Cairo University

Faculty of Dentistry
Oral and Maxillofacial Department

Zygomatic Implants Uses in Compromised Maxilla

Prepared by: Hani Taher Hibatullah Ali

PhD Candidate
Semester 1
Zygomatic Implants Uses in Compromised Maxilla

Contents:
1- Introduction
2- Historical Perspective
3- Indications and contraindications of zygomatic implant
4- Advantages and disadvantages of zygomatic implant
5- General guidelines for zygomatic implants
6- Fixture design
7- Preoperative evaluation
8- Surgical procedure (intra sinus and extra sinus techniques)
9- Prosthesis
10- Complications
11- Conclusion
12- References
Zygomatic Implants Uses in Compromised Maxilla

Introduction
Dental implants are a common mode of rehabilitation for partially and
completely edentulous patients. Numerous restrictions have arised with the use
of these implants and one of it is the lack of sufficient bone volume, especially in
the region of the posterior maxilla. This insufficient bone volume could either be
due to bone resorption, pneumatization of the sinus or both1. Different surgical
techniques have been previously described in the literature to deal with such
cases, including reconstructions using bone graft from the iliac crest associated
with or without Le Fort I osteotomy, sinus floor augmentation and onlay bone
grafting. However, these techniques require long periods of treatment and are
more prone to complications2,3.

Based on animal research and human experiments, Branemark et al4, knowing

that the introduction of an implant in the sinus could not jeopardize sinus health,
the zygomatic bone can be used as anchorage for prosthetic rehabilitation in
hemimaxillectomy patients as well as for other defects. Because these
reconstructions were successful and long-term stability of these implants was
established5. This development offers alternatives to bone grafting or sinus-lift
procedures, which involve invasive surgery1.

Ponnusamy S, 20196 found that the use of zygomatic implants should be

considered as a first-line option for management of the severely resorbed maxilla
because it decreases total treatment time, reduces the number of surgeries and
anesthetic procedures, eliminates donor graft site morbidity, and reduces the
overall cost of surgical and prosthetic treatment, and has excellent patient
satisfaction outcomes.

Migliorança et al, 20197 Proved that the zygomatic implants are a reliable
alternative treatment for total edentulous patients, with a high percentage of
success compatible with conventional implants.
Historical Perspective:
Zygoma implants were first introduced in 1998 by Per Ingvar Branemark
widely acknowledged as the "Father of Dental Implantology"8. After Branemark,
Malevez et al, 20001 described zygomatic implants as self-tapping screws in
commercially pure titanium with a well-defined machined surface, these implants
had a palatal emergence, crossed the maxillary sinus and were anchored in the
zygomatic bone. Nowadays9,10, the palatal emergence can be avoided by using
the “extramaxillary” implants technique, where the zygomatic implant goes
through the lateral wall of the maxillary sinus.

1
Zygomatic Implants Uses in Compromised Maxilla

Indications and contraindications:

Zygomatic implants can be placed in patients with severely atrophic
edentulous maxilla, reconstruction after partial or total maxillectomy, ORN and
MRONJ, in case of cleft palate and recently11 transmandibular zygomatic
implants use for mandibular defects. Contraindications include acute sinus
infection, maxillary or zygoma pathology and patients unable to undergo implant
surgery because of underlying uncontrolled or malignant systemic disease, the
use of bisphosphonates and smoking more than 20 cigarettes a day9,12.
Advantages and disadvantages of zygomatic implant:
Advantages included avoids use of grafts in atrophic maxilla, no donor site
morbidity, good anchorage from tough zygomatic bone which enhances stability
of prosthesis, zygomatic implants do not necessarily require hospitalization, a
smaller number of patient visits and fewer implants are required to support a
prosthesis. Disadvantages of zygomatic implants involving difficulty in implant
placement, the surgeon must have experience with surgery in this area while the
restorative dentist must have the clinical proficiency to fabricate a full arch
implant supported prosthesis9.
General guidelines for zygomatic implants13 fig 1:

Figure 1 showed general guideline for zygomatic implants

Fixture design:
The fixture is a self-tapping titanium implant with and is available in
lengths from 30 to 52.5 mm. The threaded apical part has a diameter of 4 mm and
the crestal part has a diameter of 4.5 mm. The implant head has an angulation of
45° and an inner thread for connection of Branemark System abutments 1 fig 2:

