FUTURE OF IMPLANTS – ZYGOMATIC IMPLANTS

Zygomatic implants have emerged as a life changing advancement in the field of implantology and prosthetic dentistry. It is a hope to patients who are not suited for traditional dental implants due to lack of bone in the jaws and is an excellent alternative, more predictable and less traumatic than complex bone grafting or sinus augmentation procedures.

What are Zygomatic implants?

Zygomatic implants were first known in the field of dentistry in the year 1988. The word “zygomatic” comes from ‘zygomatic bone’ which is basically the bone that forms prominent part of cheekbones and outer side of the eye socket. So, the dentist will place the implants in your cheekbones instead of jaws. This is usually done in patients who have lost their jaw bones owing to cancer or any infections.

Zygomatic implants have become known to many particularly after the second wave of Covid-19. Patients who have had pre-existing immune-compromising health conditions like diabetes dealt with deadly complications of Covid-19 like black fungus.

Zygomatic Implant is embedded into the cheek bone otherwise called zygomatic bone, thereby eliminating the need for bone grafting and/or sinus lifts. A specially designed long dental implant (30mm- 60 mm length) is placed through the jaw bone and then into the zygomatic bone for anchorage. After the implants are fixed, a provisional prosthesis can be fixed immediately on the same day.

Who should get zygomatic implants?

Zygomatic implants are highly indicated in the following conditions:

·????????Severely resorbed maxilla (upper jaw)

·????????Patients suffering from black fungus or mucormycosis

·????????Patients with a history of failed endosteal/traditional implants

·????????Patients with history of tumor removal leading to resection of the upper jaw

·????????Patients with failed sinus augmentation or bone regenerative procedures

Overview of the procedure

Phase I

·????????Treatment planning with CBCT scans and surgical guide preparation

·????????Presurgical medical checkup

·????????Teeth removal, if needed and followed by dental implant placement, and immediate fixed provisional denture.

Factors to consider for Zygoma Implants:

You must match the following criteria to be eligible for zygomatic implants

·????????You must be symptom less clinically with pathology-free maxillary sinuses

·????????Appropriate CBCT imaging of the maxillary sinuses and zygoma regions

·????????At least two straight implants to be placed in the frontal maxilla

In the atrophic posterior maxilla, in general one zygomatic implant is placed on each side of the maxilla, in combination with 2-4 conventional implants in the anterior region.

For the totally resorbed maxilla, when placement of anterior implants is not possible the concept can be expanded by inserting 2 additional zygomatic implants in a more anterior position (Quad zygoma). Zygomatic implants nowadays are usually immediately loaded with a fixed temporary bridge.

Phase II (usually after 6 months)

Final fixed prosthesis is delivered. Various options are:

ü?New Hybrid Acrylic (Ivoclar) wrap-around Prosthesis with Nobel Procera Titanium framework.

ü?Nobel Procera Titanium framework with Sirona in-lab Zirconium crown and bridge

Surgical protocol

Zygomatic and pterygoid implant surgeries are among the most complicated in the dental field and are normally conducted only by experienced and specialized dental surgeons. The surgical intervention, including flap design and sufficient tissue reflection, demands thorough knowledge of the local vital anatomic structures, including the infraorbital foramen and nerve, the medial part of the zygomatic body, and the zygomatic arch.

Latest technology that has resulted in many benefits for the industry involves dental implant surgical guides. These guides are the latest advancement in the dental world and they have revolutionized surgical processes beyond just dentistry.

A surgical guide helps dentists place dental implants properly and in the right locations. These guides are developed by imaging software that creates a remapped treatment plan.

To make a surgical guide, first and the foremost step is taking impressions of the desired surgical impact site, including 3D images. These impressions and imaging usually taken by intraoral scanners and are then transferred to special software that develops the guide device. These devices — which look like a clear retainer — are then placed over the patient’s teeth and the dentist can easily find the area where the implant should be placed.

These guides are especially useful when we are dealing the next level of implants i.e., zygomatic and pterygoid implants. Given the awkward angles and inability to see clearly, placing dental implants are difficult, so much so that it can lead to the implant failure. Using these guides will help increase and improve the predictability of the outcome.

One of the commonly used guide for zygoma implants are the EZ? guides by Noris Medical. A simple to use surgical set allows the predictability of immediate loading with the efficiency of a short and error-proof workflow.The EZguide? surgical set allows the full capabilities of all guide types: From pilot drilling to fully guided implant loading, for bone, tissue, or teeth supported guides.The EZguide? surgical kit is suitable for tapered or cylindrical implants and is the only guided surgical set to include the ability to place pterygoid implants – Fully guided in the same set.

Another surgical guide by Noris medical is the EZgoma? which is designed to assist in complex zygomatic and pterygoid implant procedures.

Once our treatment planning seems appropriate, we move on to the surgical part which includes incision making and exposure followed by implant placement.

ABC555 protocol is generally followed along with T.I.I.L.T while dealing with single zygoma and ABC333 protocol for quad zygoma.

What is ABC555 protocol?

ABC555 protocol is usually followed after we obtain a CBCT scan covering zygomatic bone, orbit and maxilla.

