Zygoma implant-supported midfacial - Constantin Alexander.pdf

Zygoma implant-supported midfacialprosthetic rehabilitation: a 4-yearfollow-up study including assessmentof quality of life

Constantin AlexanderLandes

Authors’ affiliation:Constantin Alexander Landes, Maxillofacial andPlastic Facial Surgery, The J.-W. Goethe UniversityMedical Centre, Frankfurt, Germany

Correspondence to:Dr Dr Constantin Alexander LandesKlinik fur Kiefer und plastische GesichtschirurgieJohann-Wolfgang Goethe UniversitatFrankfurtTheodor-Stern-Kai 760596Frankfurt am MainGermanyTel.: þ49-69-6301-5879Fax: þ49-69-6301-5644e-mail: [email protected]

Key words: maxillary defect, maxillectomy, midfacial rehabilitation, prosthetic cantilever,

zygoma implant, Zygomaticus fixture

Abstract

Objective: Successful prosthetic rehabilitation is crucial for quality of life in cases of large

maxillary defects when surgical reconstruction is not advisable because of general health or

patient refusal. For this purpose, the extended indications for Zygomaticuss fixtures in

different defect types were evaluated.

Patients and methods: Twelve patients received 28 zygoma implants and 23 dental

implants (if a segment of alveolar process was available) and were followed-up 14–53

months. Zygoma implants were positioned classically in the maxillary molar region and to

reduce leverage, a premolar and a canine position was developed. The quality of life was

assessed by a validated questionnaire after complete rehabilitation.

Results: Cumulative zygoma implant survival was 82%. Three losses occurred because of

persistent infection and gradual loosening. Lost implants were immediately replaced in

adjacent bone. Insufficient implant length within soft tissue reconstructions was prone to

chronic infection by pocketing and recurrent overgrowth of granulating tissue. Longer

implants were free of soft tissue inhibition, yet prone to overloading and high leverage in

cases when no anterior alveolar process and dental implants were present. Zygoma implant

success was therefore 71%, including the new premolar and canine Zygomatikusfixture-

position. Periotests values increased from 0 to þ7 to the fourth year, peri-implant bleeding

and plaque index were decreasing from 56% to 0% and 33% to 0%, respectively, and

good general quality of life with the priorities on chewing and activity was noted.

Conclusion: Zygoma implants can reliably anchor the midfacial maxillary prostheses and

enable a quality of life comparable with autologous maxillary reconstruction. They can be

replaced immediately if local infection or loosening should occur. A premolar and canine

position reduce leverage when no anterior alveolar process is present. The patient can

alternatively be provided with dental implants.

Patients with severe maxillary defects have

major difficulties to re-establish their mas-

tication, speaking, soft tissue projection

and, therefore, social integration. When

the options of local bone augmentation

and elevation of the sinus floor do not

supply sufficient bone for safe dental im-

plant positioning (Triplett & Schow 1996),

myocutaneous or osteo-myocutaneous tis-

sue transfer is an alternative (Swartz et al.

1996; Rogers et al. 2003). However, some

patients prefer to avoid secondary morbid-

ity from reconstructive procedures, and

others are limited by their general health

condition. These individuals benefit from

an oronasal obturator prosthesis. However,Copyright r Blackwell Munksgaard 2005

Date:Accepted 25 April 2004

To cite this article:Landes CA. Zygoma implant-supported midfacialprosthetic rehabilitation: a 4-year follow-up studyincluding assessment of quality of life.Clin. Oral Impl. Res. 16, 2005; 313–325doi: 10.1111/j.1600-0501.2005.01096.x

313

in cases of extensive palatomaxillary resec-

tion, these obturators tend to be unstable,

and residual anchoring teeth are frequently

overloaded and may be consecutively lost.

Furthermore, little frictional or capillary

retention is available when the patient is

edentulous and oronasal communication

present (Keller et al. 1987; Sakuraba et al.

2003). A dental-implant-retained obturator

frequently sustains high cantilever forces on

the anterior implants because of lack of

dorsal support, resulting in attachment loss

and finally implant loss (Parel et al. 2001).

Prosthetic rehabilitation in total alveolar

atrophy employing single bilateral Zygoma-

ticusfixturess (Branemark-System, Nobel-

Biocare Norden AB, Gothenburg, Sweden)

supporting the molar region and anterior

dental implants in residual canine alveolar

process are clinically established with

accruing follow-up (Reichert et al. 1999;

Bedrossian & Stumpel 2001; Bedrossian

et al. 2002; Malevez et al. 2004). This

study evaluates zygoma implants alone

and in combination with dental implants

as prosthetic anchors for better social re-

integration of patients suffering from max-

illary defects. Particular attention was

given to extended zygoma implant indica-

tions in 450% maxillectomies to reduce

leverage. Zygoma implant success and sur-

vival, as well as the quality of life, were

evaluated.