Figure 2 showed slandered fixture design

2
Zygomatic Implants Uses in Compromised Maxilla

Preoperative evaluation:
The examination of choice is computed tomography (CT) scan, which
makes two- and three-dimensional imaging possible in order to evaluate degree
of resorption, sinus status, maxillomandibular jaw relationship, and patient
expectations. The CT scan also gives the opportunity to visualize the health of
the maxilla and the sinus. Sinusitis, polyps or any sinuses 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
stereolithographic models to facilitate the orientation of the zygomatic implants
during the surgery with minimal errors in angulation and position14,15.

Surgical procedure (intra sinus and extra sinus):

Intra sinus:
Branemark I, 199816 used the traditional Le Fort I incision, can be made
between the first molar regions. Another option is to perform a crestal incision
allowing improved palatal access for implant placement. After raising the
mucoperiosteal flap, soft tissue dissection has to be extended along the inferior
and frontal lateral surfaces of the zygomatic bone, with identification of the
infraorbital foramen. Afterwards, a 10 x 5 mm infrazygomatic window in the
lateral wall of the maxillary sinus should be created to elevate the Schneiderian
membrane. This window should allow the observation of the palatal drilling
sequence as well as the implant placement fig 3.

Figure 3 showed steps of intra sinus technique

3
Zygomatic Implants Uses in Compromised Maxilla

Stella and Warner, 200017 altered the original technique, in which the implant
remained totally inside the maxillary sinus, making slots in the external wall of
the maxillary sinus, and thus improving in part the major problem that was the
positioning of the implant head (prosthetic positioning).
Bothur et al, 200318 described a modified technique, the authors proposed three
possible positions for the placement of implants on one side, but in the authors'
experience the placement of two zygomatic implants bilaterally is generally
sufficient for reconstruction.
Peñarrocha et al, 200519 described the sinus slot technique makes sinus window
formation unnecessary. A crestal incision is made extending from one maxillary
tuberosity to the contralateral tuberosity. A traditional LeFort I exposure is
accomplished, with a periosteal elevator. The palatal mucosa is reflected only to
expose the crest of the ridge.
Until the year 2005, all articles published in the literature described their cases
using the original technique of Branemark or it is modifications, after that extra
sinus has been appeared.
Balshi et al, 200920 published an article from 9 months to 5 years of follow-up of
56 patients who received 110 zygomatic implants performed by the intra-sinus
technique with a success rate of 96.37%.
Aparício et al, 201221 published their 10-year follow-up clinical study, in which
41 zygomatic fixations were performed by the intrasinus technique and in two
surgical stages (conventional loading). Two zygomatic implants were removed
due to perimplant infection (95.12%) and all patients maintained functional
prostheses.
Fernandez et al, 201422 published a retrospective analysis of 244 zygomatic
implants using the intrasinus technique, obtaining a high success rate.
Agliardi et al, 201723 published a prospective six-year follow-up study in which
extrasinus and intrasinus techniques were used with immediate loading of the
provisional prostheses, and there was no loss of zygomatic implants, resulting in
a rate of 100.0% success.

Extra sinus:
Basically, it consists of a modification of the implant entrance in the
alveolar process and its trajectory up to the zygomatic bone hence correcting the
palatal entrance of the Branemark technique. In its trajectory to the zygomatic
bone, the fixture goes through the lateral sinus wall keeping the Schneiderian
membrane intact. This technique not only improves the design of the prosthesis
but also seems to reduce the incidence of sinusitis10 fig 4.

4
Zygomatic Implants Uses in Compromised Maxilla

Figure 4 showed steps of extra sinus technique

Migliorança et al, 200624 published for the first time in the literature, the use of
the extra-sinus placement technique (Migliorança Technique). the implants are in
contact with the external wall of the maxillary sinus, the final positioning of the
implant platform is completely close to the ridge crest, in the first molar region,
resulting in greater support.
Aparício C, 201125 Based on the zygomatic bone morphology and the subsequent
location of the implant presenting a new classification for zygomatic implants.
Aparicio named ZAGA his classification (zygoma anatomy guided approach),
comprising five groups, ZAGA 0 to 4.
Maló et al, 201426 published a study about extrasinus zygomatic implants
placement technique. This article was a five years follow-up retrospective cohort
study, with immediate loading. This study resulted in a 98.8% success rate in
relation to zygomatic fixations.
Aleksandrowicz et al, 201927 recruited 22 patients with 35 zygomatic Brånemark
system implants; 24 implants in the standard Brånemark protocol through the
sinus and 11 extra-sinus implants outside the sinus and they found that the
survival rate of the regular implants was 93.87% and P-I Brånemark zygoma
protocol is more prone to infection.

