Innovative Solutions Using Zygoma Implants

Paul P. Binon, DDS, MSD, FAO

Private Practice, Roseville, CA

Keywords Abstract
Remote implant support; zygoma implants;
severe resorption; edentulous maxilla. The severely resorbed edentulous maxilla presents significant treatment challenges.
The introduction of remote implant support using zygoma implants has provided a
Correspondence plethora of treatment possibilities for many patients. This article presents four very
Paul P. Binon, 1158 Cirby Way, Roseville, CA different sets of circumstances successfully treated using this protocol.
95661. E-mail: binondds@gmail.com.

The author denies any conflicts of interest.

Accepted April 15, 2016

doi: 10.1111/jopr.12504

Treatment of the severely resorbed edentulous maxilla presents is transitioned into a fixed palate-less interim prosthesis. If there
a set of unique and challenging problems.1,2 Early efforts to is no bone for anchorage in the premaxilla, the quad zygoma
augment the deficient maxilla varied from hydroxyapatite (HA) approach can be used. It involves the placement of two zygoma
buildups, rib and hip bone sandwich grafts, and sinus augmenta- implants on each side of the dental arch.
tion using a variety of material combinations. Currently several The zygoma implant can also be used unilaterally in cases
different augmentation protocols can be used to build up the where there is sufficient bone for conventional implant place-
internal vertical height of the sinus floor so that implants can be ment on one side of the arch and a serious deficiency on the
placed.3-6 This is a viable protocol that requires two surgeries. other. It can also be used in conjunction with the All-on-4
After the initial surgery, a waiting period of 4 to 6 months is approach when additional posterior support is necessary.
necessary to permit graft maturation. At that time the implants The major advantages of this protocol is that it significantly
can be placed in the grafted sites, and another 6 months are reduces the treatment time line from 12/15 months to 6/7
necessary for the implants to securely integrate in the grafted months, eliminates extensive grafting surgery, and immediately
bone. During this staged sequence, the patient typically wears results in a fixed prosthesis. There is ample long-term documen-
a complete denture with a soft liner. Total treatment time will tation in the literature with 97%+ long-term success rates.14-16
range from 12 to 15 months or more. Most often this protocol In addition, it allows the prosthodontist innovative options to
requires 6 to 8 implants and typically results in a bar-retained solve exceptionally challenging circumstances. Four such chal-
overdenture (Fig 1).7-9 lenging cases are presented that highlight the flexibility of the
In an effort to reduce the number of surgeries and allow for zygoma protocol.
the immediate use of the implants, Dr. P-I Branemark developed The typical prosthetic protocol requires the following steps
the concept of remote implant support,10-13 which essentially once the patient has decided on treatment. If the existing den-
involves making a window into the lateral sinus wall, raising ture fits reasonably well it can be used. If not, an immediate
the Schneiderian membrane and gaining direct visualization denture is made in advance of the surgery date. On completion
of the base of the zygomatic arch. A series of special long of the surgery, the abutment locations are indexed with bite
drills are used to prepare an osteotomy in the medial wall of registration paste. Access holes to allow direct pick-up of the
the zygomatic arch until it exits at the outer cortex. Implant temporary cylinders are created in the denture. With the tem-
lengths and corresponding drills range from 35 to 52.5 mm porary cylinders seated on the abutments, the denture is seated.
long. The implants have a unique design with an implant body The cylinders are then bonded to the denture using the brush
from 4 to 5 mm in diameter. The coronal end has a 45 external bead technique with fast-cure resin (Qyk-Set; Holmes Dental
hex connection, allowing it to be positioned perpendicular to Co., Hatboro, PA). This is sequentially completed until all the
the palate. In the classic approach, 2 to 4 anterior implants temporary cylinders are firmly attached to the denture. The den-
are placed in the premaxilla for optimal load distribution (Fig ture is then removed from the mouth. The palate, the flanges,
2). Universal abutments are placed on the implants along with and excess tube length of the temporary cylinders are removed
temporary cylinders, and a previously made complete denture and adjusted. It is reinserted in the mouth, and the occlusion is

