Advertisement

The Zygoma Anatomy-Guided Approach: ZAGA—A Patient-Specific Therapy Concept for the Rehabilitation of the Atrophic Maxilla

Chapter
  • 332 Downloads

Abstract

Zygomatic implants are used for prosthetic rehabilitation of the severely atrophic maxilla. The original surgical technique (OST) at modum Brånemark prescribed an intra-sinus pathway of the implant from a palatal site entrance and preparation of an antrostomy for visualization during implant insertion. However, different morphologies of the edentulous maxilla exist. The more concave the maxillary anterior wall, the more palatal position the implant head position will be. If the maxilla is severely atrophic, the palatal entrance will occur through thin cortical bone. These situations frequently result in bulky prosthetic constructions, impaired hygiene and, eventually, sinus complications.

To overcome the limitation of OST and to facilitate ongoing use of zygomatic implants, different surgical approaches, including the extra-sinus technique, have been described. The author has previously introduced a novel protocol, named Zygoma Anatomy-Guided Approach (ZAGA) which aims to promote a patient-specific therapy. In most cases, this method avoids the opening of a window or slot into the lateral wall of the maxillary sinus prior to implant placement. Instead, a muco-periosteal flap, including the posterior maxillary wall and the superior zygomatic rim, is raised, to allow visualization of the complete surgical field. The surgical management of the implant site is guided by the anatomy of the patient and the conservation of eventual remaining alveolar bone is critical.

A classification describing the variations of the zygomatic buttress anatomy helps the surgeon to choose the coronal and apical entrance points for the zygomatic drill. A rationale is proposed to choose the osteotomy position and characteristics, which usually leads to perforating the anterior Zygoma cortex twice. As a consequence, the path of the implant may vary from completely intra-sinus to completely extra-sinus. Using specific success criteria for zygomatic implants, the ZAGA method has yielded significantly improved results along with a reduced number of long-term complications compared to previous techniques.

In addition to the clinical aspects, we present a concept: Zygoma ZAGA Centers network, aiming to disseminate the ZAGA principles and methodology among professionals and patients for safe and predictable zygoma-related rehabilitation.

Keywords

ZAGA Extra-sinus Extra-maxillary Zygomatic implants Immediate loading Zygomatic success criteria Patient-specific therapy Atrophic maxilla Zygoma ZAGA Centers 

Notes

Acknowledgements

The ZAGA protocol arises from the desire to overcome the drawbacks of the original technique. Like almost all innovations, the one described in this chapter would not have happened without an origin from which to evolve. In this regard, I wish to deeply thank my teacher and mentor Prof. P-I Brånemark for sharing his vision of the use of zygoma bone for remote implant anchorage. I am also grateful for the opportunity he gave me to publish the first report in 1993 showing the utility of zygomatic implants in maxillary rehabilitation. In addition, I would like to recognize the generosity and support of Prof. Dr. Chantal Malevez during my first three surgeries. I still smile when remembering those first intense moments. I would like to acknowledge Mr Graham Blackbeard, CEO of SouthernImplants Cº, for the intense discussions we have had to achieve the best possible zygomatic implant design. SouthernImplants is the manufacturer Cº of “Zygan”, the Zygomatic model of implant used to illustrate this chapter. Finally, I would like to acknowledge all the colleagues who have generously shared their experiences in the field of zygomatic implants through publications. Without them, I could not be presenting this work.