Prosthesis:
The prosthetic procedure follows conventional protocols which ranging
from simple technique which is crown and bridge till more complicated designs
of over denture, as the emergence of the zygomatic implant is often 10–15 mm
medial to the ridge, the bridge should be designed to enable proper oral hygiene
in the area. Originally, a two-stage procedure was recommended for the zygoma
technique. However, over time, the original protocol has been replaced with
immediate loading28,29.

5
Zygomatic Implants Uses in Compromised Maxilla

Complications:
Sinus pathology and sinusitis:
The zygomatic implant placement may result in a foreign body reaction, in
the form of inflammation of the sinus membrane, may be triggered by a treated
implant surface against a finished one, sinusitis is the most frequently observed
complication, Becktor et al30, with 19,4% cases and Chrcanovic et al31. with
5,2% fig 5.

Figure 5 showed sinus pathology

Non-osseointegrated implants
Causes include overheating, contamination and trauma during the surgery,
insufficient bone quantity or quality, lack of primary stability and incorrectly
indicated immediate loading32. Non-osseointegrated implants appear with a mean
frequency of 2,44%, Duarte et al33, with 2,08% and Migliorança et al34, with
2,5% others such as Sartori et al35 and Zwahlen et al36 report an osseointegration
success rate of 100%.
Local infections:
Directly related to the sinusitis, favoured by the lack of osseointegration
and prosthodontic rehabilitation also plays a relevant role, the prevalence
obtained by Chrcanovicet al31 and Kahnberg et al37 showed a result of 3,6%
and 4% respectively.
Fistula at implant level:
Lack of osseointegration at the marginal area of the implant at its palatal
aspect, along with functional forces, and the posterior development of sinusitis
The frequency of this complication in the mentioned studies varies between 1,5
and 7,5%31, except in the case of Becktor et al30, who reached 29%.

6
Zygomatic Implants Uses in Compromised Maxilla

Paresthesia:
In a systematic review conducted by Chrcanovic et al31, 15 cases of
paresthesia from affection of infraorbitary and zygomaticofacial nerves were
reported, however, in the majority of reviewed cases, paresthesia remits
between 3 and 8 weeks postintervention13.

Mucositis and periimplantitis:

This complication depends on the feature of mucosa, type of prosthetic
connection, form of convenience of the prosthesis and specially on the capacity
of control of bacterial plaque by the patient, the incidence of mucositis is
considered high. The difficulty to control mucositis can result in an evolution of
the disease with bone destruction, featuring periimplantitis, which is a high level
when related to zygomatic implant. The loss of 2-3 mm may result in loss of total
bone volume favouring a bucco sinusal communication38 fig 6.

Figure 6 showed mucositis caused by zygomatic implant.

Prosthetic complication:
Postoperative concerns regarding difficulty with speech, articulation and hygiene
caused by the bulky prosthesis due to palatal emergence of the zygomatic implant.

Conclusion:
The zygomatic implant appears to be a promising development in implant
technology. It offers an interesting alternative solution to heavy bone grafting in
the severely resorbed posterior maxilla, extra sinus technique appears to be more
ease and less prone to complications than intra sinus, zygomatic placement
require a lot of skill and experience and should only be performed by well-trained
surgeons in order to minimize and treat the accompanying complications.

