Q U I N T E S S E N C E I N T E R N AT I O N A L

Rehabilitation with zygomatic implants:

A treatment option for the atrophic
edentulous maxilla9-year follow-up
Marcos Rikio Kuabara, DDS, MSc1/Edilson Jos Ferreira, DDS, MSc2/
Jssica Lemos Gulinelli, DDS, MSc3/
Luis Guillermo Peredo Paz, DDS, MSc4
This article reports the 9-year clinical outcome of the two-stage surgical rehabilitation of a
severely atrophic edentulous maxilla with a metal-resin fixed denture supported by
implants anchored in the zygomatic bone and the maxilla. After clinical and radiographic
examination, zygomatic implants were inserted bilaterally and four standard implants were
placed in the anterior region of the maxilla. Six months later, the implants were loaded with
a provisional acrylic resin denture, and the definitive implant-supported metal-resin fixed
denture was provided 1 year after implant placement. After 9 years of follow-up, no painful
symptoms, peri-implant inflammation or infection, implant instability, or bone resorption
was observed. In the present case, the rehabilitation of severe maxillary atrophy using the
zygomatic bone as a site for implant anchorage provided good long-term functional and
esthetic results. Therefore, with proper case selection, correct indication, and knowledge
of the surgical technique, the use of zygomatic implants associated with standard implants
offers advantages in the rehabilitation of severely resorbed maxillae, especially in areas
with inadequate bone quality and volume, without needing an additional bone grafting
surgery, thereby shortening or avoiding hospital stay and reducing surgical morbidity.
(Quintessence Int 2010;41:912)

Key words: atrophic maxilla, dental implants, zygomatic bone, zygomatic implants

The reconstructive rehabilitation of atrophic

maxillae using bone grafts inevitably involves
risk because it demands an accurate surgical
technique, good quality soft tissues covering

Master in Oral and Maxillofacial Surgery, Dental School of

Araatuba, So Paulo State University Jlio de Mesquita Filho,
So Paulo, Brazil; Specialization Professor, Imppar Odontologia,
Londrina, Paran, Brazil.

Master in Oral Rehabilitation and Doctorate Student, Sagrado

Corao University, Bauru, So Paulo, Brazil; Specialization
Professor, Dentistry Imppar, Londrina, Paran, Brazil.

Master in Oral and Maxillofacial Surgery and Doctorate

Student, Dental School of Araatuba, So Paulo State University
Jlio de Mesquita Filho, So Paulo, Brazil; Specialization
Professor, Dentistry Imppar, Londrina, Paran, Brazil.

Master in Oral Rehabilitation and Doctorate Student, Sagrado

Corao University, Bauru, So Paulo, Brazil.

Correspondence: Dr Jssica Lemos Gulinelli, Imppar Odontologia, School of Dentistry, Av. Arthur Thomas, 100, CEP: 86065-00,
Londrina, Paran, Brazil. Email: jessilemos@yahoo.com.br

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the graft, a great deal of patient cooperation,

and a good general health condition favorable
to the healing process.1 In addition, bone
grafting techniques involve surgical morbidity,
such as complications after removal of bone
blocks, longer time during which patients
remain without rehabilitation during the graft
consolidation and healing periods, need of
hospitalization, and higher treatment costs.2
In view of this, the placement of implants in
the zygomatic bone as an alternative to maxillary reconstruction with autogenous bone
grafts has been considered a viable option in
the rehabilitation of atrophic maxillae.
This article reports the 9-year clinical outcome of the two-stage surgical rehabilitation
of a severely atrophic edentulous maxilla with
a metal-resin fixed denture supported by
zygomatic implants and standard implants
anchored in the anterior region of the maxilla.

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Q U I N T E S S E N C E I N T E R N AT I O N A L
Kuabara et al

Fig 1 Preoperative panoramic radiograph showing edentulous maxillary ridge and extensive pneumatization of the maxillary sinuses
bilaterally.

