Zygomatic and Pterygoid Implants in Severe Resorbed Maxilla

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Posted on By Maurice Salama In Full Arch & Dentures

Full Maxillary Prosthesis with minimal Bone remaining for routine implant placement. Ideas, treatment options, and case management approaches??
This should be a great discussion and debate. Thoughts on Treatment. This approach is one I have learned from my dear friend Professor Alexander Salvoni and his TEAM in Sao Paolo, Brazil.
Compare this method to the 3 Part RELATED POSTS on the TOP RIGHT of your Screen that I posted months ago? Which way would you rather go? Dr. Salama

Double Zygomatic and 2 Pterygoid Implants
Panoramic

CBCT
Zygomatic Prep


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29 Comments

Seems like a Class 3 situation as well. Perhaps this will require an anterior cantilever to correct the malocclusion as well as replace the teeth.
Bone is needed in Sinus and anteriorly. BMP-2 Ti-Mesh in anterior and BMP-2 in Sinus Lift. Then return 6-8 month later and place 6-8 implants for Hybrid prosthesis.
Sam


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if you graft with ti-mesh in the anterior, are you comfortable with the patient wearing a maxillary complete denture over this? or are you going to ask your patient to go without it for six months?


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augment the maxillary sinus place 6 implants and galvano bridge on them ,


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How old is this subject?(observing cervical spondylosis may at least be over 65)
Various solutions can be suggested depending on several factors like healthy status, psicological behaviour, outcome expectancy...


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I think one option is the placement of 4 zygomatic implants, to place an overdenture to compensate the class III.


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i think the easiest way is to augment the sinuses and then go for all on 4 approach to solve the problem in maxilla.also using overdenture in mandible.
tnx for sharing this case


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cases like this i have 1) referred to Tom Balshi at Prosthodontics Intermedica and he has routinly delivered immediate load cases using Zygoma and Pterygoid plate implants for his No Bone solution... I have been very impressed with his results and know that those cases are NOT for me!


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Maxilla: Bilateral sinus augmentation, 4 implants each side, bar overdenture with full palatal coverage.
Madible: this is a hip graft case. Has to go with out any prosthesis during graft maturation.Lower hybrid or bar overdenture with 4 to five implants


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OK. Here are the BIG questions for all that responded??
Pklease let me know your answers.
In the Maxilla: Zygomatic vs. Bilateral Sinus LIFT??
In the Mandible: Short Implants vs. Onlay Bone Grafts??
Thanks
Dr. Salama


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Maxilla: I would go for bilateral sinuslift (or Sam Lee approach if possible) since the implants will have a better position. The crestal bone heights is not sufficient for good long term prognosis of the Zygomaticus implants (need 5mm according to the lit.)

Mandible: "short implants". P-I Brånemarks very first case had similar bone heights and his team placed 8,5mm long implants. Excellent prognosis long term.

As mentioned above the Galvano would be a great option.

Good Luck and please come back and show us how You did the case!

// Erik


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Maxilla: 5 short implants, with the posterior ones 45° and the front 3 parallel between.

Mandible: 4 short implants.

Less trauma, less cost.


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I think if there is enough soft tissue thickness, the option of subperiosteal implants should be considered


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sinus lift left then 2 implants left and 2 implants right(you can avoid sinus lift on this site) metal cast frame with locators .removable denture can be palate free with metal plate.so far i did about 15 cases ,works very good for the pt.no need for zygomatic implants.6 implants would be the ideal.($$?)
mandible 2-4 implants and over denture+locators unsplintted


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If you use 6 implants on the maxilla and individual Locators then do you engage all of the implants with the Locator attachments? if so what strength/color do you use? Have you had all 15 of your successes with unsplinted implants in the maxilla opposing lower full dentures?
Thank you!!!


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the unsplinted locators were used ONLY for the mandible.
Maxilla:
for tha maxilla all locators were inserted on a metacast i.e implants were connected to each other.
blue clips provide enought retention if 3-4 locators are used.
i want to mention also something about the implant placement.:due to extrem bone resorption most of the time it is difficult to have parallel implants to each other.
recommendations:
1) use an implant system with external hex.
2) with internal hex choose a company that provides angulated abuntments15 or 25 degr.
3) or 2 separated bars left/right in the maxilla.


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Theo, Implant Direct makes 15 and 30 degree angle corrected locators that fit internal connections for their product line. Which also fit The Zimmer ,Nobel and Straumann counterparts.


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I view this case as does Theo. 4 implants in maxilla. Keeping sinus lifts to a minimum. Utilizing crestal approach where necessary. 2-4 implants anterior mandible. Locator attachments, metal framework ect.
Chuck


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Gentlemen. Compare this method to the 3 Part RELATED POSTS on the TOP RIGHT of your Screen that I posted months ago? Which way would you rather go? Dr. Salama


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I would rather go for bone augmentation including bilateral sinus lifts and implant placement at a later stage with more confidence, short and Wide diameter implant in the mandible. I would go for a tenting screws technique or onlay bone graft majorly for horizontal deficiency in posterior Mandible.
Looking at all the answers it seems no body denying the success with zygomatics & ptyregoid implants, inferior alveolar nerve transposition but I think most of us GPs, perio. Prostho do not like to be so far from our comfort zone (alveolar ridges and adjacent structures) but maxilla-facial surgeons they do.
Just my thoughts.