Patients and methods

Twelve patients received 28 zygoma im-

plants (Zygomaticusfixtures, Branemark-

System, Nobel-Biocare Norden AB).

Twenty-three additional dental implants

were inserted when a partial alveolar pro-

cess (i.e. a residual alveolar segment) was

present. Average age at implantation was

59 years (24–79 years), and 10 females and

two males were included, see Table 1. The

first patient suffered from total absence of

the maxillary alveolar process when all

teeth had been extracted at 20 years of

age because of amelogenesis imperfecta.

Earlier osteoplasty and a Le Fort I osteo-

tomy resulted in complete bone-transplant

resorption making dental implant place-

ment apart from the left canine region

impossible. The second patient had had

cleft lip, alveolar process and palate, a

severely scarred hard and soft palate pre-

senting with a complex defect with con-

comitant loss of the alveolar process

because of long-time edentulousness and

atrophy. A local osteoplasty was considered

hazardous for postoperative bone exposure

and resorption because of local scars after

multiple palatal reconstructive surgery. A

free combined bone-soft tissue flap with

microvascular anastomosis was considered

overtreatment. Patient no. 3 had a max-

illary osteosarcoma and refused free flap

reconstruction out of concern for masking a

tumor recurrence. The patient initially had

a 2/3 maxillectomy after the ablation of the

recurrence this defect became a 3/4 max-

illectomy. Patient no. 4 had a hemimax-

illectomy of a palatal squamous cell

carcinoma with cardiopulmonary disease

at 72 years, precluding major reconstruc-

tion. Patient no. 5 had palatal adenoid-

cystic carcinoma ablated 4.5 years ago

with hemimaxillectomy and successful re-

habilitation by a tooth retained obturator.

The retaining teeth had been lost because

of local cantilever overloading from absent

dorsal prosthesis support. A new obturator

retention without major surgery was re-

quested by the patient and major recon-

structive surgery was contraindicated.

Patient 6 had a recurrent malignant mixed

salivary carcinoma and cardiopulmonary

disease at 77 years of age. The tumor

recurred during follow-up, resulting in a

total maxillectomy. Patients no. 7–9 and

11 with hemimaxillectomy after palatal

and maxillary sinus squamous cell carcin-

oma ablation had cardiopulmonary disease.

Case no. 10 with an ameloblastoma (3/4

maxillectomy) is a diagnosed anxiety dis-

order and no. 12 a depressive disorder

making elaborate reconstructive operations

a high-risk intervention.

Implants were inserted intraoperatively

up to 59 months postoperatively, an aver-

age of 16 months later. For example, pa-

tient no. 6 received implants at the time of

tumor resection when frozen margins were

tumor free. Patients no. 1 and 2 were not

included in the calculation of the time

interval to the primary operation, as these

were more than 20 years previously. Six

patients received preoperative chemother-

apy and five patients were postoperative-

ly irradiated. When irradiation was

performed, the implants were inserted

on average after an 18-month disease-free

interval.

The implantation was performed under

general anaesthesia and 1 g of Cephalexine

(Rocephins, Roche, Basel, Switzerland)

intraoperatively and 250 mg of oral Cefur-

oxim (Elobacts, Cascan, Bad Oldeslone,

Germany) postoperatively twice for 5 days

were given. Resorbable stitches were used.

The insertion was readily performed accor-

ding to the technique given by Reichert

et al. (1999) and Parel et al. (2001). The

zygoma implant required a vestibular

Le-Fort I incision from the canine to the

molar area and local mucoperiosteal mobi-

lization. Thus, intraoral access to the zygo-

matic buttress area was directly created

after a partial maxillary resection. Alterna-

tively, when an intact maxillary sinus was

present, a suitable window in the anterior

wall was created. After the anterolateral

sinus mucosa had been mobilized, piloting

and implant placement were carried out

under direct visualization of the receptor

site from the sinus opening. Transcuta-

neous palpation of the exit area ensured

that the peripheral cortex was punctured.

When the diameter of the drill-hole was

correct, the tip of the inserted fixture could

be palpated transcutaneously piercing the

cortex by 1 or 2 mm. The patient’s indivi-

dual number of zygoma implants and den-

tal implants, implant length, position,

diameter, brand and abutment type can be

seen in Table 2. Complications and dura-

tion of follow-up are shown in Table 3. All

implants were allowed to heal for 6 months

and were loaded in succession. After the

healing period, the abutment procedure

followed under local anaesthesia, in three

cases combined with a peri-implant soft-

tissue reduction. All patients were seen at

monthly to 6-month intervals depending

on their primary affliction. The mean Perio-

tests-values (Gulden-Medizin technik,

Beusheim, Germany) (Lukas & Schulte

1990), peri-implant bleeding indices (PBIs)

and plaque indices (PIs), (Loe 1967) were me-

asured after implant loading at 6 months,

and every 6 months. Probing depths could

not be measured when zygoma implants

had bulky local flaps and hypertrophic

sinus mucosa at their point of mucosal pene-

tration. Follow-up radiographs 12 months

after insertion or 6 months after loading

and every following year were scrutinized

for peri-implant radiolucencies. Dental to-

mograms gave inferior information and

therefore in preoperative, postoperative

Landes . Zygoma implant-supported midfacial prosthetic rehabilitation

314 | Clin. Oral Impl. Res. 16, 2005 / 313–325

Tab

le1.

