No bone structure, no problem with zygomatic dental implants
Patients with extreme maxilla atrophy often find themselves unsuitable for conventional dental implants, their lack of quality bone disqualifying them from the procedure. However, these days patients who don’t have enough bone structure in their upper jaws can be successfully rehabilitated using specialised implants such as customised 3D printed implants, and remote anchorage implants such as pterygoids and zygomatic dental implants. These implants are longer – ranging between 30mm and 52.5mm[i] – and are firmly into the zygomatic bone.
There are both two-stage and immediate loading protocols with most placed today using an immediate loading protocol- so called “same day teeth” approach.[ii]
Zygomatic implants offer a huge breakthrough for patients and significantly reduce the time and the number of surgeries compared to regular dental implants as they don’t require bone grafts.[iii] Additionally, long-term studies and systematic reviews on zygomatic implants document high success rates with only minimal complications. The cumulative survival rate of zygomatic implants is 96% after 12 years.[iv]
Yet, while zygomatic dental implants offer many advantages, they also present some unique challenges and necessitate higher surgical skills.
Intricate anatomy
One of the primary factors contributing to the success of the procedure is the possession of higher surgical skills and the knowledge of intricate anatomy of the maxillofacial structures and the zygomatic bone itself.[v] The zygomatic bone is a complex and curved structure that forms the framework of the middle of the face. This bone extends from the temporal bone of the skull to the maxilla and serves as an anchor for various important structures, such as the infratemporal fossa, the orbit and the maxillary sinuses.
Proper placement of zygomatic dental implants requires a thorough understanding of this anatomy to avoid damage to adjacent structures and ensure successful outcomes. The dental clinician needs to carefully navigate around vital structures such as nerves and blood vessels, which increases the level of expertise required for successful implantation.[vi]
Not all zygomatic procedures are the same. Unlike traditional implant placement, which often requires a bone graft or sinus lift to create sufficient bone volume, the anatomically guided ZAGA technique allows for immediate implant placement without the need for additional procedures. The procedure, especially when planned and delivered using 3D digital workflow, is considered minimally invasive because it requires less surgical trauma and a shorter recovery time compared to conventional techniques.[vii]
Minimally invasive
The implants are anchored into the zygomatic bone, which provides increased stability and support for the dental prosthesis. It is typically performed under local anaesthesia with or without sedation. Research shows that immediately loaded quad zygomatic implants may offer more successful outcome compared with delayed loading protocols. Initially a temporary bridge is fitted which is replaced with a permanent prosthesis after a few months to allow for modifications to achieve the best phonetic, aesthetic, functional results iv
Potential complications
Zygomatic dental implants can carry a slightly higher risk of complications compared to traditional dental implants due to the proximity to vital structures, such as the sinuses and nerves.[viii] Inexperienced or unskilled surgeons may encounter difficulties during the placement process, which could result in complications like sinus perforation, nerve damage, or a suboptimal implant position.[ix]
In the majority of studies, sinusitis is the most frequently observed complication. However early results show that sinusitis is indeed a very rare complication associated with the modern ZAGA implant system. Non-osseointegration of zygomatic implants can occur too, often caused by overheating, malpositioning, contamination or trauma during the surgery. Insufficient bone quantity or quality, a lack of primary stability and incorrectly indicated immediate loading can be factors too.v
Local infections or mucositis are directly related to the appearance of sinusitis, favoured by the lack of osseointegration, lack of contact between the implant and the bone crest, superficial infection and lack of cicatrisation of the soft tissues. Poor osseointegration at the marginal area of the implant at its palatal aspect, along with functional forces, may increase the risk of oroantral communication and the posterior development of sinusitis. Paresthesia has also been recorded, along with bruising and labial laceration due to poor surgical technique.ii
Limited availability
Zygomatic dental implants are not readily available at all dental practices. Due to the advanced nature of the procedure, not all dentists are trained to perform zygomatic implant surgeries. A two-day course taking place in 2024 at the ZAGA Centre in Manchester – a clinic that is part of the international network of oral surgeons highly trained and experienced in zygomatic implant rehabilitation – provides intensive hands-on surgical training, in the use of zygomatic, nazalus, trans-sinus and pterygoid implants for the treatment of severely atrophic maxilla. Lead by eminent oral surgeon, Professor Cemal Ucer the course has been structured specifically for those wishing to introduce zygomatic implants into their practice.
With the exciting advances offered by Straumann-ZAGA implant system as developed by Carlos Aparicio, Zygomatic implants offer a viable and arguably less invasive solution for patients who lack sufficient bone in the upper jaw for conventional solutions. By addressing these challenges with proper surgical planning and expertise, the success rate of zygomatic dental implants can be maximised and patients with extreme maxilla atrophy can smile with confidence once again.
