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The use of zygomatic implants for the rehabilitation of atrophic maxillas with 2 different techniques: Stella and Extrasinus

Ernesto Barquero Cordero, MSD,a Cesar A. Magalhes Benfatti, PhD,b Marco A. Bianchini, PhD,c Leonardo Vieira Bez, MSD,d Kyle Stanley, DDS,e and Ricardo de Souza Magini, PhD,f Santa Catarina, Brazil
UNIVERSITY FEDERAL OF SANTA CATARINA

The zygomatic implant anchorage is a surgical technique that provides a new perspective for patients with severe maxillary atrophy, increasing predictability and reduced cost of treatment, besides being a tool for the hardships of the rehabilitation of such a challenging region. This article describes 2 clinical cases with zygomatic implants with different techniques (Stella and Extrasinus) and both with immediate loading and accompanying clinical radiographic follow-up procedures of 12 and 24 months, respectively. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112:e49-e53)

The rehabilitation of patients with severely atrophied maxillas presents a major challenge owing to the complexity of its implementation. The problem presents itself because of the lack of height and width of the alveolar ridge, this being a result of insufcient bone, extractions, trauma, infection, or maxillary sinus pneumatization.1-3 Several surgical techniques have been developed to successfully increase the volume of bone: iliac crest graft, Le Fort I, guided bone regeneration, sinus lifting, and combinations of these procedures.4-9 These treatments also reduce patient comfort, increase morbidity, require several surgeries, and require the use of removable prostheses for a long period of time.10,11 Implants placed in grafted areas have various success rates, with the literature suggesting a rate of 82% to 84% with a clinical follow-up of 12 to 60 months.12 Aiming to simplify the treatment of these patients, increasing the predictability of outcomes and decreasing morbidity, treatment time, and avoiding bone grafts,
PhD program in Implantology, University Federal of Santa Catarina, Santa Catarina, Brazil. b Associate Professor of Implantology, University Federal of Santa Catarina, Santa Catarina, Brazil. c Professor of the Phd and Masters Degree Program of Implantology, University Federal of Santa Catarina, Santa Catarina, Brazil. d Resident of Implantology Program, University Federal of Santa Catarina, Santa Catarina, Brazil. e Resident of Implantology Program, University Federal of Santa Catarina, Santa Catarina, Brazil. f Chairman and Professor of PhD and Masters Degree Program of Implantology, University Federal of Santa Catarina, Santa Catarina, Brazil. Received for publication Apr 28, 2011; accepted for publication May 15, 2011. 1079-2104/$ - see front matter 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2011.05.008
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Brnemark and his team13 in 1988 implemented the anchoring technique known as zygomatic implants (ZI) in some research centers. Initially this technique was designed to treat victims of trauma, tumor resection, or congenital defects. These patients present with a considerable loss of bone structure14 and few regions offering anchorage for the implants. These regions consisted of the body of the zygoma or the frontal portion of the zygomatic bone15 presenting a great alternative. With time, the technique has been rened, allowing patients with severe bone resorption to be restored predictably to proper function and esthetics and with a success rate similar to implants placed using the conventional technique.16 There are different techniques for xation of zygomatic implants. The technique developed by Brnemark17 calls for a Le Fort I incision, allowing the displacement of a large ap to facilitate exposure of the zygomatic bone, and the realization of a window for the displacement of the sinus membrane. The technique of Stella and Warner18 differs from the original technique, as there is no need for a window opening on the wall of the maxillary sinus, only 1 channel orientation, and there is no concern for the integrity of the sinus membrane. The third technique19 has no need for a window opening or a channel in the wall of the maxillary sinus because of the externalization of the zygomatic implants in relation to sinus. This article reports 2 clinical cases that were rehabilitated with different xation techniques, with a radiographic follow-up of 24 and 48 months, respectively. CASE DESCRIPTION Case 1
A 65-year-old female patient at the Center for Teaching and Research in Dental Implants (CEPID) at the Federal University of Santa Catarina (UFSC) presented to perform an

