presents a review of recent literature for implant based fixed restorations in the maxilla using different surgical treatment options, comparing the graftless approach with straight, tilted and Zygomatic implants and the grafting approach. The graftless approach shows higher success rates and offers the advantage of immediate loading. Discussion of typical complications and potential solutions. Dr Bedrossian summarizes importance of understanding patient's needs and demands, to apply adequate, simplified vs optimal procedures, following an interdisciplinary approach and understanding the limitations of the case in order to provide predicable, evidence based treatments.
The lecture reviews the principles of the rehabilitation of the extremely resorbed maxilla and compares Zygomatic implants with sinus lift and augmentation procedures, and highlights the importance of the Zygomatic concept for implantology.
Dr Davo discusses available literature data and own clinical experience and concludes that this treatment has only a low rate of complications. Dr Davo reviews some of the rare complications such as e.g. oro-antral communication, loss of maxillary anchorage, peri-implantitis, palatal instead of crestal implant emergence, failing osseointegration, sinus reactions to the Zygomatic implants, and how to solve these.
Depending on available bone, treatment options range from 4 regular size implant cases to hybrid or full quad constructions with 2 or 4 Zygomatic or other extramaxillary implants.
Supported by impressive patient cases, Dr Dawood reviews a treatment solution with structural grafting including a LeFort 1 osteotomy and ridge expansion and a treatment time of over 18 months, and compares this treatment to minimal invasive, graftless alternatives using zygomatic, narrow and short implants, and immediate provisionalization and loading the day of implant placement.
Dr Fortin presents systematic pre-treatment evaluation for these solutions, discusses the benefits of tilted implants and explains placement options and techniques for Zygomatic implants. Supported by a 10 - 21 year follow up study, Dr Fortin concludes, that maximizing the use of available bone with established procedures is a treatment approach in favor of patient's quality of life.
Dr Bedrossian presents a patient case with the clinical findings: loss of posterior support, primary periodontal disease, secondary occlusal trauma, CR MI (centric relation to maximum intercuspation) slide of 2 mm, tardive dyskinesia, labial incompetence, and discusses his treatment approach. The lecture reviews the digital treatment planning, extraction, placement of 2 zygomatic implants and two regular implants in the anterior maxilla, chair-side conversion of the denture into a screw retained fixed provisional and final restoration into an implant supported bridge.
Insight into treatment options for highly resorbed edentulous maxilla cases with zygomatic implants. For cases with almost no maxilla bone available Dr Davo presents the quad technique with 4 zygomatic implants, which depending on the anatomical situation can be placed within or or outside the sinus. In comparison to grafting procedures, treatment with zygomatic implants offers less invasive surgery, shorter treatment time, immediate loading and restoration option, no donor site morbidity and higher success rate.

トリートメントガイドライン

When bone volume deficiencies are present, zygomatic implants should be considered as an alternative to conventional bone grafting. For the totally atrophied maxilla, the concept has been expanded to anchoring 2 additional implants in each zygomatic bone: by means of 4 well-distributed zygomatic implants a fixed bridge is immediately loaded (Quad zygoma approach).
In the classical protocol, zygomatic implants are inserted through the alveolar crest and maxillary sinus involving the zygomatic bone for anchorage. For visualization of the correct implant position access to the maxillary sinus is necessary. Alternatively the extrasinus placement approach has been described in order to reduce incidence of sinus complications and to improve the implant location and position of the emergence profile more crestally.

Treatment Histories

Treatment history showing surgery performed under general anesthesia. The failing implants were removed and the maxillary bone and the sinus were cleaned (detritus, fibrous tissues…). All the zygomatic implants were inserted at the level of the zygomatic bone and allocated in the maxillary bone. After taking impressions, an acrylic fixed bridge was designed and screwed down on the abutments over the implants. After 4 months of healing, the definitive prosthesis was designed (implant bridge titanium).
The failing implants were removed and the maxillary bone and sinus were cleaned (detritus, fibrous tissues). The implants were inserted at the level of the zygomatic bone and allocated at the level of the maxillary bone. An “all acrylic” fixed bridge was connected after taking the corresponding impressions. After 4 months of healing a realignment of the prosthesis was performed. The patient decided to keep on using the “all acrylic bridge”for the time being.
22-year old male presents with ectodermal dysplasia with resultant lack of permanent maxillary and mandibular teeth. He has only 4 malformed maxillary teeth and mandibular cuspids.
A female patient lacks the maxillary posterior support and has tardive dyskinesia which results in sudden, uncontrolled movement of voluntary muscles. The treatment illustrates virtual planning for the use of zygomatic implants coupled with posterior retraction of the anterior replacement teeth for a more asthetic result.
Patient is a 43-year old male. Over several years of endodontic treatment, usually treating one or two teeth at a time, his dentition continued to deteriorate. Ultimately, esthetics and function became a great concern. Patient realized that traditional dental restorations would not be the solution. Also the patient was not comfortable with the idea of a denture and expressed how hard it was for him to think of loosing his natural teeth. The loss of anterior teeth finally stimulated the urgency to move forward with a solid reconstructive plan. The patient also acknowledged the broad systemic implications of dental disease and the relationship with cardiovascular disease and other systemic conditions. A restoration provided at day of surgery proved to be the optimal solution for this patient.
A protocol considering four zygomatic implants was chosen to avoid lengthy and invasive bone grafting procedures.