Th

eb

en

chm

ark

pati

en

td

ata

,d

iag

no

ses,

pre

op

era

tive

chem

oth

era

py,

am

ou

nt

of

rese

ctio

nan

dp

ost

op

era

tive

irra

dia

tio

n

Pati

en

tn

o.

Ag

eat

pri

mary

op

era

tio

n(y

ears

)

Dia

gn

ose

sD

efe

ctsi

zeo

rext

en

to

ftu

mo

rab

lati

on

Ch

em

oth

era

py

Rad

iati

on

(Gy)

Ind

icati

on

for

zyg

om

aim

pla

nts

vs.

op

era

tive

maxi

llary

reco

nst

ruct

ion

Tim

eg

ap

toim

pla

nta

tio

n(m

on

ths)

120

Am

elo

gen

esi

sim

perf

ect

a,

lon

g-t

ime

full

pro

sth

esi

sTo

tal

ab

sen

ceo

fM

axi

llary

alv

eo

lus

Ost

eo

pla

sty

fail

ure

460

215

Bil

ate

ral

cleft

lip

an

dp

ala

te,

lon

g-t

ime

full

pro

sth

esi

sLa

rge

med

ian

defe

ct,

40%

of

the

hard

pala

tean

dalv

eo

lus,

seve

resc

arr

ing

Seve

rem

uco

-peri

ost

eal

scarr

ing

,h

igh

risk

for

ost

eo

pla

sty

reso

rpti

on

460

319

Maxi

llary

an

do

rbit

al

ost

eo

sarc

om

aT4N

0M

02/3

maxi

llect

om

yC

arb

op

lati

n-e

top

osi

dp

ho

sph

ate

45

Co

nce

alm

en

to

fre

cid

ive

by

free

flap

59

471

Maxi

llary

squ

am

ou

sce

llca

rcin

om

aT4N

1M

0H

em

imaxi

llect

om

y,so

ftti

ssu

ep

ala

tal

reco

nst

ruct

ion

61.5

Hig

her

ag

e,

card

iop

ulm

on

ary

dis

ease

6

558

Pala

tal

ad

en

oid

cyst

icca

rcin

om

a,

T4N

0M

0H

em

imaxi

llect

om

yLi

mit

ed

too

thlo

ssb

eca

use

of

ove

rlo

ad

ing

aft

er

4.5

years

too

th-b

orn

eo

btu

rato

rre

hab

ilit

ati

on

54

677

Recu

rren

tm

axi

llary

mix

ed

sali

vary

carc

ino

ma

T4N

0M

0To

tal

maxi

llect

om

yH

igh

er

ag

e,

card

iop

ulm

on

ary

dis

ease

0

757

Maxi

llary

squ

am

ou

sce

llca

rcin

om

aT4N

1M

0H

em

imaxi

llect

om

yPre

op

era

tive

cisp

lati

nem

bo

liza

tio

n51.3

Card

iop

ulm

on

ary

dis

ease

10

860

Maxi

llary

squ

am

ou

sce

llca

rcin

om

aT4N

0M

0H

em

imaxi

llect

om

y,so

ftti

ssu

ep

ala

tal

reco

nst

ruct

ion

wit

hlo

cal

flap

Cis

pla

tin

em

bo

liza

tio

np

reo

pera

tive

ly,

fou

rcy

cles

of

Do

xeta

cel

po

sto

pera

tive

ly

58

Card

iop

ulm

on

ary

dis

ease

9

977

Maxi

llary

squ

am

ou

sce

llca

rcin

om

a,

T4N

0M

0H

em

imaxi

llect

om

y,so

ftti

ssu

ep

ala

tal

reco

nst

ruct

ion

wit

hlo

cal

flap

Pre

op

era

tive

cisp

lati

nem

bo

liza

tio

nH

igh

er

ag

e,

card

iop

ulm

on

ary

dis

ease

6

10

46

Larg

em

axi

llary

am

elo

bla

sto

ma

3/4

maxi

llext

om

yLa

tep

rim

ary

inte

rvie

w,

gen

era

lan

xiety

dis

ord

er

14

11

52

Maxi

llary

squ

am

ou

sce

llca

rcin

om

aT4N

1M

0H

em

imaxi

llect

om

yPre

op

era

tive

cisp

lati

nem

bo

liza

tio

n51.3

Card

iop

ulm

on

ary

dis

ease

11

319

Maxi

llary

ost

eo

sarc

om

are

curr

en

ceT4N