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Fig. 1. Patient 1. A, Intraoral photograph. B, Initial radiograph. C, A channel or slot was completed to dene the orientation of the trajectory of the drills. D, Zygomatic and conventional implants installed. E, Postoperative radiograph. F, Clinical photograph showing the nal prosthetic result. G, Radiographic follow-up at 24 months.

implant reconstruction. Examining the panoramic radiograph revealed bone loss around the upper and lower teeth, observed clinically. With the impossibility of keeping these teeth, treatment options were introduced in the upper arch that would use 4 implants, 2 anchored in the zygomatic bone and 2 in the anterior region. The lower jaw had a treatment plan to place 4 implants. Both treatments had the possibility of immediate loading. The procedure was performed under general anesthesia and was initiated by tooth extractions and smoothing maxillary and mandibular alveolar ridges. Once the tissue was reected and the body of the zygoma was located, drilling was initiated. With a round bur, a channel or slot was completed to dene the orientation of the trajectory of the drills. Then, the following sequence was used: 2.9-mm drill bit, 2.9-mm twist drill, 3.5-mm pilot drill, and 3.5-mm twist drill, always aiming the position of the platform of the implant to lie as close as possible to the crest of the ridge. The next step was the installation of the zygomatic implants, 4.1 diameter 52.0 mm in the posterior left ridge and 4.1 diameter 45.0 mm in the right posterior border. Two implants measuring 4.1 13.0 mm were placed in the anterior. We used the posterior multiunit abutments on 17 (right side) and 30 (left side), both with a height of 4 mm, in order to have the emergence prole located in the molar region. Because the torque was greater than 40 Ncm for the implants in both arches, an immediate loading protocol was initiated, tissue was sutured, and acrylic resin (Duralay, Reliance) was used to secure the abut-

ment transfers in both arches and an impression for manufacturing the prostheses was completed. After 48 hours, the prostheses were installed, restoring function and esthetics for the patient. Panoramic radiographs were performed at 12 and 24 months for the control treatment (Fig. 1, A-G).

Clinical case 2
A 68-year-old male patient presented to the CEPID at UFSC for rehabilitation of the upper jaw. On clinical examination there was a xed prosthesis supported by implants in the lower jaw and upper jaw with a thin ridge. It was suggested that the patient have implants anchored in the zygomatic bone owing to the desire not to undergo a complex reconstruction with extraoral donor sites. The procedure started in the hospital with a LeFort type I incision, using the ZI externalized technique. After the ap was reected, the sequence of drilling included 2.9-mm pilot drill, 2.9-mm twist drill, 3.5-mm pilot drill, and 3.5-mm twist drill. After the placement of the implant platform directly over the ridge, the installation of four zygomatic implants was completed, two on the left side: 4.1 diameter 48 mm and 4.1 diameter 45 mm; on the right side 4.1 diameter 45 mm, 4.1 diameter 48 mm. We used a microunit-type abutment 17 with a height of 4 mm, so as to have the emergence prole located in the molar region. Because the torque was greater than 40 Ncm for the implants in both arches, an immediate loading protocol was initiated, tissue was sutured, and acrylic resin (Duralay, Reliance) was used to secure the abutment transfers in both

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Fig. 2. Patient 2. A, Intraoral photograph. B, Initial radiograph. C, Extrasinus zygomatic implant. D, Four zygomatic implants. E, Clinical photograph. F, Postoperative radiograph. G, Final result (a, intraoral; b, extraoral). H, Radiographic follow-up at 48 months.

arches and an impression for manufacturing the prosthesis was completed. After 48 hours, the prosthesis was installed, reestablishing the function and esthetics for the patient. Panoramic radiographs were performed at 24 and 48 months for the control treatment (Fig. 2, A-H).

