Chantal Malevez Clinical outcome of 103 consecutive

Marcelo Abarca
Françoise Durdu
zygomatic implants: a 6–48 months
Philippe Daelemans follow-up study

Authors’ affiliation: Key words: zygomatic implants, zygoma bone, atrophic maxilla, oral implants, edentulism
Chantal Malevez, Marcelo Abarca, Françoise
Durdu, Philippe Daelemans, Department of
Maxillofacial Surgery and Dentistry, Erasme Abstract: The purpose of this study was to evaluate retrospectively, after a period of 6–48
Hospital, Université Libre de Bruxelles, Brussels months follow-up of prosthetic loading, the survival rate of 103 zygomatic implants inserted
Belgium
in 55 totally edentulous severely resorbed upper jaws. Fifty-five consecutive patients, 41
Correspondence to: females and 14 males, with severe maxillary bone resorption were rehabilitated by means of
Dr Chantal Malevez
a fixed prosthesis supported by either 1 or 2 zygomatic implants, and 2–6 maxillary implants.
Department of Maxillofacial Surgery and Dentistry
Erasme Hospital Université Libre de Bruxelles This retrospective study calculated success and survival rates at both the prosthetic and
808 Route de Lennik 1070 Brussels implant levels. Out of 55 prostheses, 52 were screwed on top of the implants, while 3 were
Belgium
Tel.: +32 2 555 44 74 modified due to the loss of standard additional implants and transformed in semimovable
Fax: +32 2 555 45 99 prosthesis. Although osseointegration in the zygomatic region is difficult to evaluate, no
e-mail: cmalevez@ulb.ac.be
zygomatic implant was considered fibrously encapsulated and they are all still in function.
This study confirms that the zygoma bone can offer a predictable anchorage and support
function for a fixed prosthesis in severely resorbed maxillae.

Date:
Accepted 20 January 2003
To cite this article:
Malevez C, Abarca M, Durdu F, Daelemans P. Clinical
outcome of 103 consecutive zygomatic implants: a 6–48
months follow-up study.
Clin. Oral Impl. Res. 15, 2004; 18–22
doi: 10.1046/j.1600-0501.2003.00985.x
Copyright r Blackwell Munksgaard 2003
Long-term results of fixed prosthesis on 2-
stage c.p. titanium screw-shaped oral im-
plants indicate a predictable treatment
outcome (Adell et al. 1990; van Steen-
berghe et al. 1990).
However, implant insertion and prosthe-
tic rehabilitation of patients with an ex-
tremely atrophied maxilla are especially
difficult issues. Bone resorption in the
posterior region, widening of the sinuses,
and anterior alveolar bone resorption can
dramatically reduce the possibility of im-
plant insertion and prosthetic rehabilita-
tion. Ideally, these patients would have to
be treated with bone augmentation techni-
ques or onlay or veneer bone grafting,
combined with sinus grafts or possibly
nasal floor augmentation (Triplett et al.
2000; Kahnberg et al. 2001).
Localised ridge augmentations by means
of a membrane, the so-called guided bone
regeneration (GBR) technique, is a docu-
mented procedure, but data are limited for
the totally edentulous patient (Buser et al.
1993; Simion et al. 2001).
Autologous bone grafting has given sa-
tisfactory success rates. This well-docu-
mented technique implies heavy surgery,
and sometimes considerable morbidity also
at the donor site (Breine & Branemark
1980; Isaksson 1994; Hürzeler et al. 1996;
Lekholm et al. 1999).
The new zygomatic implantation tech-
nique proposes an alternative to this bone
grafting by using the zygoma as a strong
anchorage. Indications for the placement of
zygomatic implants are:
 Sufficient bone volume in the anterior
region of the maxilla: the length of the
maxillary arch with a minimum height
of 10 mm and width of 4 mm allows the
placement of 2–4 implants, but the
resorption of the posterior maxilla re-
duces the possibility of placement of
standard implants.

18

 Insufficient bone volume in the anterior
region of the maxilla: this situation
necessitates onlay graft or GBR for
implant placement. Sinus grafting for
the posterior region could be contra-
indicated for clinical reasons or avoided
by the use of the zygomatic implants.
The aim of this retrospective study in
consecutive patients was to evaluate the
clinical outcome of the zygomatic implants
and the prostheses they carry.
