ZYGOMATIC AND PTERYGOID IMPLANTS.pptx

1. ZYGOMATIC AND
PTERYGOID IMPLANTS
`
Moderated by: Dr Rahul Kashyap (Prof. and Head of OMFS)
Presented by : Gauri Bargoti

2. Contents
Introduction
History Of Implants
Zygomatic implants (indications; contraindications)
Surgical procedures
Post-op care
Prosthesis fabrication
Advantages and disadvantages
Pterygoid implants

3. Anatomy of edentulous maxilla: Problem
for implant placement
Introduction
Maxillary sinuses
and the position of
the nasal floor:
Limit Vertical
Volume
Palatal and Posterior
resorption pattern :
Limit Horizontal
pattern
REFERENCE: Wood M, Vermilyea SG: A review of selected dental literature on evidence-based treatment planning for dental implants: report of the
committee on research in fixed prosthodontics of the Academy of Fixed Prosthodontics, J Prosthet Dent 92:447- 462, 2004

4. Problems with Atrophic Maxilla
Centripetal bone resorption
Pneumatization of maxillary sinus
Lack of internal osseus stimulation
Lack of stability for
fixed prosthesis
REFERENCES : Bedrossian E, Stumpel L, Beckely M, Indersana T. The zygomatic implant: preliminary data on treatment of severely resorbed maxillae. A clinical report. Int J Oral Maxillofac
Implants 2002;17:861–5
Breine U, Branemark PI: Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and performed autologous bone grafts in combination with osseointegrated
implants, Scand J Plast Reconstr Surg 14:23-48, 1980

5. Treatment Options For Atrophy
Graft Reconstruction
Guided Bone Regeneration
Sinus Floor Elevation
References: Baj A, Trapella G, Lauritano D, Candotto V, Mancini GE, Giannì AB. An overview on bone reconstruction of atrophic maxilla: success parameters and critical issues. J Biol Regul
Homeost Agents. 2016 Apr 1;30(2 Suppl 1):209-15.
Alveolar Bone Distraction
Leforte 1 Osteotomy

6. Disadvantages Of These Techniques
These procedures are time consuming
Donor site morbidity
Presence of second surgical site
Increase in treatment time
References: Zygomatic Implants by James Chow
Massive Hemorrhage
Invasive surgical procedure

7. Non- Grafting solution
No donor site morbidity
Less time consuming
References : 1) Bedrossian E, Stumpel L, Beckely M, Indersana T. The zygomatic implant: preliminary data on treatment of severely resorbed maxillae.
A clinical report. Int J Oral Maxillofac Implants 2002;17:861–5.
2) Pterygoid implants: anatomical considerations and surgical placement P. GEORGE1 , G. M. KURTZMAN
Solution… Zygomatic and Pterygoid Implants
Avoid Bony substitute
Zygoma being the stable point

8. ZYGOMATIC IMPLANTS

9. BRANEMARK’S
STUDY
Introduced zygomatic implants in 1999
In 10 years follow-up, 110 implants were placed
Only two were lost in first year of occlusal loading.
3 failed in coming 8 years, Success rate of 95%
References: Brånemark PI, Gröndahl K, Ohrnell LO, Nilsson P, Petruson B, et al. (2004) Zygoma fixture in the management of advanced atrophy of the maxilla: technique and
long-term results. Scand J Plast Reconstr Surg Hand Surg 38: 70-85.

11. Indications
MODERATE
ATROPHY
SEVERE
ATROPHY
INADEQUATE
POSTERIOR
SUPPORT
SYNDROME
PATIENT
ACQUIRED AND
CONGENITAL
DEFECT
IMMEDIATE
LOADING
PARTIAL
EDENTULISM
References : Schnitman PA, Wohrle PS, Rubenstein JE, et al. Ten-year results for Brånemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac
Implants 1997;12:495–503..
Jaffin RA, Kumar A, Bermann CL. Immediate loading of implants in partially and fully edentulous jaws: a series of 27 case reports. J Periodontol 2000;71:833–5
Salama H, Rose LF, Salama M, Betts NH. Immediate of bilaterally splinted titanium root-form implants in prosthodontics – a technique reexamined: two cases. Int J Periodontol Rest Dent
1995;15:344–60