Omar


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Great case Maurice! It looks like the anterior implants are "extramaxillary". A recent publication on extramaxillary zygomatic implants stated, "Until the biomechanical aspects are more predictable and also because of the complexity of the surgical technique, this rehabilitation approach is not ready for every implant clinician to begin using in practice".
If there was available bone for standard implants in the anterior maxilla then the combination with zygomatic and ptyergoid implants may be more predictable with fewer long term complications.

Maló P, de Araújo Nobre M, Lopes A, Ferro A, Moss S.
Extramaxillary Surgical Technique: Clinical Outcome of 352 Patients Rehabilitated with 747 Zygomatic Implants with a Follow-Up between 6 Months and 7 Years. Clin Implant Dent Relat Res. 2013 Sep 4. doi: 10.1111/cid.12147. [Epub ahead of print]


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Omar and Craig; This is exactly the kind of discussion I was looking for. If you see my Related post you will see a case where I did perform Bone Grafting and Sinus Augmentation in multiple steps on a similar case type. The case took much longer to restore, had multiple surgeries required, more healing time, more expense and more patient management problems BUT was clearly more in my and my Prosthodontists "comfort zone".
Having said that, Craig, as you say, this technique is still clearly still being researched and evaluated for long term success and results. There seems to be 3 different methods out there, Extramaxillary technique (like the one mentioned in the article you cited), Intramaxillary and through the Sinus and remaining Alveolar ridge, and Trans Sinus with the schniderian membrane lifted and sinus grafted. No comparisons of each method against one another that I can find. An interesting note, I have heard from those with experience that when Zygomatic Implants are connected to conventional implants in the Anterior Maxilla that the conventional implants seem to lose crestal bone and have failed over time due to the natural movement found with these longer fixtures and distances from the Cortical Stability in the Zygoma to the load area on the Maxillary ridge often some 30-40mm away.
Maurice


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Maurice. I am more in agreement with Omar and Craig (at this point and time). However, if long term results prove to be favorable, the advantages you have mentioned are significant. Perhaps incorporation of guided surgery would reduce risk. Did you use guided surgery here? Either way, your precision of implant placement is impressive. Thank you for sharing. Best regards Chuck.


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Chuck,
I'm not sure guided surgery is the answer. This recent publication found unacceptable marginal bone loss in a significant number of "All on Four" implants placed with flapless guided surgery.

“However, unacceptable ongoing bone loss was seen in 49.2% of the patients; this may be a warning sign for future problems and needs clinical attention”.

Browaeys H, Dierens M, Ruyffelaert C, Matthijs C, De Bruyn H, Vandeweghe S. Ongoing Crestal Bone Loss around Implants Subjected to Computer-Guided Flapless Surgery and Immediate Loading Using the All-on-4® Concept. Clin Implant Dent Relat Res. 2014 Jan 8. doi: 10.1111/cid.12197. [Epub ahead of print]


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Craig. Good point to consider. I am not a big fan of flapless surgery, but does guided surgery always need to be flapless? Chuck


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Chuck, I don't favor flapless surgery either. It is difficult to use a soft tissue borne guide in the edentulous maxilla when a flap is elevated. I usually make an crestal incision towards the palate to allow lateralization the keratinized gingiva. After the implant osteotomies and/or implant placement the facial flap can be reflected to reposition the keratinized tissue. I have been surprised to see exposed threads in some cases.


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Scientific evidence is all about: up to date scientific published data, PATIENT DESIRES & EXPECTATIONS (something we sometimes may forget) and at last (but not least): the clinician SKILL to accomplish a certain procedure or sequence of procedures. That said, Zygomatic implants can really be an option, as they may provide for the possibility of immediate load, on extraordinarily difficult "absent bone" clinical cases. This can be an issue for some patients. As to predictability I've been with Ruben Davós in Alicante and he has got really impressive results with zygomatics. But then again SKILL is essential! Something else worth considering is SKILL to solve problems that may appear when utilizing this kind of approach. Any of the 3 approaches you presented are equally valuable, specially when performed by such a gifted surgeon as yourself. Perhaps the previous 2 are more in the comfort zone of the vast majority of oral surgeons and GPs that do perform some implant dentistry. Thank you for sharing these impressive cases. Filipe.


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Zygomatic implants are a well documented and useful method to manage the atrophic maxilla. The discussion was on EXTRAMAXILLARY zygomatic implants. This approach has not been studied as much as the classic zygomatic implant and research to date does not support routine use.


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I must ask: Does the patient need upper implants?
Many of my happiest patients like this case have been treated with lower subperiosteal implants and upper conventional denture.. Some done one-stage from medical CT scan.(early '90s).
I urge my colleagues to do a number of lower subs and find out how easy and predictable the modality is.
Maxillae totally different and I would not do sub for upper. As most of you know upper full arch failing implants are a disaster for all. We need to proceed with caution.
PK


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Paul; Please post a Sub-Periosteal Implant Case that you have done recently using a CBCT. Would love to see a case as it is an option i am aware of but have NEVER considered.
Craig, thanks so much for your comments on this FORUM. We all benefit immensely from your experience and knowledge of the LITERATURE!!!
Thanks Dr. S


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