Material and methods
Patients
The study was based on 55 patients treated
at the Department of Maxillofacial Surgery
and Dentistry of the Erasme Hospital
(Université Libre de Bruxelles), between
December 1997 and November 2001.
All 55 patients were provided with
Brånemark Systems Zygomaticus fixtures
(Nobel Biocare AB, Göteborg, Sweden), 41
women and 14 men. The average age for
the men was 62 (range 40–76) years and for
the women 57 (range 22–79) years.
All patients were totally edentulous in
the upper jaw: 21 patients were full
edentulous, while 34 patients were par-
tially edentulous. Thirty-seven patients
were nonsmokers, 11 patients smoked
more than 10 cigarettes a day, and 7
patients reported that they smoked occa-
sionally, but less than 10 cigarettes a day.
The medical history of the patients is
shown in Table 1.
The selection criteria for the zygomatic
implantation were: no possibility to insert
5–6 standard implants in the anterior region
of the maxilla, a posterior bone height of
less than 5 mm. If the anterior maxillary
height was less than 13 mm and the width
less than 4 mm, an additional bone grafting
was performed in the anterior region.
Table 1. Summary of patients’ medical his-
tories
Medical history Study group
Diabetes (type 2) 1
Hypertension 6 Regular Platform diameter 3.75 mm (54
Allergy 5 patients) and Wide Platform diameter 5.0
Antidepressive drugs 1 mm (1 patient) in the anterior maxilla. In
Parkinson 1
Hepatitis 2
Malevez et al . Clinical outcome of 103 consecutive zygomatic implants
Fig. 1. The zygomatic implant and its different measures.
Table 2. Distribution of the different zygo-
ma implants according to their length
Length of zygomatic Number of zygoma
implants in mm implants placed
30 0
35 6
40 43
42.5 3
45 42
47.5 0
50 9 Total of patients
52.5 0
Total of fixtures 103
Exclusion criteria were acute infections
of the sinuses.
Implants
Zygomatic implants are available in 8
different lengths ranging from 30 to 52.5
mm. The portion that engages the residual
maxillary alveolar process has a diameter of
4.5 mm, while the apical portion inserted
in the zygoma has a diameter of 4.0 mm
(Fig. 1).
The distribution lengths of implants are
shown in Table 2.
A total of 103 zygomatic implants were
placed, generally 2, in each patient. Indeed
in 7 patients unilateral anatomical reasons
prevented the placement of 2 implants.
Bone density and bone quantity were
evaluated by eye inspection on the basis
of orthopantomographs and CT scans.
A number of 194 standard Brånemark
Systems implants (Nobel Biocare AB,
Göteborg, Sweden) were placed in the
anterior maxilla following the protocol
defined by Brånemark (Brånemark et al.
1985). Patients had a combination of 1 or 2
zygoma implants with 2, 3, 4, 5 or 6
Brånemark Systems implants of type
patients where 6 implants were placed, 2
were inserted in the maxillary tuberosity.
Table 3. Relation between number of im-
plants in the anterior sector of the maxilla
and the number of zygomatic implants in
the posterior sector in the group of
patients
Number of implants 2 3 4 5 6
in the anterior sector
of the maxilla
1 zygoma implant 0 0 1 2 3
2 zygoma implants 15 7 24 3 0
15 7 25 5 3
The distribution of zygomatic and anterior
implants is shown in Table 3.
Surgical procedures
All the zygomatic implants were placed
under general anesthesia. A Le Fort I
osteotomy incision was used in 2 patients.
For the others, this incision was modified
for technical reasons to a palatal incision,
which exposes the entire maxillary alveolar
process from zygomatic buttress to zygo-
matic butress. The drilled hole ends at the
junction of the zygomatic arch and the
lateral orbital rim. The zygomatic implant
ultimately engages the bone in both the
zygoma and the maxillary alveolus
(Brånemark 1998).
Antibiotic prophylaxis, mostly amoxicil-
lin 2 g/day for 5 days, was used in all
patients. Except for the first 2 patients, all
received corticoids to avoid the important
swelling of the lips and face.
Normally, the placement of additional
standard implants in the anterior sector of
the maxilla is done at the time of the
placement of the zygomatic implants, but
in 7 patients, due to the extreme bone
resorption they presented, an autologous
onlay or veneer bone graft was placed at the
time of the first surgery (Fig. 2). The
placement of the standard implants was
then delayed to a second surgery a few
months later (4–6 months).