12. Contraindication
Systemic compromise or sinus disease
Presence of adequate maxillary bone
Insufficient premaxillary support for at least two stable implants
REFERENCES: Peterson’s principles of oral and maxillofacial surgery

13. ClinicalAssessment
Pathology Free maxillary sinus
Adequate soft tissue at site of implant placement
Patient should be medically fit to withstand 2 hour long
surgery
Mandibular range of motion must be adequate to provide zygoma
fixture
REFERENCES: Peterson’s principles of oral and maxillofacial surgery

14. Radiographic Evaluation
 Although computerized and conventional tomography can be used, the Panorex radiograph is
critical in the initial diagnosis.
 Axial CT scans can be obtained to further evaluate the maxillary sinus.
 Computerized and conventional tomography can be used
References : Nkenke E et al.: Anatomic site evaluation of the zygomatic bone for dental
implant placement, Clin Oral Implants Res 14:72-79, 2003

16. References : Nkenke E et al.: Anatomic site evaluation of the zygomatic bone for dental
implant placement, Clin Oral Implants Res 14:72-79, 2003

17. Pre-operative Consideration
Infiltrations and nerve blocks include circumvestibular infiltration of
the maxilla, greater palatine blocks, and bilateral transcutaneous
infiltration of the temporal areas over the zygomatic body
It is recommended that direct visualization of the path of the implant
from the premolar area to the base of the zygoma be visualized
whenever possible.
The proper axis is a path extending from the bicuspid region through
the maxillary sinus, entering the midportion of the zygomatic body.
REFERENCES: Peterson’s principles of oral and maxillofacial surgery

18. SURGICAL PROTOCOL
Crestal incision
across maxillary
arch
Bilateral vertical
incision over
maxillary tuberosity

19. Stella and Warner: sinus slot approach

20. REFERENCES : Grecchi F, Bianchi AE, Siervo S, Grecchi E, Lauritano D, Carinci F. A new surgical and technical approach in zygomatic implantology. ORAL & implantology. 2017
Apr;10(2):197.

21. Extra-sinus zygomatic implant
REFERENCE: Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, Codesal M, Barluenga N, Manresa C, Franch M. Extrasinus
zygomatic implants: three year experience from a new surgical approach for patients with pronounced buccal concavities in the edentulous maxilla.
Clinical implant dentistry and related research. 2010 Mar;12(1):55-61.

22. Post-operative Care
Patients are asked to maintain a soft diet.
Postoperative medications include oral antibiotics for 1 week and an analgesic of
choice, as needed.
All patients are asked to use 2% chlorhexidine rinse 20 minutes before sleeping every
night.
 A 1-week follow-up appointment is made to ensure proper occlusion, wound healing,
and stability of the prosthesis.
 If screw loosening is encountered, occlusion is checked, eliminating hyperocclusion
on selected areas and interference in lateral excursions. Patients are seen as needed over
the next 6 month

23. Surgical Complications
Penetration of orbit and pterygomaxillary space
Soft tissue irritation around implant
Foreign bodies in nose and sinus
Neurosensory Disturbance
References: Zwahlen R et al.: Survival rate of zygomatic implants in atrophic or partially resected maxillae prior to functional loading: a retrospective clinical report, Int J Oral
Maxillofac Implants 21:413- 420, 2006.
Farzad P et al.: Rehabilitation of severely resorbed maxillae with zygomatic implants: an evaluation of implant stability, tissue conditions, and patient’s opinion before and after
treatment, Int J Oral Maxillofac Implants 21:399-404, 2006

24. Cutaneous fistula with
suppuration
Exposure of the apical part of the
implant.
Advanced bone resorption
around zygomatic implant
because of periimplantitis
REFERENCES: Tzerbos F, Bountaniotis F, Theologie-Lygidakis N, Fakitsas D, Fakitsas I. Complications of zygomatic implants: our clinical experience with 4 cases.
Acta stomatologica Croatica: International journal of oral sciences and dental medicine. 2016 Sep 23;50(3):251-7.