References

  1. 1.
    Aparicio C, Brånemark PI, Keller EE, Olive J. Reconstruction of the premaxilla with autogenous iliac bone in combination with osseointegrated implants. Int J Oral Maxillofac Implants. 1993;8:61–7.Google Scholar
  2. 2.
    Higuchi KW. The zygomaticus fixture: an alternative approach for implant anchorage in the posterior maxilla. Ann R Australas Coll Dent Surg. 2000;15:23–33.Google Scholar
  3. 3.
    Stevenson AR, Austin BW. Zygomatic fixtures–the Sydney experience. Ann R Australas Coll Dent Surg. 2000;15:337–9.PubMedGoogle Scholar
  4. 4.
    Parel SM, Brånemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent. 2001;86:377–81.CrossRefGoogle Scholar
  5. 5.
    Bedrossian E, Stumpel L III, 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.PubMedGoogle Scholar
  6. 6.
    Malevez C, Daelemans P, Adrianssens P, Durdu F. Use of zygomatic implants to deal with resorbed posterior maxillae. Periodontol 2000. 2003;33:82–9.CrossRefGoogle Scholar
  7. 7.
    Brånemark PI, Gröndahl K, Ohrnell LO, Nilsson P, Peturson B, Svensson B, et al. Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results. Scand J Plast Reconstr Surg Hand Surg. 2004;38:70–85.CrossRefGoogle Scholar
  8. 8.
    Aparicio C, Ouazzani W, Garcia R, Arévalo X, Muela R, Fortes V. A prospective clinical study on 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;8:114–22.CrossRefGoogle Scholar
  9. 9.
    Davó R. Zygomatic implants placed with a two-stage procedure: a 5-year retrospective study. Eur J Oral Implantol. 2009;2:115–24.PubMedGoogle Scholar
  10. 10.
    Bedrossian E. Rehabilitation of the edentulous maxilla with the zygoma concept: a 7-year prospective study. Int J Oral Maxillofac Implants. 2010;25:1213–21.PubMedGoogle Scholar
  11. 11.
    Aparicio C, Manresa C, Francisco K, Ouazzani W, Claros P, Potau JM. The long-term use of zygomatic implants: a 10-year clinical and radiographic report. Clin Implant Dent Relat Res. 2014;16:447–59.CrossRefGoogle Scholar
  12. 12.
    Ouazzani W, Arevalo X, Sennerby L, Lundgren S, Aparicio C. Zygomatic implants: a new surgical approach. J Clin Periodontol. 2006;33(Suppl II):128.Google Scholar
  13. 13.
    Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, et al. Extra-sinus zygomatic implants: three year experience from a new surgical approach for patients with pronounced buccal concavities in the edentulous maxilla. Clin Implant Dent Relat Res. 2008;12:55.  https://doi.org/10.1111/j.1708-8208.2008.00130.x.CrossRefPubMedGoogle Scholar
  14. 14.
    Aparicio C, Hatano N, Ouazzani W. The use of zygomatic implants for prosthetic rehabilitation of the severely resorbed maxilla. Periodontol 2000. 2008;47:162–71.CrossRefGoogle Scholar
  15. 15.
    Aparicio C. A proposed classification for zygomatic implant patients based on the zygoma anatomy guided approach (ZAGA). A cross-sectional survey. Eur J Oral Implantol. 2011;4:269–75.Google Scholar
  16. 16.
    Aparicio C, editor. Zygomatic implants. The anatomy-guided approach. Surrey, UK: Quintessence Publishing Co Ltd; 2012. ISBN 978-1-85097-225-9.Google Scholar
  17. 17.
    Aparicio C, Manresa C, Francisco K, Aparicio A, Nunes J, Claros P, Potau JM. Zygomatic implants placed using the zygomatic anatomy-guided approach versus the classical technique. A proposed system to report rhino-sinusitis diagnosis. Clin Implant Dent Relat Res. 2013;16:627.  https://doi.org/10.1111/cid.12047.CrossRefPubMedGoogle Scholar
  18. 18.
    Aparicio C, Manresa C, Francisco K, Ouazzani W, Claros P, Alandez J, Albrektsson T. Zygomatic implants: indications, techniques & outcomes. Zygomatic Success Code (ZSC). Periodontol 2000. 2013;64:1–19.Google Scholar
  19. 19.
    Stella JP, Warner MR. Sinus slot technique for simplification and improved orientation of zygomaticus dental implants. A technical note. Int J Oral Maxillofac Implants. 2000;15:889–93.PubMedGoogle Scholar
  20. 20.
    Peñarrocha M, Uribe R, Garcia B, Martí E. Zygomatic implants using the sinus slot technique: clinical report of a patient series. Int J Oral Maxillofac Implants. 2005;20:788–92.PubMedGoogle Scholar
  21. 21.