0M

03/4

maxi

llect

om

y,p

ala

tal

soft

tiss

ue

reco

nst

ruct

ion

wit

hlo

cal

flap

45

Co

nce

alm

en

to

fre

cid

ive

by

free

flap

15

679

Mali

gn

an

tm

ixed

sali

vary

tum

or

recu

rren

ceT2N

0M

0To

tal

maxi

llect

om

yH

igh

er

ag

e,

card

iop

ulm

on

ary

dis

ease

,m

ult

iple

po

ssib

lyco

nce

ale

dtu

mo

rre

curr

en

ces

0

12

60

Maxi

llary

squ

am

ou

sce

llca

rcin

om

aT4N

0M

0H

em

imaxi

llect

om

y,so

ftti

ssu

ep

ala

tal

reco

nst

ruct

ion

wit

hlo

cal

flap

Pre

op

era

tive

cisp

lati

n-e

mb

oli

zati

on

Dep

ress

ive

dis

ord

er

3

Th

eti

me

gap

betw

een

op

era

tio

no

rir

rad

iati

on

toth

eim

pla

nt

inse

rtio

nis

list

ed

.N

ote

that

pati

en

ts3

an

d6

are

list

ed

twic

eas

they

had

two

pro

ced

ure

so

fzy

go

ma

imp

lan

tin

sert

ion

.



Tab

le2.

Th

ed

en

tal

statu

s,su

rgery

data

an

dp

rost

heti

ctr

eatm

en

t

Pati

en

tn

o.

Ag

eat

imp

lan

tati

on

(years

)

Den

tal

statu

sN

o.

of

zyg

om

aim

pla

nts

Imp

lan

tati

on

site

Zyg

om

aim

pla

nt

len

gth

(mm

)

Loca

lan

ato

my,

nu

mb

er,

loca

tio

nan

db

ran

do

fth

ead

dit

ion

al

den

tal

maxi

llary

imp

lan

tsPro

sth

eti

ctr

eatm

en

taft

er

6m

on

ths

heali

ng

peri

od

147

Ed

en

tulo

us

216,2

645,4

5B

ilate

ral

sin

gle

zyg

om

afi

xtu

re,

on

ed

en

tal

imp

lan

tat

23

resi

du

al

bo

ne

tran

spla

nt,

man

dib

leed

en

tulo

us

1O

ne

Bra

nem

ark

10�

4m

mfi

xtu

rere

gio

23

Th

ree

ind

ivid

ual

go

ldte

lesc

op

es

an

do

verd

en

ture

268

Ed

en

tulo

us

216,2

645,4

5B

ilate

ral

sin

gle

zyg

om

afi

xtu

re,

no

alv

eo

lus

pre

sen

t,m

an

dib

leed

en

tulo

us

0Tw

oin

div

idu

al

go

ldte

lesc

op

es

an

do

verd

en

ture

324

Part

iall

yd

en

tate

216,1

535,3

0D

en

tate

resi

du

al

alv

eo

lus

at

23–2

7,

man

dib

leco

mp

lete

lyd

en

tate

0Tw

om

ag

neti

cte

lesc

op

es

an

dp

art

ial

den

ture

wit

hb

race

sto

reta

inin

gte

eth

472

Ed

en

tulo

us

216,2

635,3

5N

oalv

eo

lus

pre

sen

t,d

en

tal

imp

lan

tin

sert

ion

on

lym

ed

ial,

incl

ud

ing

nasa

lsp

ine,

man

dib

leed

en

tulo

us

1O

ne

med

ian

Bra

nem

ark

10�

4m

mfi

xtu

reTh

ree

ind

ivid

ual

go

ldte

lesc

op

es

an

do

verd

en

ture

562

Part

iall

yd

en

tate

126

45

Teeth

24,

25

were

lost

beca

use

of

ove

rlo

ad

ing

an

dd

ors

al

can

tile

ver

forc

es,

resi

du

al

maxi

lla

an

dm

an

dib

led

en

tate

2Tw

oB

ran

em

ark

MK

IV4�

13

mm

fixt

ure

sat

reg

io24,

25

Th

ree

ind

ivid

ual

go

ldte

lesc

op

es

an

do

verd

en

ture

677

Ed

en

tulo

us

216,2

645,4

5N

oalv

eo

lus

aft

er

tota

lm

axi

llect

om

y(a

part

fro

mth

eo

rbit

al

flo

or)