25. Final Prosthesis Fabrication
1. After 6 months of osseointegration time, the prosthesis is removed, and the stability of the implants is
checked.
2. Osseointegration is confirmed by observation of the lack of mobility of the implants and the lack of
sensitivity during percussion. (Fazad et al).
3. Upon determination of osseointegration, the patient is ready for either the fabrication of an all-acrylic
profile prosthesis or a metal-based and acrylic profile prosthesis using resin teeth

26. Advantages Of Zygomatic Implants
1) Reduced Surgical Intervention
2) Overall shortened time
3) Graft less procedure
4) Treatment of patients with zygomatic implants is
an in office surgical procedure that allows them to
use existing maxillary dentures after surgery
5)Immediate temporization
Disadvantages Of Zygomatic Implants
1. Access to the surgical site.
2. Difficulty in speech, due to the placement of these
implants in the palate, the implant head affects the
space available for the tongue.
REFERENCES : Gulia S, Vigarniya MM. A comprehensive review on zygomatic implants. Journal of Health and Allied
Sciences NU. 2017 Dec;7(04):043-8.

30. Case 2

31. Pterygoid Implants

32. Why to use pterygoid implants
It helps to overcome the need for maxillary sinus lift and grafting
procedures
It allows a prosthesis to have sufficient posterior extensions, which
eliminates the need for detrimental distal cantilevers
Shortens the treatment time
References: Balshi TJ, Wolfinger GJ, Balshi SF. Analysis of 356 pterygomaxillary implants in edentulous arches for fixed prosthesis anchorage. Int J Oral
Maxillofac Implants 1999: 14: 398–406

33. Placement Of Pterygoid Implant
The implant enters in the region of the former maxillary first or second molar
and follows an oblique mesio-cranial direction
Proceeds upwards between both wings of the pterygoid processes and finds its
encroachment in the pterygoid or scaphoid fossa of the sphenoid bone
Implant is passed through this juncture at an angle of 45 degrees, it can
incorporate up to 8– 9 mm of dense cortical bone and its apex protrudes 2
mm into the pterygoid fossa
References : Graves SL. The pterygoid plate implant: a solution for restoring the posterior maxilla. Int J Periodontics
Restorative Dent 1994: 14: 512–523
IMPLANT IN PTERYGOID PROCESS
IMPLANT IN PTERYGOMAXILLARY
PROCESS

34. Should implants be placed in the pterygoid
process or the pterygomaxillary region
The classic technique of pterygoid implants was described by Tulasne: This technique
used 22-mm-long implants.
Some researchers, including Bahat and Balshi have placed implants as long as 7 or
8.5 mm in : pterygomaxillary region without anchorage in the pterygoid process.
The findings in the literature showed no clear differences between pterygoid and
pterygomaxillary implant.

35. A crestal incision is made from the hamular notch mesially to the premolar area, a vertical
releasing incision is made at the anterior aspect of the incision and a full thickness flap is
elevated to expose the tuberosity
A dimple is created at the planned osteotomy at the center of the tuberosity with a #6 round bur
in the surgical handpiece
The alignment drill is next used to initiate the osteotomy to a depth of 5 mm at the angulation planned
based on radiographic analysis
Next, the 1.5 mm starter drill is utilized to a depth until the dense bone of the pterygoid plates are felt
The osteotomy is continued with the 2.5 mm PTG drill to final depth

36. When the osteotomy has been completed, the handpiece driver is placed into the surgical
handpiece and inserted into the implant in the container with the hex on the driver engaging
the implants internal hex
The implant is carried to the osteotomy on the driver and at 30 rpm and set at 35 ncm
torque, the PTG implant is threaded into the site until it is placed ¾ into the osteotomy or
the surgical unit reaches insertion torque
PTG implant placed at the site, which will act as a guide for the bone profile drill to be
utilized.
References: Pterygoid implants: anatomical considerations and surgical placement P. GEORGE1 , G. M. KURTZMAN

39. Summary Of Pterygoid Implants
References: Bidra AS, Huynh-Ba G. Implants in the pterygoid region: a systematic review of the literature.
International journal of oral and maxillofacial surgery. 2011 Aug 1;40(8):773-81.