    Boyes-Varley J, Howes D, Lownie J, Blackbeard G. Surgical modifications to the Brånemark zygomaticus protocol in the treatment of the severely resorbed maxilla: a clinical report. Int J Oral Maxillofac Implants. 2003;18:232–7.PubMedGoogle Scholar
  22. 22.
    Migliorança RM, Llg JP, Serrano AS, Souza RP, Zamperlini MS. Exteriorização de fixações zigomáticas em relação ao seio maxilar: uma nova abordagem cirúrgica. Implant News. 2006;3(1):30–5.Google Scholar
  23. 23.
    Migliorança RM, Coppedê AR, Zamperlini MDS, Mayo T, Viterbo RBS, Lima DM. Reabilitação da maxila atrófica sem enxertos ósseos: resultados de um novo protocolo utilizado em casos de edentulismo total. Implant News. 2007;4(5):557–64.Google Scholar
  24. 24.
    Migliorança RM, Coppedê A, Dias Rezende RC, de Mayo T. Restoration of the edentulous maxilla using extrasinus zygomatic implants combined with anterior conventional implants: a retrospective study. Int J Oral Maxillofac Implants. 2011;26:665–72.PubMedGoogle Scholar
  25. 25.
    Maló P, Araujo M, Lopes I. A new approach to rehabilitate the severely atrophic maxilla using extra-maxillary anchored implants in immediate function: a pilot study. J Prosthet Dent. 2008;100:354–66.CrossRefGoogle Scholar
  26. 26.
    Davo R, Pons O, Rojas J, Carpio E. Immediate function of four zygomatic implants: a 1-year report of a prospective study. Eur J Oral Implantol. 2010;3:323–34.Google Scholar
  27. 27.
    Duarte LR, Filho HN, Francischone CE, Peredo LG, Brånemark PI. The establishment of a protocol for the total rehabilitation of atrophic maxillae employing four zygomatic fixtures in an immediate loading system a 30-month clinical and radiographic follow-up. Clin Implant Dent Relat Res. 2007;9:186–96.CrossRefGoogle Scholar
  28. 28.
    Stievenart M, Malevez C. Rehabilitation of totally atrophied maxilla by means of four zygomatic implants and fixed prosthesis: a 6–40-month follow-up. Int J Oral maxillofac Surg. 2010;39:358–63.CrossRefGoogle Scholar
  29. 29.
    Chow J, Wat P, Hui E, Lee P, Li W. A new method to eliminate the risk of maxillary sinusitis with zygoma implants. Int J Oral Maxillofac Implants. 2010;25:1233–40.Google Scholar
  30. 30.
    Aparicio C, Rangert B, Sennerby L. Immediate/early loading of dental implants: a report from the Sociedad Española de Implantes World Congress Consensus Meeting in Barcelona, Spain, 2002. Clin Implant Dent Relat Res. 2003;5(1):55–60.CrossRefGoogle Scholar
  31. 31.
    Balshi SF, Wolfinger GJ, Balshi TJ. A retrospective analysis of 110 zygomatic implants in a single-stage immediate loading protocol. Int J Oral Maxillofac Implants. 2009;24:335–41.PubMedGoogle Scholar
  32. 32.
    Bedrossian E, Rangert B, Stumpel L, Indresano T. Immediate function with the zygomatic implant: a graftless solution for the patient with mild to advanced atrophy of the maxilla. Int J Oral Maxillofac Implants. 2006;21:937–42.PubMedGoogle Scholar
  33. 33.
    Chow J, Hui E, Lee PK, Li W. Zygomatic implants protocol for immediate occlusal loading: a preliminary report. J Oral Maxillofac Surg. 2006;64:804–11.CrossRefGoogle Scholar
  34. 34.
    Davó R, Malevez C, Rojas J, Rodríguez J, Regolf J. Clinical outcome of 42 patients treated with 81 immediately loaded zygomatic implants: a 12-to-42 month retrospective study. Eur J Oral Implantol. 2008;1:141–50.Google Scholar
  35. 35.
    Davo C, Malevez C, Rojas J. Immediate function in the atrophic maxilla using zygoma implants: a preliminary study. J Prosthet Dent. 2007;97:S44–51.CrossRefGoogle Scholar
  36. 36.
    Mozzati M, Monfrin SB, Pedretti G, Schierano G, Bassi F. Immediate loading of maxillary fixed prostheses retained by zygomatic and conventional implants: 24-month preliminary data for a series of clinical case reports. Int J Oral Maxillofac Implants. 2008;23:308–14.PubMedGoogle Scholar
  37. 37.
    Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, Codesal M, Barluenga N, Manresa C, Franch M. Immediate/early loading of zygomatic implants: clinical experiences after 2 to 5 years of follow-up. Clin Implant Dent Relat Res. 2010;12(Suppl 1):e77–82. Epub 2008 Dec 3.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Hepler Bone Clinic, ZAGA Center BarcelonaBarcelonaSpain

Personalised recommendations