DISCUSSION After extractions, the process of bone remodeling in the jaw suffers, causing inadequate dimensions for implant placement. This atrophy is physiological and occurs in a chronic and irreversible fashion.6 The lack of internal pressure along with posterior tooth extraction leads to bone resorption of the edentulous alveolar ridge, making the retention of functional prostheses difcult and can lead patients to a disabled state in their mouth with a decreased quality of life.20,21 Patients with major destruction of the premaxilla, maxillary sinus pneumatization, or defects owing to tumor resection have limitations on treatment with oral implants. Maxillary bone atrophy is classied by several authors19,20,21 as a major challenge, with a high difculty of rehabilitating a severely resorbed maxilla, indicating a major reconstruction with autogenous bone grafts using extraoral donor sites,22 subsequent to the placement of implants or anchoring techniques, without bone reconstruction. The reconstruction techniques involve an increase in the jawbone structure, aiming at the application of

conventional xation in places where there is sufcient alveolar height and thickness, providing the use of implants in a much better position and, consequently, better biomechanic distribution. The reconstructions can be made on the alveolar ridge (onlay) or within cavities, particularly the sinus (inlay).22 The grafts have inevitably some element of risk, because they demand good surgical technique, good quality of recipient bone, soft tissue overlying the graft, great cooperation from the patient, and general health of the patient that encourages healing.23 The literature shows a variability in the survival percentage of the different techniques of bone grafting being 80% to 95%,24-26 with a follow-up time of 12 to 124 months. It also reports that the success rate of implants in bone grafts is 74% to 87%.27-29 Initially, the ZI was designed to treat patients suffering from trauma or surgically resected tumors, where there is great loss of jaw structures.11,23,30 Subsequently, the technique was applied to patients with severe maxillary atrophy to simplify the treatment and avoid a reconstruction.31 There are different techniques for xation of zygomatic implants, including the original technique by Brnemark, which recommends opening a window on the wall of the maxillary sinus as well as maintaining the integrity of the sinus membrane. The rst case used a protocol originally pro-

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posed by the Stella technique with the use of a channel or slot through which the implant installation is guided into the sinus, eliminating the bony window and the sinus lifting, having a larger implant bone interface with a vertical orientation and better emergence placement of the implant closest to the crest of the alveolar ridge. In the second case study, the extrasinus zygomatic implant technique traces an imaginary line from the insertion point on the ridge to the point of attachment to the body of the zygoma and the implant can be completely or partially outside the sinus cavity. The choice of technique is determined by the patients bone anatomy as well as technical skill of the clinician. The zygomatic implant requires care in relation to the biomechanical forces of curvature, whose forces may impair the long-term stability of an implant-supported restoration and, because of this, there must be stiff prosthetic work, because exing of the materials used can cause deformation and deviation resulting in loss of xation of the implants or loosening of the junction between the prosthesis and xation.32 The use of immediate loading with the 1 or 2 ZI on each side is justied by some authors because they believe that the quality of the zygomatic bone, the rigid stabilization and polygons created in the technique, coupled with the benets provided to the patient (less time, less cost, and possibility of social life) allows this procedure to be used.33,34 The use of prototypes seems to be an interesting tool in the planning of this technique, but high cost still hampers its use.35 An important question is what could cause the presence of zygomatic implants inside the maxillary sinus. A study by Nakai et al.36 in 2003 reported using computed tomography scans, performed 6 months after the installation of 15 zygomatic implants, in 9 patients and showed no signs of sinusitis. Petruson, in 2004,37 evaluated the zygomatic implants in the maxillary sinus through a sinuscopy in 14 patients, nding no infection or inammation in the mucosa around the implants. The success rates of implants in the zygomatic bone vary from 95% to 97% with 12 to 124 months of follow-up observation,16,19,23,36-42 and a patient satisfaction rate of 80% after 1 year of installation of the prosthesis.43 CONCLUSIONS Clinically, the technique of zygomatic implants is an excellent therapeutic modality for patients with atrophic maxillas wishing to avoid a bone graft and therefore increasing predictability and reducing costs and morbidity of treatment. The most important point in this procedure is the clinical mastery of the techniques for this surgical approach, determining the success of the treatment.