All anterior implants were placed routi-
nely according to a 2-stage procedure.
19 | Clin. Oral Impl. Res. 15, 2004 / 18–22
Malevez et al . Clinical outcome of 103 consecutive zygomatic implants
Fig. 2. Installation of the left zygomatic implant. The top of the implant is seen on the top of the zygoma.
Fig. 3. Final bridge made of gold and porcelain screwed on the 2 zygomatic implants and 4 standard ones.
Prosthetic procedures
On the day of the abutment connection,
standard abutments were installed on all
implants and all the implants were immedi-
ately connected by a rigid bar or a provisional
acrylic prosthesis screwed on top of them.
The final prosthetic procedure started
about 10 days after abutment connection
according to the standard prosthetic proto-
col (Brånemark et al. 1985).
The final prosthesis consisted of a con-
ventional gold framework with acrylic
20 | Clin. Oral Impl. Res. 15, 2004 / 18–22
teeth. In 2 patients, the teeth were made
of porcelain (Figs. 3, 4)
Results
None of the 103 zygomatic implants failed.
A life table of zygomatic implants is shown
in Table 4.
Out of all the 194 placed in the anterior
maxilla, 16 were lost, which means the
success rate was 91.75%.
These losses clustered in 7 patients but
all, except 3, still wear a fixed prosthesis.
These 3 patients went back to a removable
prosthesis, of whom 1, who lost all the
standard implants (3), got 2 magnets on the
zygomatic implants.
One complication was observed prior to the
placement of the prosthesis, 1 patient pre-
sented a severe infection of the sinus, which
was successfully treated with antibiotics.
After prosthesis placement, patients
were controlled after 1 week, 1 month, 3
months, 6, 12, 24, 36 up to 42 months.
Stability of the zygomatic implants, con-
trol of plaque and inflammation, bleeding on
probing were performed at all the implants
sites and for the anterior standard implant
retroalveolar radiographies were also realised
at 3 and 6 months and once a year.
Orthopantomograms were realised on all
the patients after surgery at the time of the
insertion of the prosthesis, but this exam-
ination could not give relevant information.
In 3 patients, facial X-rays gave a better
information concerning the localisation of
the zygomatic implant.
In cases where bone grafting was per-
formed, CT scans were realised but could not
contribute to any conclusions concerning
osseointegration of the zygomatic implants.
After prosthesis placement, 5 patients
had sinusitis that, however, could not be
associated with the zygoma implants. One
patient had a variety of several complaints
due to psychological problems, 1 patient
had problems with oral hygiene control,
and 1 patient had aesthetic problems.
Discussion
Few reports have been published about
zygomatic implants (Higuchi 2000;
Schramm et al. 2000; Stevenson & Austin
2000; Bedrossian & Stumpel 2001; Parel et
al. 2001; Uchida et al. 2001). None offers a
follow-up as long as the present study. The
use of zygomatic implants represents an
interesting alternative in the rehabilitation
of the fully edentulous patient. It offers a
solid and an extended anchorage in a region
situated at an important distance from the
occlusal level. Indeed, histological analysis
of the zygoma shows regular trabeculae and
compact bone with an osseous density of
98% (Gosain et al. 1998).

Fig. 4. Facial X-ray showing a global image of the rehabilitation on 2 zygomatic implants and 2 standard ones.
Table 4. Life-table analysis showing survival rates and cumulative survival rates (CSR) of
zygomatic implants
Period of time
zygomatic implants
Placement–Prosthesis insertion
Prosthesis insertion–6 months
6–12 months
12–24 months
24–36 months
36–48 months
48 months
The zygoma bone can be compared to a
pyramid, offering an interesting anatomy
for the insertion of implants (Karlan &
Cassisi 1979). The proven strength of
this anchorage contrasts with the poor
bone quality (mostly type IV) of the poster-
ior maxilla.
Owing to this bone density, it has also
been used in the treatment of the max-
illofacial fractures, for the insertion of
miniplates (Champy et al. 1986). It has
also been used as well during orthodontic
treatment, offering a fixed anchorage to
allow tooth movements (Melsen et al.
1998). In the protraction of the maxilla,
one animal study uses the zygoma bone as
Malevez et al . Clinical outcome of 103 consecutive zygomatic implants
Only clinical appreciation about the
stability of the implants was performed:
no pain, no swelling, no infection, and no
mobility.