,m

an

dib

leed

en

tulo

us

0Tw

oin

div

idu

al

go

ldte

lesc

op

es

an

do

verd

en

ture

758

Ed

en

tulo

us

116

30

Seve

realv

eo

lar

atr

op

hy

den

tal

imp

lan

tin

sert

ion

on

lyp

oss

ible

incl

ud

ing

the

nasa

lsp

ine,

man

dib

leed

en

tulo

us

1O

ne

med

ian

Bra

nem

ark

10�

4m

mfi

xtu

reTw

ore

ad

y-m

ad

eb

all

ab

utm

en

tsan

do

verd

en

ture

861

Ed

en

tulo

us

126

35

Suffi

cien

tan

teri

or

alv

eo

lar

bo

ne

for

ad

dit

ion

al

den

tal

imp

lan

tp

lace

men

t,m

an

dib

leed

en

tulo

us

5Fi

veIT

ISL

Aso

lid

scre

ws

12�

4.1

mm

reg

io15,

13,

11,

21,

23

Six

read

y-m

ad

eb

all

ab

utm

en

tsan

do

verd

en

ture

977

Part

iall

yd

en

tate

215,1

630,3

5A

nte

rio

rd

en

tate

pati

en

t,w

ith

ed

en

tulo

us

alv

eo

lus

an

teri

or

toth

ezy

go

ma

imp

lan

ts,

man

dib

leed

en

tulo

us

2Tw

oIT

ISL

Aso

lid

scre

ws

reg

io11,

13

Go

lden

ind

ivid

ual

bar-

ab

utm

en

tan

do

verd

en

ture

10

47

Ed

en

tulo

us

225,2

630,3

5C

on

trala

tera

led

etu

lou

salv

eo

lus,

man

dib

leed

en

tulo

us

4Fo

ur

ITI

SLA

soli

dsc

rew

sre

gio

12,

13,

14,

15

Fou

rin

div

idu

al

go

ldte

lesc

op

es

an

do

verd

en

ture

11

53

Part

iall

yd

en

tate

215,1

630,3

5C

on

trala

tera

led

etu

lou

salv

eo

lus,

resi

du

al

maxi

llary

inci

sors

man

dib

leed

en

tulo

us

4Fo

ur

ITI

SLA

soli

dsc

rew

sre

gio

11,

21,

23,

25

Six

ind

ivid

ual

go

ldte

lesc

op

es

an

do

verd

en

ture

327

Part

iall

yd

en

tate

416,1

5,1

3,2

335,4

0,3

5,4

0R

esi

du

al

alv

eo

lus

at

teeth

24–2

7,

man

dib

leco

mp

lete

lyd

en

tate

1O

ne

Bra

nem

ark

MK

IV15

mm

fixt

ure

reg

io26

betw

een

resi

du

al

teeth

Go

lden

ind

ivid

ual

bar-

ab

utm

en

tan

dp

art

ial

den

ture

,si

ng

lecr

ow

nsu

pra

stru

ctu

reto

imp

lan

tat

26

679

Ed

en

tulo

us

315,2

5,2

640,4

0,4

5N

oalv

eo

lus

aft

er

tota

lm

axi

llect

om

y(a

part

fro

mo

rbit

al

flo

or)

,m

an

dib

leed

en

tulo

us

0Fo

ur

ind

ivid

ual

go

ldte

lesc

op

es

an

do

verd

en

ture

12

60

Ed

en

tulo

us

216,2

635,3

5Ed

en

tulo

us

an

teri

or

alv

eo

lus

pre

sen

t,m

an

dib

leed

en

tulo

us,

fou

rin

terf

ora

min

al

ITI-

imp

lan

ts

2Tw

oIT

ISL

Aso

lid

scre

ws

reg

io13,

23

Two

ind

ivid

ual

para

llel

barc

lip

san

do

verd

en

ture

Pati

en

ts3

an

d6

req

uir

ed

zyg

om

aim

pla

nt

rep

lace

men

tb

eca

use

of

chro

nic

infl

am

mati

on

inco

nju

nct

ion

wit

ho

verl

oad

an

dco

nse

cuti

velo

ose

nin

g.



Tab

le3.

Data

fro

mth

efo

llo

w-u

pin

clu

din

gco

mp

lica

tio

ns

an

dlo

sses,

peri

od

on

tal

para

mete

rsan

dsc

ore

sat

the

qu

ali

tyo

fli

feq

uest

ion

nair

e



and follow-up, the occipitomental Water’s

projection was preferred. The dental im-

plants were, however, judged based on

dental tomograms.

Weber two-point discrimination deter-

mined the accuracy of skin sensitive discri-

mination; that is, the distance between two

points that must be spanned before subjects

report feeling two distinct sensations. Static

or moving assessment measures the adapt-

ing fiber-receptor system. When this test

was bilaterally equal in those dermal seg-

ments innervated by the infraorbital and

zygomaticofacial nerve, a positive result

was noted (Dellon 1978). When there was

bilateral maxillary resection, the supraorbi-

tal segment was examined and the area of

lesser sensitivity in comparison noted as

negative. Likewise negative results were

recorded when it was known the nerve

had been intra-operatively cut.