40. Success Rate Of Pterygoid Implants

41. Complications
Bleeding
Arterial Venous

42. Anchorage Problem
Due to drilling beyond pterygoid process
Vrielinck et al lost 4 of 6 implants due to problems in placing
them in the initially drilled implant bed and having to place
them in a different position, which resulted in insufficient bone
anchorage.

43. Summary
The zygomatic implant is a predictable fixture to establish posterior maxillary support
for a fixed, implant-supported maxillary prosthesis without the need for bone
grafting.
In the hands of experienced surgical and prosthetic teams, the zygomatic implant is a
viable addition to existing treatment modalities.
Pterygoid implants have high success rates, similar bone loss levels to those of
conventional implants, minimal complications, and good acceptance by patients;
therefore, they are an alternative for treating patients with atrophic posterior maxilla.

44. References
1. PETERSONS PRINCIPLES OF OMFS
2. Oral and Maxillofacial Surgery - Volume 1(FONSECA)
3. Bedrossian E, Stumpel L, Beckely M, Indersana T. The zygomatic implant: preliminary data on treatment of severely resorbed maxillae. A
clinical report. Int J Oral Maxillofac Implants 2002;17:861–5.
4. Pterygoid implants: anatomical considerations and surgical placement P. GEORGE1 , G. M. KURTZMAN
5. Schnitman PA, Wohrle PS, Rubenstein JE, et al. Ten-year results for Brånemark implants immediately loaded with fixed prostheses at implant
placement. Int J Oral Maxillofac Implants 1997;12:495–503..
6. Jaffin RA, Kumar A, Bermann CL. Immediate loading of implants in partially and fully edentulous jaws: a series of 27 case reports. J
Periodontol 2000;71:833–5
7. Salama H, Rose LF, Salama M, Betts NH. Immediate of bilaterally splinted titanium root-form implants in prosthodontics – a technique
reexamined: two cases. Int J Periodontol Rest Dent 1995;15:344–60
8. Nkenke E et al.: Anatomic site evaluation of the zygomatic bone for dental implant placement, Clin Oral Implants Res 14:72-79, 2003

45. Grecchi F, Bianchi AE, Siervo S, Grecchi E, Lauritano D, Carinci F. A new surgical and technical approach in zygomatic
implantology. ORAL & implantology. 2017 Apr;10(2):197.
Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, Codesal M, Barluenga N, Manresa C, Franch M.
Extrasinus zygomatic implants: three year experience from a new surgical approach for patients with pronounced
buccal concavities in the edentulous maxilla. Clinical implant dentistry and related research. 2010 Mar;12(1):55-61.
Tzerbos F, Bountaniotis F, Theologie-Lygidakis N, Fakitsas D, Fakitsas I. Complications of zygomatic implants: our clinical
experience with 4 cases. Acta stomatologica Croatica: International journal of oral sciences and dental medicine. 2016 Sep
23;50(3):251-7.
Zwahlen R et al.: Survival rate of zygomatic implants in atrophic or partially resected maxillae prior to functional loading: a
retrospective clinical report, Int J Oral Maxillofac Implants 21:413- 420, 2006.
Farzad P et al.: Rehabilitation of severely resorbed maxillae with zygomatic implants: an evaluation of implant stability, tissue
conditions, and patient’s opinion before and after treatment, Int J Oral Maxillofac Implants 21:399-404, 2006
Pterygoid implants: anatomical considerations and surgical placement P. GEORGE1 , G. M. KURTZMAN
Bidra AS, Huynh-Ba G. Implants in the pterygoid region: a systematic review of the literature. International journal of oral and
maxillofacial surgery. 2011 Aug 1;40(8):773-81.