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carefully checked and adjusted. Six months later the temporary coepidermoid tumor. The surgery resulted in a large palatal de-
hybrid denture is removed from the mouth, the implants are fect (662.5 mm) (Fig 11). A pretreatment CT scan showed
checked for stability, and an impression is taken. At the next the extent of the palatal defect (Fig 12). The patient was a
appointment a cast verification jig is used to verify the accuracy heavy smoker with advanced periodontal disease. The remain-
of the master cast. A framework is then constructed out of tita- ing maxillary dentition had a hopeless prognosis. Alternatives
nium, bite relationship records are obtained, and denture teeth to a complete maxillary denture were evaluated. Following ini-
are set on the framework. The setup is tried in the mouth for the tial periodontal efforts to retain selected teeth, the patient se-
normal prosthetic evaluations of vertical dimension, phonetics, lected a zygoma implant-based fixed prosthesis treatment plan.
occlusion, and esthetics. On patient approval, the prosthesis is The maxillary teeth were removed, and two anterior implants
processed and inserted at the next appointment. Post-insertion and two zygoma implants (Nobel Biocare Holding AG) were
instructions are given, and the patient is monitored closely for placed. The maxillary denture made in advance of surgery was
the first 3 months. converted to a fixed interim hybrid denture (Fig 13). A tem-
porary obturator bulb was made and relined with soft denture
Clinical case #1: the rescue concept liner (Visco-gel; Dentsply, York, PA). Subsequently a more sta-
ble and retentive temporary obturator was constructed (Fig 14).
A 60-year-old woman presented with a primary complaint that Healing was uneventful, and at 6 months a definitive impres-
her maxillary implants were painful, the gum tissue chroni- sion of the maxilla was made (Fig 15). Following the usual
cally bled, and was growing over her tissue bar. Her dental protocol, a titanium retention bar (Cagenix Inc.) was designed
history showed a maxillary subperiosteal implant followed by with lingual wings in the bicuspid area to incorporate bilateral
several blade implants placed in the early 1980s. Subsequent Locator retentive elements (Zest Anchors LLC., Escondido,
to failure, she had a ridge graft with hipbone, bilateral sinus CA.) to retain the removable obturator portion of the prosthesis
augmentations, and the placement of six HA-coated implants (Fig 16). After completion of a wax try-in, the fixed hybrid was
in 1997. processed. In addition, a cobalt chrome palatal strap that incor-
Figure 3 illustrates the condition of the soft tissues. Periodon- porated Locator retention cups to retain the obturator portion
tal evaluation indicated generalized pocket depths in excess of was made (Fig 17). This permitted fixed restoration for function
7 mm around the six implants. Intake radiographs verified sig- and esthetics (Fig 18) that is easily accessible for hygiene with
nificant cratering and bone loss around all implants (Fig 4). a removable and stable obturator prosthesis. A postoperative
Treatment plans were presented that included (1) removal of radiograph taken in 2015 after more than 5 years of function