The Kaplan–Meier analysis was made for

implant success after the following criteria:

clinical mobility 0–1, no peri-implant

radiolucency, no prevalent peri-implant

infection with purulent secretion, no pain,

discomfort or dysaesthesia related to the

implant placement (adapted after Buser

et al. 1990). Survival referred simply to

whether the implant was in situ or not.

After the completion of the prosthetic re-

habilitation, 6 months after implant inser-

tion all patients were asked to fill out a

University of Washington Quality-of-Life

scale questionnaire (UW-QOL, Weymuller

et al. 2001; Rogers et al. 2002). The UW-

QOL is a validated 12-item questionnaire,

completed by the patient and emphasizing

critical issues of oral, head and neck tu-

mors and their treatment, i.e. pain, appear-

ance, activity, recreation, swallowing,

chewing, speech, shoulder mobility, taste,

saliva, mood and anxiety. Version 4 in-

cludes the psychological dimension of

quality of life (Rogers et al. 2002, 2003).

An importance rating on an individual

basis, two health-related quality-of-life

questions and one general quality-of-life

question are included. The domains are

scored from no symptoms (i.e. pain) to

severe symptoms in four or five grades,

the corresponding values are 100, 75, 50,

25 and 0 or 100, 67, 33 and 0, respectively.

These can be applied in individual long-

itudinal follow-up and the composite UW-

QOL score is obtained by averaging the

domain scores. In this study, the time-

point average percentage and percentile of

maximum life quality (i.e. minimum

pathology after completed prosthetic reha-

bilitation) were evaluated.

Results

With a follow-up of 14–53 months the

Kaplan–Meier cumulative 4-year zygoma

implant survival/in situ rate was 82% (see

Tables 3 and 4, Fig. 1). Assuming intra-

individual dependence, 83% of patients

had no zygoma implant loss (Chuang et al.

2001). The rate of chronic zygoma implant

infection was 11% and all were lost during

follow-up. One loaded implant loss within

the first year probably was because of local

overloading (patient no. 6) (see Fig. 2). It

was explanted, two zygomafixtures were

immediately inserted anterior and dorsal to

the original implant slot. At the right

zygoma, a parallel zygomafixture was posi-

tioned anterior to support the premolar

region. Seven identical ‘pairs’ of parallel

zygomafixtures were inserted in six pa-

tients in an identical fashion to reduce the

prosthetic leverage and support the pre-

molar region. The patient with two implant

losses in the second year (no. 3) had

chronic infection around two zygomafix-

tures that were buried in granulation tissue

(Fig. 3). After replacement by a right-sided

pair of parallel zygoma implants, one addi-

tional third zygoma implant was positioned

anteriorly on each side and supported the

canine region. This should once more re-

duce leverage on the zygoma implants and

consecutive overloading from anterior bi-

ting and mastication, as addressed in patient

no. 6 (Fig. 2). Insufficient zygoma implant

length within flap reconstructions was

prone to recurrent local infection by pock-

eting and overgrowth of granulating tissue

(i.e. patients no. 3 and 10). In the last case

two implants for the above reason could

not become integrated in the prosthetic

rehabilitation. Although these implants

were osseointegrated and they survived,

they could not be counted as successes.

Longer implants were free of soft tissue

inhibition yet prone to overloading by

high leverage as seen in Fig. 2. PI, PBI at

the end of the follow-up can be seen in

Table 3 decreasing from 56% to 0% and

33% to 0%, which may be attributed to

repeated personal hygiene instruction and

better compliance once local scarring had

set and the prostheses were incorporated

into the patient’s body concept. No im-

plant had infection or purulent secretion at

the end of the follow-up.

All implants were clinically stable, and

the latest Periotests values can be seen in

Table 3 increasing from average 0 to 7 in

the fourth year. No peri-implant radio-

lucencies were noted on Water projections

at the end of follow-up. Because of over-

projection of the cranial base peri-implant

bone loss could not be evaluated.

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

1 3

%

Implant survival (in white) and success (in black) was assessed for a 4 year follow-up

2 4

Fig. 1. Kaplan-Meier analysis of implant survival and success.



The zygomaticofacial nerve sensitivity

was intact in all cases except patient no. 3

who had it resected at tumor removal. The

infraorbital nerve was never severed during

zygoma implant insertion, however, five of

12 patients had primary nerve resection

when tumor ablation was performed (see

Table 3). No patient reported foreign-body

sensation, dysaesthesia coming from the

implants or pain on implant percussion.

Therefore, a zygoma implant success

rate of 71% was reached when the three

losses and two zygoma implants that could

not be loaded were subtracted (Fig. 1).

Assuming intraindividual dependence 75%

of patients had immediately successful

treatment (Chuang et al. 2001).