7
Zygomatic Implants Uses in Compromised Maxilla

References:

1- Malevez C, Daelemans P, Adriaenssens P, Durdu F. Use of zygomatic

implants to deal with resorbed posterior maxillae. Periodontol 2000. 2003;
33:82–89.
2- Van der Mark EL, Bierenbroodspot F, Baas EM, De Lange J.
Reconstruction of an atrophic maxilla: comparison of two methods. Br J
Oral Maxillofac Surg. 2011; 49:198–202.
3- Pelo S, Gasparini G, Moro A, Boniello R, Amoroso PF. Segmental
Le Fort I osteotomy with bone grafting in unilateral severely atrophied
maxilla. Int J Oral Maxillofac Surg. 2009;38(3):246–9.
4- Branemark PI, Adell R, Albrektsson T, Lekholm U, Lindstro m J,
Rockler B. An experimental and clinical study of osseointegrated implant
penetrating the nasal cavity and maxillary sinus. J Oral Maxillofac Surg.
1984; 42:497–505.
5- Parel S, Branemark PI, Ohrnell LO, Svensson B. Remote implant
anchorage for the rehabilitation of maxillary defects. J Prosthet Dent.
2001; 86:377–381.
6- Ponnusamy S. Outcomes of Zygomatic Dental Implants: Surgeon, Dentist,
and Patient Satisfaction. J Oral Maxillofac Surg. 2019;S0278-
391(19)30726-8/abstract
7- Migliorança RM, Irschlinger AL, Peñarrocha-Diago M, Fabris RR, Javier
Aizcorbe-Vicente and Zotarelli Filho IJ. History of zygomatic implants: A
systematic review and meta-analysis. Dent Oral Craniofac Res, 2019;
Volume 5: 1-9
8- Kato, Yorihisa; Kizu, Yasuhiro; Tonogi, Morio. "Internal Structure of
Zygomatic Bone Related to Zygomatic Fixture". J Oral Maxillofac Surg.
2005; 63: 1325–1329.
9- Aziz Pahadwala, Padmasree Patowary., Sanyukta Raut., Santhosh Kumar
SN., Kalyani Bhate and Manju Singh. Zygomatic Implants in Maxillofacial
Rehabilitation – A Critical review. Int. J. Recent Sci. Res.2016; pp.
14755-14760
10- Aparicio C, Ouazzani W, Aparicio A. Extrasinus zygomatic
implants: three-year experience from a new surgical approach for patients
with pronounced buccal concavities in the edentulous maxilla. Clin
Implant Dent Relat Res. 2010; 12:55–61
11- Ruben Muñoz Golaszewski GajosJose BladimirDiaz
CarvajalAlvaro LuisGrace Del Valle Speranza. Protocol for mandibular
reconstruction with zygomatic implants (zygomatic mandibular implant).
Oral Maxillofac Surg 2018; 22:39–44

8
Zygomatic Implants Uses in Compromised Maxilla

12- Aparicio C, Manresa C, Francisco K, Claros P, Alández J.

Zygomatic implants: indications, techniques and outcomes, and the
zygomatic success code. Periodontol 2000.2014; 66: 41-58
13- Bedrossian E. Rehabilitation of the edentulous maxilla with the
zygoma concept: a 7-year prospective study. Int J Oral Maxillofac
Implants. 2010: 25: 1213–1221.
14- van Steenberghe D, Malevez C, Van Cleynenbreugel J, Bou Serhal
C, Dhoore E, Schutyser F, Suetens P, Jacobs R. Accuracy of drilling guides
for the transfer from 3-D CT based planning to placement of zygomatic
implants in human cadavers. Clin Oral Implants Res 2003: 14: 131–136.
15- 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; 18:902–4.
16- Branemark PI.The zygomatic fixture: Clinical procedures (ed 1).
Gothenburg, Sweden, 1998. Nobel Biocare AB, pp: 1.
17- Stella JP, Warner MR. Sinus slot technique for simplification and
improved orientation of zygomaticus dental implants: A technical note. Int
J Oral Maxillofac Implants. 2000; 15: 889-893.
18- 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.
19- Peñarrocha M, Uribe R, García B, Martí E. Zygomatic implants
using the sinus slot technique: Clinical report of a patient series. Int J Oral
Maxillofac Implants. 2005 20:788-792.
20- Balshi SF, Wolfinger GJ, Balshi TJ. A retrospective analysis of 110
zygomatic implants in a single-stage immediate loading protocol. Int J
Oral Maxillofac Implants.2009; 24: 335-341
21- Aparicio C, Manresa C, Francisco K, Ouazzani W, Claros P. The
long-term use of zygomatic implants: a 10-year clinical and radiographic
report. Clin Implant Dent Relat Res.2014;16: 447-459.
22- Fernández H, Gómez-Delgado A, Trujillo-Saldarriaga S, Varón-
Cardona D, Castro- Núñez J. Zygomatic implants for the management of
the severely atrophied maxilla: A retrospective analysis of 244 implants. J
Oral Maxillofac Surg.2014; 72: 887-891.
23- Neugarten J, Tuminelli FJ, Walter L (2017) Two bilateral zygomatic
implants placed and immediately loaded: a retrospective chart review with
up-to-54-month follow-up. Int J Oral Maxillofac Implants. 2017; 32:
1399-1403.