the implants and grafting of the ridge defects and a conven- shows excellent osseous stability (Fig 19).
tional denture, (2) removal of the implants, bilateral sinus grafts
followed in 6 months with the placement of six implants and Clinical case #3: a congenital defect
a new, more-hygienic bar, (3) removal of the failing implants, solution
grafting of the ridge defects, and the placement of two conven-
tional implants in the premaxilla and bilateral zygoma implants. A male patient of record since 1984 had a history of right side
The implants would be loaded immediately if insertion torques cleft palate and lip surgically repaired. The maxilla was con-
permitted. The patient decided on the zygoma immediate load tracted with a longitudinal fistula and no bony union. There
treatment plan. was a pharyngeal flap with a narrow pedicle. Initially there
At the time of surgery the loss of the HA coating on the failed were four teeth remaining that helped secure his prosthesis.
implants and the advanced cratering and bone loss was veri- Because of advanced periodontal disease, two of the four teeth
fied (Fig 5). Two conventional and two zygoma implants were were removed, and the remaining two molars (#3 and 14) were
purchased from Nobel Biocare Holding AG, Kloten, Switzer- restored with gold sub-crowns and a bar interconnected with
land. Four implants were placed, the denture was indexed, two ERA attachments (Sterngold Dental LLC., Attleboro, MA)
and temporary cylinders were picked up in the denture. The (Fig 20). This arrangement functioned for 22 years. The bar
denture was then appropriately modified, the occlusion ad- was removed at that time to limit anterior/posterior loading.
justed, and inserted in the mouth (Fig 6). Healing was un- The teeth were fibrous encapsulated and demonstrated plus 3
eventful, and 6 months later (Fig 7) an impression was made mobility. The patients palate was flat with anterior areas of
and sent to the laboratory. A titanium milled bar (Cagenix Inc., easily compressed mobile tissue (Fig 21). Limited alternatives
Memphis, TN) was made and tested in the mouth for passive to a complete denture were available. The patient opted for
fit. The denture sequence was completed, and the definitive a zygoma-assisted (Nobel Biocare Holding AG) fixed hybrid
prosthesis inserted (Fig 8). The patient transitioned from a fail- prosthesis. Locating anterior bone for support proved challeng-
ing, six HA-coated, implant-supported bar to a fixed prosthesis ing. Two small islands of bone were located, and the surgery
in 7 months (Fig 9). A postoperative radiograph showed well- was completed uneventfully (Fig 22). The temporary prosthesis
integrated implants (Fig 10). was secure and functional following surgery. After 3 months
the left anterior conventional implant failed. A second zygoma
Clinical case #2: the acquired defect implant was then inserted, and the temporary prosthesis was
solution modified to accept an additional temporary coping (Fig 23).
Six months from insertion of the second zygoma implant, the
A 45-year old female patient presented in 2002 with a need implants were tested, and a final impression was obtained. The
to restore the upper arch following ablative surgery of a mu- cast was verified, and a milled titanium bar was made. The