CASE REPORT
A 46-year-old man sought treatment in 2000
complaining of the lack of stability and poor
esthetics of his maxillary complete denture,
which caused difficulty in wearing, nausea,
and great dissatisfaction. The intra-oral clinical examination revealed a totally edentulous
maxilla with a thin residual alveolar bone
ridge. The panoramic radiograph revealed
severe atrophy in the posterior region of the
maxilla bilaterally (Fig 1).
Under general anesthesia, zygomatic
implants were inserted bilaterally, and four
standard implants were placed in the anterior maxilla, with final torque values above
45 N/cm (Fig 2). An acrylic resin guide was
fabricated to orient implant insertion, the registration of the occlusal relationship, the

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Fig 2 Zygomatic implants and standard implants

in the anterior region of the maxilla.

emergence profile, and the biomechanics of

the future fixed denture. Then, cover screws
were placed over the implants, the mucoperiosteal flap was repositioned and sutured,
and the patient was discharged. The sutures
were removed 1 week after the surgical procedure, and monthly appointments were
scheduled to evaluate the periodontal conditions and perform occlusal adjustments. The
patients complete denture was adjusted and
relined with soft material, and he wore it during the postoperative course. After 6 months,
the cover screws were removed, and healing
abutments were connected to the implants
and tightened appropriately. The definitive
metal-resin fixed denture with a nickelchromium bar was screwed to the implants 1
year after the first surgical stage.

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2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Kuabara et al

Fig 3 CT scan of the head in bone windows taken at 9-year followup. Note the bilateral mucous retention cysts in the maxillary sinus.
Fig 4 3D reconstruction of with skull with implants at 9-year follow-up.

Fig 5

The patient has been followed for 9 years,

and annual clinical, radiographic, and computed tomography (CT) controls have been
undertaken. At all visits, the denture was
removed for cleaning and the quality of the
soft tissues and implants verified. No signs of
peri-implant mucosa inflammation/infection
or implant instability were observed. Pain was
not reported at any of the follow-up visits.
Panoramic radiographs, CT scans, and a 3D
reconstruction of the skull did not show bone
resorption processes or maxillary sinus
pathologies (Figs 3 to 5).

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Final rehabiliation after 9 years.

DISCUSSION
In the present case, the patient was not satisfied with his oral condition, especially the
poor esthetics and discomfort caused by an
ill-fitting denture on his severely resorbed
maxilla. This type of complaint is frequent
among patients with severe maxillary atrophy
who do not present sufficient bone volume
for insertion of implants. During case planning, the possible treatment modalities for
rehabilitation of the severe maxillary atrophy
reconstruction with autogenous bone grafts
from an extraoral donor area before implant
placement, palatine approach, tilting implants,
and zygomatic implantswere discussed
with the patient. The decision to use zygomatic implants along with regular implants in
the maxilla was made based on clinical and

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2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

Q U I N T E S S E N C E I N T E R N AT I O N A L
Kuabara et al

radiographic examinations and considering

the patients choice.3
Immediate loading was not used in this
case because at the time of implant surgery,
there were no long-term studies investigating
the behavior and survival of zygomatic
implants subjected to immediate loading, and
most conclusions derived from case reports.4,5
More recently, the placement of immediately
loaded zygomatic implants is guided and facilitated by use of computer-assisted 3D and
rapid prototyping planning,5 which offers a better treatment perspective in the rehabilitation
of the severely atrophic maxilla.
Reported complications associated with
zygomatic implants include postoperative
sinusitis, oroantral fistula formation, periorbital and conjunctiva hematoma or edema,
lip lacerations, pain, facial edema, temporary
paresthesia, epistaxis, gingival inflammation,
and orbital penetration. In some cases,
although there is loss of bone structure, it is
suitable for the removal of zygomatic
implants. The placement of zygomatic
implants associated with standard implants
in the anterior region of the maxilla is a viable
alternative to maxillary reconstruction with
autogenous bone grafts and facilitates the

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rehabilitation of patients with severely atrophic maxillae, substantially reducing surgical

morbidity and treatment duration compared
to bone grafting.

REFERENCES
1. Duarte LR, Nary Filho H, Francischone CE, Peredo LG,
Branemark PI. The establishment of a protocol for
the total rehabilitation of atrophic maxillae employing four zygomatic fixtures in an immediate loading systemA 30-month clinical and radiographic
follow-up. Clin Implant Dent Relat Res 2007;9:
186196.
2. Aghabeigi B, Bousdras VA. Rehabilitation of severe
maxillary atrophy with zygomatic implants. Clinical
report of four cases. Br Dent J 2007;202:669675.
3. Ferrara ED, Stella JP. Restoration of the edentulous
maxilla: The case for the zygomatic implants. J Oral
Maxillofac Surg 2004;62:14181422.
4. Aparicio C, Ouazzani W, Garcia R, Arevalo X, Muela R,
Fortes V. A prospective clinical study of titanium
implants in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a
follow-up of 6 months to 5 years. Clin Implant Dent
Relat Res 2006;8:114122.
5. Chow J, Hui E, Lee PK, Li W. Zygomatic implants
Protocol for immediate occlusal loading: A preliminary report. J Oral Maxillofac Surg 2006;64:804811.

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2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

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