9
Zygomatic Implants Uses in Compromised Maxilla

24- Migliorança R, Ilg JP, Serrano AS, Souza RP, Zamperlini MS. Sinus
exteriorization of the zygoma fixtures: a new surgical protocol. Implant
News 2006; 3: 30-35.
25- Aparicio C. A proposed classification for zygomatic implant patient
based on the zygoma anatomy guided approach (ZAGA): A cross-sectional
26- Maló P, Nobre M de A, Lopes A, Ferro A, Moss S (2014) Five-year
outcome of a retrospective cohort study on the rehabilitation of completely
edentulous atrophic maxillae with immediately loaded zygomatic implants
placed extra-maxillary. Eur J Oral Implantol. 2014;7: 267-281.
27- Paweł Aleksandrowicz, Marta Kusa-Podkańska, Katarzyna
Grabowska, Lidia Kotuła, Anna Szkatuła-Łupina, Joanna Wysokińska-
Miszczuk. Extra-sinus zygomatic implants to avoid chronic sinusitis and
prosthetic arch malposition: 12 years of experience. J Oral Implantol.
2019;45(1):73-78
28- Davo C, Malevez C, Rojas J. Immediate function in the atrophic
maxilla using zygoma implants: a preliminary study. J Prosthet Dent
2007: 97: S44–S51.
29- Davo R, Malevez C, Rojas J, Rodrıguez J, Regolf J. Clinical
outcome of 42 patients treated with 81 immediately loaded zygomatic
implants: a 12-to-42-month retrospective study. Eur J Oral Implantol
2008: 1: 141–150.
30- Becktor JP, Isaksson S, Abrahamsson P, Sennerby L. Evaluation
of 31 zygomatic implants and 74 regular dental implants used in 16
patients for prosthetic reconstruction of the atrophic maxilla with
cross-arch fixed bridges. Clin Implant Dent Relat Res. 2005; 7:159-65.
31- Chrcanovic BR, Abreu MH. Survival and complications of
zygomatic implants: a systematic review. Oral Maxillofac Surg. 2013;
17:81-93.
32- Levin L. Dealing with dental implant failures. J Appl Oral
Science. 2008; 16:171-5.
33- Duarte LR, Filho HN, Francischone CE, Peredo LG, Brånemark P.
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; 9:186-96.
34- Migliorança RM, Sotto-Maior BS, Senna PM, Francischone CE,
Del Bel Cury AA. Immediate occlusal loading of extrasinus zygomatic
implants: a prospective cohort study with a follow-up period of 8 years. Int
J Oral Maxillofac Surg. 2012; 41:1072-6.

10
Zygomatic Implants Uses in Compromised Maxilla

35- Sartori EM, Padovan LE, de Mattias Sartori IA, Ribeiro PD Jr,
Gomes de Souza Carvalho AC, Goiato MC. Evaluation of satisfaction
of patients rehabilitated with zygomatic fixtures. J Oral Maxillofac
Surg. 2012; 70:314-9.
36- Zwahlen RA, Grätz KW, Oechslin CK, Studer SP. Survival rate of
zygomatic implants in atrophic or partially resected maxillae prior to
functional loading: A retrospective clinical report. Int J of Oral Maxillofac
Implants. 2006; 21:413-20.
37- Kahnberg KE, Henry PJ, Hirsch JM. Clinical evaluation of the
zygoma implant: 3-year follow-up at 16 clinics. J Oral Maxillofac Surg.
2007; 65:2033-8.
38- Al-Nawas Wegener J, Bender C, Wagner W. Critical soft tis-sue
parameters of the zygomatic implants. J Clin Periodontol.2004;31:497-
500

11