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Figure 1 Example of typical conventional restorative treatment protocol

following bilateral sinus augmentation using 6 to 8 implants with a bar-
retained overdenture.

Figure 4 Intake radiograph indicating extensive bone loss and cratering

around existing implants.

Figure 2 Surgery planning imagery indicating the location of the pro-

jected implants in the zygoma as well as the anterior maxilla for a typical
zygoma case.
Figure 5 With the palatal tissues reflected, the condition of the failed
HA surgical coated implants is quite obvious.

Figure 3 Pretreatment condition of the soft tissues.

Figure 6 Following placement of bilateral zygoma implants and two

conventional anterior implants, the modified provisional denture was at-
challenge with cases with minimal palatal bone is that the exit
tached to the implant abutments, and the patient left with an immediate
point of the head of the zygoma implant is typically located
load fixed prosthesis.
closer to the midline. This is true because the zygoma implant

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Figure 10 Post-insertion radiograph.

Figure 7 Appearance of the tissues at 6 months, following removal of
the interim fixed prosthesis. Impression copings are in place immediately
prior to taking the impression for the definitive restoration.

Figure 8 Anterior view of the completed definitive restoration in place. Figure 11 Second patient documenting the results of ablative surgery
and the active advanced periodontal disease.

Clinical case #4: the untreatable maxilla

In 2004 a 79-year-old female Asian patient presented with
a primary complaint that she could not wear a denture. She
used considerable adhesive and still there was no retention,
stability, function, or comfort. She related that she had a rib
graft augmentation that completely resorbed in short order, fol-
lowed by an HA particulate augmentation that also failed in
a short time. Examination indicated advanced atrophy, a mo-
bile and easily compressed soft tissue roll, and the presence
of no vestibule. CT images verified the dramatic lack of bone
(Fig 26). Due to previous surgical experiences with limited
results, sinus augmentation was ruled out, leaving only re-
construction with a hybrid fixed prosthesis supported by the
quad zygoma approach. The implants were placed, and the
denture was converted to a fixed prosthesis following the stan-
Figure 9 Palatal view of the completed fixed implant-supported hybrid. dard protocol. Healing was uneventful. Six months later an
impression was made of the maxilla (Fig 27). Occlusal records
lies almost flat due to the minimal difference in angulation be- were obtained, the casts mounted, and a wax-up was completed
tween the zygoma and the residual hard palate. This is amplified (Fig 28). Note the severe vertical and horizontal bone defi-
further in cleft palate patients due to the contracted shape of the ciency present (Fig 29). To minimize intrusion of the palatal
maxillary arch (Fig 24). It results in horizontal extension from area, a custom cast frame was designed and cast. Once the
the body of the prosthesis to engage the abutment locations (Fig passive fit was confirmed, the prosthesis was processed and in-
25). The prosthesis has successfully functioned for more than serted. Esthetically and functionally this was a successful result
9 years. (Fig 30, 31). The patient functioned with the prosthesis for

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Figure 12 Radiographic indication of the extensive palatal defect.

Figure 15 Definitive impression taken 6 months following implant place-

Figure 13 Interim fixed prosthesis in place immediately following
ment.
surgery.

Figure 16 Milled titanium bar and the processed definitive fixed pros-
thesis illustrating the two Locator attachments on the lingual area of
the second bicuspids. There is also a step and lingual guide plane for
insertion of the obturator portion of the secondary prosthesis.

Figure 17 Fixed prosthesis with the obturator in place. The obturator

sits over the Locator attachment and completes the occlusal and lingual
Figure 14 Temporary palatal obturator used during the integration stage.
contour of the 2nd bicuspids.
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Figure 18 View of the completed prosthesis in place.

Figure 22 Radiograph following the initial surgery.

Figure 19 Radiograph 5 years after completion of treatment.

Figure 23 Radiograph showing the addition of one more zygoma implant
following the failure of integration of one of the anterior conventional
implants.

Figure 24 Palatal view of the implant locations and the connecting arms
of the left side implants.

Figure 20 Palatal view of the palate of the congenital defect patient

with the two remaining failing molars still in place.

Figure 25 The prosthesis was well anchored. The metal fingers extend-
ing into the palatal area did not have a significant effect on phonetics
since they were contoured to coincide with the palatal architecture. The
Figure 21 Radiograph illustrating the generalized lack of bone, the failing major challenge was from a hygiene standpoint. Aggressive use of a
molars, and the large palatal defect. water irrigation device was encouraged and necessary.

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Figure 26 Illustrated 3D radiographic image and the clinical condition of

this patient.

Figure 30 Completed restoration in place. Patient was pleased with

the functional and esthetic result. The biggest challenge, however, was
hygiene. Due to the extensive tissue coverage, the prosthesis required
removal on a regular basis.

Figure 27 Quad zygoma implants and one short anterior implant were
placed. Due to the lack of bone and flattened exit trajectory of the zygoma
implants, the abutments were almost midline located. Custom tray was
designed for combined pick-up transfer impression copings.

Figure 31 Radiographic view of the completed quad zygoma patient.

4 years before moving from the area. The biggest challenge was
hygiene maintenance due to the broad area of tissue coverage.
This required regular removal of the prosthesis.

Conclusion
To some, zygoma implants may seem like a radical treat-
ment approach. In reality the authors experience has been
that this is no more invasive than bilateral sinus grafting and
Figure 28 Mounted wax-up illustrated the dramatic lack of bone and the implant placement. In the authors observation, the immedi-
loss of vertical ridge height. ate postoperative patient response as to pain and edema is
no greater than conventional multiple implant placements. For
these four patients the zygoma treatment was quality of life
altering.

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