1. Adell R, Eriksson B, Lekholm U, Brnemark PI, Jemt T. Longterm follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-59. 2. Tolman DE, Laney WR. Tissue-integrated prosthesis complications. Int J Oral Maxillofac Implants 1992;7:477-84. 3. Jemt T, Lekholm U. Implant treatment in edentulous maxillae: a 5-year follow-up report on patients with different degrees of jaw resorption. Int J Oral Maxillofac Implants 1995;10:303-11. 4. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. Series I. Success criteria and epidemiology. Eur J Oral Sci 1998; 106:527-51. 5. Breine U, Brnemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and preformed autologous bone grafts in combination with osseointegrated implants. Scand J Plast Reconstr Surg 1980;14:23-48. 6. Isaksson S, Ekfeldt A, Alberius P, Blomqvist JE. Early results from reconstruction of severely atrophic (class VI) maxillas by immediate endosseous implants in conjunction with bone grafting and Le Fort I osteotomy. J Oral Maxillofac Surg 1993; 22:144-8. 7. Adell R, Lekholm U, Grndahl K, Brnemark PI, Lindstrom L, Jacobsson M. Reconstruction of severely resorbed edentulous maxillae using osseointegrated xtures in immediate autogenous bone grafts. Int J Oral Maxillofac Implants 1990;5:233-46. 8. Isaksson S, Alberius P. Maxillary alveolar ridge augmentation with onlay bone-grafts and immediate endosseous implants. J Craniomaxillofac Surg 1992;20:2-7. 9. Boyne PJ, James RA. Grafting of the maxillary sinus oor with autogenous marrow and bone. J Oral Surg 1980;38:613-6. 10. Wood RM, Moore DL. Grafting of the maxillary sinus with intraorally harvested autogenous bone prior to implant placement. Int J Oral Maxillofac Implants 1988;3:209-14. 11. Bedrossian E, Stumpel L, Beckely ML, Indresano T. The zygomatic implant: preliminary data on treatment of severely resorbed maxillae. A clinical report. Int J Oral Maxillofac Implants 2002;17:861-5. 12. Sjrtrom M, Sennerby L, Nilson H, Lundgren S. Reconstruction of the atrophic edentulous maxilla with free iliac crest grafts and implants: a 3-year report of a prospective clinical study. Clin Implant Dent Relat Res 2007;9:46-59. 13. Brnemark PI. Surgery and xture installation zygomaticus xture clinical procedures. 1st ed. Gotemburgo, Sweden: Nobel Biocare; 1998. 14. Darle C. Minimized treatment for maximal predictability: a new procedure for rehabilitating the severely resorbed maxilla. Talk of the times 4. 1st ed. Gteborg, Sweden: Nobel Biocare; 1999. p. 5. 15. Balshi TJ, Wolnger GJ. Treatment of congenital ectodermal dysplasia with zygomatic implants: a case report. Int J Oral Maxillofac Implants 2002;17:277-81. 16. Aparicio C, Ouazzani W, Hatano N. The use of zygomatic implants for prosthetic rehabilitation of the severely resorbed maxilla. Periodontol 2000 2008;47:162-71. 17. Parel SM, Brnemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent 2001;86:377-81. 18. Stella JP, Warner MR. Sinus slot technique for simplication and improved orientation of zygomaticus dental implants: a technical note. Int J Oral Maxillofac Implants 2000;15:889-93. 19. Migliorana RM, Ilg JP, Serrano AS, Souza RP, Zamperlini MS. Exteriorizao de xao zigomticas em relao Ao seio maxilar: Uma nova abordagem cirrgica. Implant. News 2006;3:30-4.

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Reprint requests: Ernesto Barquero Cordero, PhD Rua Duarte Schuttel 262, Ap 301 Centro, Florianpolis Santa Catarina, Brasil 88015-640 erbarquer@yahoo.es