Here, we mark 3 imaginary points – A, B, and C on different locations of the face. A corresponds to the 5th tooth (2nd premolar) on that side, which is also the point of entry. B is the point where you enter the zygomatic bone. It is always 5mm away from the zygomatic crest. Now, when we join points A and B, we arrive at C which is the point where implant actually comes out and is always 5mm away from the orbit.

What is T.I.I.L.T technique?

T.I.I.L.T stands for Tilted Implants with Immediate Loading Technique. The use of tilted implants parallel to the anterior wall of the maxillary sinus or the mental foramen/inferior alveolar nerve has been proposed as a conservative solution for the treatment of the atrophic edentulous maxillae

The ideology of this technique is to engage all the 3 vertical buttresses, nasomaxillary, zygomaticomaxillary and pterygomaxillary buttresses.

This is because the buttress system absorbs and transmits the forces to the facial skeleton. Masticatory forces are transmitted to the skull base primarily through the vertical buttresses, which are joined and additionally supported by horizontal buttresses.

The tilting may also allow for improved cortical anchorage and primary stability as well as the use of a longer implant. By tilting the implant infact, a more posterior implant position can be reached, and improved implant anchorage can be achieved by benefiting from the cortical bone of the wall of the sinus and the nasal fossa.

Once the implants are placed, we place the cover screw or multi-unit abutment, after which a post-op CBCT is taken for analysis. Immediate provisional restoration can be placedor delayed final prosthesis can be placed once uncovered after 4 to 6 months. If we go for immediate provisionalization, we give the patient immediate fixedprosthesis the day of or the day after surgery. After 6 months of osseointegration, the final prosthesis can be fabricated. It is imperative that the restorations are retainedby screws to provide cross-arch stabilization ofthe implants.

Just as with conventional implants, the optimalimplant placement is critical for an ideal prostheticoutcome. In the past, stereolithographic modelswere used to plan the ideal implant position and angulation. At present, custom surgical guides can becreated for the initial pilot drills. Navigation can alsobe used to precisely position the zygomatic implants.

The science has advanced much and we at Dr. RajatSachdeva’s dental clinic have also constantly evolved ourselves to serve our patients better.

While this information holds good for zygomatic implants, we would also like to discuss about quad zygomas briefly.

Quad zygoma

The concept of quad zygoma aims to address severely atrophic maxilla. The term “quad” is an abbreviation used loosely for something with 4 sides. Quad zygoma involves the use of 4 zygomatic implants on the upper arch on each side. The greatest advantage of using this procedure is that there is no need for any bone grafting or bone augmentation procedures. This makes quad zygoma not only a cost-effective treatment option but also time saving.

Traditionally a fixed prosthesis is fabricated over these zygomatic implants but these can also be used to retain an overdenture.

These implants are highly indicated in the following conditions:

·????????Severely resorbed maxilla (upper jaw)

·????????Patients suffering from black fungus or mucormycosis

·????????Patients with a history of failed endosteal/traditional implants

·????????Patients with history of tumor removal leading to resection of the upper jaw

·????????Patients with failed sinus augmentation or bone regenerative procedures

What is the key take-home message about zygomatic implants?

ü?The extrasinus placement of implants can helpavoid the development of chronic sinusitis andposition implant emergence to a more ideal prosthetic location.

ü?Cross arch stabilization is mandatory for zygomatic implants

ü?To improve the anteroposterior spread and minimize an anterior cantilever when placing 4 zygomatic implants, the implants should emerge atthe area of the first molars and canines, if possible

ü?Exposure of the lateral–inferior orbital rim willminimize the risk of injury to the globe and orbitalcontents

ü?Gently loosen the implant transfer abutmentbefore placing it in the mouth—these generallyhave a tight seal; thus, breaking the seal before intraoral placement will allow for easier removalonce the implant has been placed.

In conclusion, oral and maxillofacial surgeons with additional training in zygomatic implants areuniquely qualified to place these highly techniquesensitive implants. Zygomatic implants are an integralpart of dental rehabilitation of patients with severemaxillary atrophy and those with post-traumatic defects. They offer a predictable graftless technique to restore the edentulous maxilla in asingle procedure.

They are definitely the future of dental implants and prosthetic rehabilitation.

Why chose us?

Zygomatic implant placement using computer-guided implant placement software is a very modern and technique-sensitive modality. Our clinic is well-equipped with all the necessary state-of-the-art modern infrastructure so that we deliver fast, accurate and high quality treatments.

We are living in the world of digital revolution and our clinic has not missed on this agenda. The surgical guides that we use for computer guided implant surgery are of high standards and unmatched quality form Noris Medicals. The guided surgical set helps the surgeon to accurately control the location, orientation and positioning of the implants. It also minimizes the human error thus increasing the accuracy of implant placement.

Our main aim at Dr. Sachdeva’s dental clinic is that every patient leaves happy and confident in their smiles. Dr. RajatSachdeva believes that zygomatic implants have shown remarkable changes in patient’s quality of life. He further agrees that zygomatic implants have come as a blessing for patients who have lost a significant amount of bone structure owing to black fungus.

If you think that zygomatic implants are for you, feel free to come for a no-obligation consultation today.