As abutments gold or magnetic tele-

scopes were used in nine prostheses. Three

prostheses had individual bar-clips and two

ready-made ball abutments. Two patients,

because of implant removal and tumor

recurrence ablation, required a second pros-

thesis. Only the first prosthesis in patient

no. 3 braced the remaining teeth, all other

cases did not. After recurrence, the bar-clip

was sufficient for retention.

The UW-QOL questionnaire was re-

turned in eight cases after prosthetic treat-

ment (80%), two cases were not oral tumor

or cancer patients (nos. 1 and 2) and, there-

fore, the questionnaire did not apply to

them (presented in Tables 3 and 4). Half

of the patients did not register any pain, the

other half only had accidental to moderate

pain. One case reported painkiller taking

at intervals because of scarring, impaired

swallowing, xerostomia and mucositis

after irradiation (no. 11). The majority of

cases noted little changes in their outward

appearance, however, two complained of

major changes in conjunction with exen-

teration (Fig. 3, no. 3) or severe local radio-

dermatitis of the cheek and malar complex

(no. 11). All patients noted none to min-

imal limitation in activities. Three patients

reported 100% and five medium chewing

capacity. Speech without limitation was

noted by 63% of the patients, the remain-

der reported minor difficulties but were

heard speaking on the telephone. Taste in

all cases was 75–100% present. Most pa-

tients reported adequate saliva, but two had

xerostomia. Except in one young osteo-

sarcoma case with exenteration (Fig. 3,

patient no. 3), all reported good emotional

stability and little anxiety. The patientTab

le4.

Th

eU

niv

ers

ity

of

Wash

ing

ton

Qu

ali

ty-o

f-Li

fe(U

W-Q

OL)

inh

ead

an

dn

eck

can

cer

qu

est

ion

nair

esc

ore

s

Item

no

.Sy

mp

tom

0%

25%

30%

50%

70%

75%

100%

Mean

(%)

%B

est

sco

re

1Pain

11

24

78

50

2A

pp

eara

nce

26

63

03

Act

ivit

y7

178.1

13

4R

ecr

eati

on

62

82

25

5Sw

all

ow

ing

17

92

88

6C

hew

ing

53

69

38

7Sp

eech

35

89

63

8Sh

ou

lder

21

579

63

9Ta

ste

26

94

75

10

Sali

va1

16

76

79

11

Mo

od

16

172

13

12

An

xiety

16

169

13

Pain

Ap

peara

nce

Act

ivit

yR

ecr

eati

on

Swall

ow

ing

Ch

ew

ing

Speech

Sho

uld

er

Tast

eSa

liva

Mo

od

An

xiety

13

Pri

ori

ties

21

33

13

21

12

Mu

chw

ors

eW

ors

eId

en

tica

l/m

od

era

teB

ett

er/

go

od

Mu

chb

ett

er

Exc

ell

en

tM

ean

(%)

%O

pti

mal

valu

e

14

Healt

h-r

ela

ted

qu

ali

tyo

fli

feco

mp

are

dw

ith

the

pre

thera

-p

eu

tic

situ

ati

on

12

12

2Id

en

tica

l54

0

15

Healt

h-r

ela

ted

qu

ali

tyo

fli

fein

the

last

7d

ays

16

1B

ett

er

67

0

16

Gen

era

lq

uali

tyo

fli

fe5

3G

oo

d73

0

Resu

lts

of

eig

ht

of

ten

pati

en

tsw

ho

retu

rned

their

an

swere

dU

W-Q

OL

qu

est

ion

nair

e.

Pati

en

tsw

ere

mo

stco

nce

rned

wit

hch

ew

ing

,re

creati

on

an

dact

ivit

yin

gen

era

l.Th

eg

en

era

lli

feq

uali

tyw

as

go

od

,m

ost

pati

en

tsexp

eri

en

ced

iden

tica

lh

ealt

h-r

ela

ted

qu

ali

tyo

fli

feco

mp

are

dw

ith

the

pre

thera

peu

tic

situ

ati

on

.



priorities in judging successful rehabilita-

tion were in descending order: chewing,

activity, recreational activity and speech,

emotional stability, and pain. Appearance,

swallowing, shoulder mobility and xero-

stomia were noted by one patient to be

major concern (no. 11). Half of the patients

reported better health-related quality of life

than before treatment onset. The other

reported worsening of their general health.

However, the general quality-of-life aver-

age was reported to be much better.

Discussion

The use of the zygomatic bone as implant

site in conjunction with ablative tumor

surgery has been previously described

(Parel et al. 1986; Vuillemin et al. 1990;

Jensen et al. 1992; Izzo et al. 1994; Rou-

manas et al. 1994; Evans et al. 1996;

Weischer et al. 1997; Reichert et al.