A relevant radiographic analysis of bone
apposition is also impossible around the
implant in the zygoma.
All zygomatic implants in this series are
still in function, without complications,
and with no signs of pain, infection or any
pathology.
Conclusions
The zygomatic implants have been devel-
oped for compromised maxillary situations.
The zygomatic implant offers a predictable
therapeutic solution as has been shown in
this up-to-4-year observation on more than
100 consecutive implants without a single
implant loss.
There is a need to develop clinical and/or
radiological criteria to assess whether zy-
goma implants have achieved an intimate
bone-to-implant contact.
Résumé
Number of Failed Survival CSR % Le but de cette étude a été d’évaluer rétrospective-
rate % ment, après une période de six à 48 mois après la
placed mise en charge prothétique, le taux de survie de 103
implants zygomatiques insérés chez 55 édentés
103 0 100 100 complets avec mâchoires supérieures extrêmement
103 0 100 100 résorbées. Cinquante-cinq patients (41 femmes et
101 0 100 100 quatorze hommes) avec une résorption osseuse
64 0 100 100 maxillaire très sévère ont été soignés à l’aide d’une
34 0 100 100 prothèse fixée supportée par un ou deux implants
10 0 100 100 zygomatique et deux à six implants maxillaires.
2 0 100 100
Cette étude rétrospective a calculé le taux de survie
et le taux de succès tant au niveau prothétique et
qu’implantaire. Des 55 prothèses, 52 ont été vissées
sur les implants tandis que trois ont été modifiées vu
an anchorage place (Smalley et al. 1988). In la perte d’implants standards supplémentaires et
maxillofacial prosthesis, the zygoma bone transformées en prothèses semi-amovibles. Bien que
was utilized as an anchorage for the l’ostéoı̈ntégration dans la région zygomatique soit
difficile à évaluer, aucun implant zygomatique n’a
placement of implants for a facial pros-
été considéré comme encapsulé fibreusement et ils
thesis (Sabin et al. 1995). Finally after sont encore tous en fonction. Cette étude confirme
maxillectomy, zygomatic implants were que l’os zygomatique peut offrir un ancrage pré-
connected with other standard implants visible et unun support de support pour une
in a conventional screwed prosthesis (Izzo prothèse fixée dans les cas de maxillaires fortement
résorbés.
et al. 1994).
For all these reasons, zygoma bone
should be considered as a steady anchorage
for rehabilitation of the very resorbed Zusammenfassung
maxilla.
Die klinischen Ergebnisse von 103 Implantaten im
In the present study, only survival was Jochbein. Eine Langzeitstudie über 6–48 Monate.
reported since the application of success Das Ziel dieser Studie war es, bei 55 vollständig
criteria is technically impossible. zahnlosen und massiv resorbierten Oberkiefern die
21 | Clin. Oral Impl. Res. 15, 2004 / 18–22
Malevez et al . Clinical outcome of 103 consecutive zygomatic implants
Überlebensrate von 103 Implantaten im Jochbein
retrospektiv zu untersuchen. Die Beobachtungszeit
betrug 6–48 Monate nach prothetischer Versorgung.
55 Patienten, 41 Frauen und 14 Männer, die eine
ausgedehnte Knochenresorption des Oberkiefers
zeigten, wurden mit einer festsitzenden Brücke
versorgt, die von 1–2 Implantaten im Jochbein und
2–6 weiteren Oberkieferimplantaten getragen wurde.
Diese retrospektive Studie errechnete Erfolgsrate
und Überlebensrate sowohl der prothetischen Re-
konstruktion, wie auch der Implantate. Von den 55
Brücken waren 52 auf den Implantaten verschraubt,
und 3 infolge Verlust von Standardimplantaten zu
bedingt abnehmbaren Brücken umgebaut.
Obwohl die Osseointegration in der Region des
Jochbeins schwierig zu beurteilen ist, musste keines
dieser Implantate als bindegewebig eingeheilt be-
zeichnet werden und alle sind immer noch in
Funktion.
Diese Arbeit belegt, dass der Knochen des Jochbeins
ein voraussagbare Verankerung und Haltefunktion
für eine festsitzende Brücke bei massiv resorbierten
Oberkiefern liefern kann.
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La intención de este estudio fue evaluar retro-
spectivamente, tras un periodo de 6–48 meses de
seguimiento de carga prostética, el ı́ndice se super-
vivencia de 103 implantes zigomáticos insertados en
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