To find out more, contact Ucer Education today. Contact Professor Ucer at
ucer@icedental.institute or Mel Hay at mel@mdic.co; call 01612 371842 or
visit www.ucer-clinic.dental.
Professor Cemal Ucer (BDS, MSc, PhD, Oral Surgeon, ITI Fellow)
FYI
Prof. Cemal Ucer, BDS, MSc, PhD, FDTFEd., ITI Fellow, Specialist Oral Surgeon
Cemal Ucer first established an implant referral centre in 1995. He was awarded an MSc in Implantology at Manchester Dental Hospital following his research into guided bone regeneration and osteopromotion. He later gained a PhD for his clinical and laboratory studies into the factors affecting the success of implant treatment in iliac grafts and the investigation of the effect of skeletal bone density on implant survival. He has personally trained and mentored more than 1,000 dentists in implant dentistry as one of the main providers of implant education in the UK.
Cemal’s current clinical research interests include immediate implant placement, reconstructive bone surgery, nerve damage and the effect of bone density on the success of implant treatment. Academically, he has gained European recognition for his work on the development of a new framework for teaching and assessment of clinical competence in implantology. He is a co-author of the consensus paper produced by the Association for Dental Education in Europe (ADEE) following the first pan-European collaboration between EU universities to establish common training and assessment standards in dental implantology. He is an invited member of the working group convened by the FGDP (UK) and the General Dental Council (GDC) to update the Training Standards in Implant Dentistry (TSID) guidelines in 2012 and 2016.
Cemal is a Fellow of the Dental Trainers Faculty of the Royal College of Surgeons of Edinburgh (RCSEd) and a Fellow of the International Team for Implantology (ITI) and a member of Megagen’s MINTEC UK & I Board for education and clinical research. He is a member of the editorial board of JOMR (Journal of Oral & Maxillofacial Research) and the chair of the editorial advisory board of Implant Dentistry Today. Cemal is Professor and Clinical Lead of the MSc programme in Dental Implantology and a member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh’s Diploma in Implant Dentistry. He is a past president of The Association of Dental Implantology (ADI) (2011-2013).
Cemal has been appointed by FGDP (UK) to lead the working group to develop the “national standards in implant dentistry” which is due to be published later in 2018 following the completion of an external consultation process.
[i] Agbara R, Goetze E, Koch F, Wagner W. Zygoma implants in oral rehabilitation: A review of 28 cases. Dent Res J (Isfahan). 2017 Nov-Dec;14(6):370-375. doi: 10.4103/1735-3327.218561. PMID: 29238374; PMCID: PMC5713059. [Accessed December 2023]
[ii] Foundation for Oral Rehabilitation https://www.for.org/en/treat/treatment-guidelines/edentulous/treatment-procedures/surgical/surgical-protocols-maxilla/zygomatic-implants
[iii] Alexandre Laventure, Ludovic Lauwers, Romain Nicot, Maéva Kyheng, Joël Ferri, Gwénaël Raoul,
Autogenous bone grafting with conventional implants vs zygomatic implants for atrophic maxillae: a retrospective study of the oral health-related quality of life, Journal of Stomatology, Oral and Maxillofacial Surgery, Volume 123, Issue 6, 2022, Pages e782-e789, ISSN 2468-7855, https://doi.org/10.1016/j.jormas.2022.06.028. [Accessed December 2023]
[iv] Solà Pérez A, Pastorino D, Aparicio C, Pegueroles Neyra M, Khan RS, Wright S, Ucer C. Success Rates of Zygomatic Implants for the Rehabilitation of Severely Atrophic Maxilla: A Systematic Review. Dent J (Basel). 2022 Aug 12;10(8):151. doi: 10.3390/dj10080151. PMID: 36005249; PMCID: PMC9406716. [Accessed December 2023]
[v] Yu M, Wang SM. Anatomy, Head and Neck, Zygomatic. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544257/ [Accessed December 2023]
[vi] VeryWellHealth The Anatomy of the Zygomatic Bone https://www.verywellhealth.com/zygomatic-bone-anatomy-4692051
[vii] Aparicio, C., Olivo, A., de Paz, V. et al. The zygoma anatomy-guided approach (ZAGA) for rehabilitation of the atrophic maxilla. Clin Dent Rev 6, 2 (2022). https://doi.org/10.1007/s41894-022-00116-7 [Accessed December 2023]
[viii] Science Direct https://www.sciencedirect.com/topics/neuroscience/zygomatic-nerve
[ix] Molinero-Mourelle P, Baca-Gonzalez L, Gao B, Saez-Alcaide LM, Helm A, Lopez-Quiles J. Surgical complications in zygomatic implants: A systematic review. Med Oral Patol Oral Cir Bucal. 2016 Nov 1;21(6):e751-e757. doi: 10.4317/medoral.21357. PMID: 27694789; PMCID: PMC5116118. [Accessed December 2023]