1999). Autologous bone grafting, myocuta-

neous or osteo-myocutaneous tissue trans-

fer implies major surgery. Considerable

donor site morbidity may occur although

satisfactory success rates have been well-

documented (Breine & Branemark 1980;

Isaksson 1994; Hurzeler et al. 1996;

Swartz et al. 1996; Lekholm et al. 1999;

Rogers et al. 2003). For zygomafixtures,

survival rates of 65% to 75% were reported

when they were inserted after ablative

tumor surgery (Weingart et al. 1992), and

a similar 71% zygoma implant success

was found in the present study in 4-year

follow-up. Only multi-centre studies pro-

vide cases in adequate numbers for a defect-

specific success analysis. The value of a

homogenous collective for clinical use is

limited as most centres face variant defect

severity in few patients. Large maxillary

cleft-palate defects are a sequel of no better

up-to-date treatment today for elderly pa-

tients. Extended maxillary resections are

individually different for each patient. Dif-

ferent treatment regimens and safety mar-

gins are used for different malignomas at

different centers. Detailed analysis of mul-

tiple cases, with examination of the tech-

nical possibilities using zygomafixtures

broadens the indication range. Similar to

Malevez et al. (2004), the intimacy of bone

to implant contact and marginal bone loss

were difficult to evaluate. Water’s projec-

tion seemed reliable for judging peri-im-

Fig. 2. (a, b) Patient no. 6, aged 77 years, suffered from recurrent malignant maxillary salivary gland carcinoma

and cardiopulmonary disease precluded operative maxillary reconstruction. At first one zygoma implant on

each side provided obturator retention by telescopes. The left loaded zygoma implant was lost within the first

year probably because of overload and leverage. Before the left implant definitely failed, a local infection with

extraoral fistulation occurred. (c, d) Furthermore, a local recurrent tumor was resected and the left fixture was

explanted. Three new implants were immediately positioned as can be seen on the Water’s projection. Two

implants were positioned on the left, anterior and posterior to the original implant site. A second implant was

positioned anterior in the right zygoma to support the premolar region as well. (e, f) The telescoped fixtures

piercing the bulky mucosa, an absent alveolar process and the complete rehabilitation can be seen.



plant radiolucency when compared with

CT and dental tomograms.

In this study 17% of patients faced zy-

goma implant losses. However, uneventful

and successful replacement was possible.

Parel et al. (2001) reported that zygoma

implant-borne dorsal defect prosthesis sup-

port decreased the leverage on the remain-

ing teeth and anterior dental implants. This

concept is supported by the fact that zy-

goma implants are overloaded when posi-

tioned in the molar region in the absence of

an anterior maxilla. Parallel anterior zy-

goma implants enabled a trapezoid pros-

thesis support. Moreover, anteroposterior

zygomafixtures created support in the can-

ine region as called for by Reichert et al.

(1999). Four factors of zygoma implant

failure could be determined: overloading

leverage in extensive maxillectomy, over-

growth of local soft tissues restricting the

abutment connection, recurrent infection

triggered by the above factors and tumor

recurrence. The latter did not force zygoma

implant removal in this series as recur-

rences did not occur at implant sites. The

follow-up did not show implant fatigue

fractures as hypothesized (Reichert et al.

1999) because of the long arm of lever.

Reichert et al. (1999) and this study used

zygoma implants in cases when patients

refused the morbidity of bone transplanta-

tion from the iliac crest or fibula and when

the general condition did not permit major

reconstruction. The authors report five

indications for zygoma implants: tumor

ablation maxillectomy, osteoplasty failure,

osteoplasty avoidance, local stress relief

after osteoplasty and an alternative to si-

nus-lifting or sinuslift failure. Implant po-

sitioning in the alveolar crest or slightly

palatinal could not be maintained in bigger

maxillary defects. The implant head should

then rest close to the residual bone to

reduce leverage. However, it should not

be submerged in soft tissue to reduce the

risk of a local infection. Lastly soft tissue

thickness over the residual bone should be

kept to a minimum. Soft-tissue flaps create

deep peri-implant pockets that are prone to

infection.

Microporous implant surfaces compared

with machined surfaces have higher re-

moval torques after osseointegration and

the data documents a superior osseointe-

gration (Buser et al. 1991; Cochran et al.

1996). Therefore, SLA dental implants

were used in patients no. 8–12. Micropor-

ous surface in zygoma implants should be

prospectively considered. Wide opening of

the mouth with tongue protusion required

for zygoma implant insertion causes an

increased risk of intraoperative contamina-

tion. The vicinity to sinus mucosa and

moving gingiva at the implant-shaft are

unfavourable (see Fig. 2d) with open-lying

thread convolutions. A feasible compro-

mise may be a microporous surface re-

stricted to the zygoma implant tip.

Nkenke et al. (2003) evaluated the zygo-

matic bone diameter and report highly

trabecular bone quality. Employment of

at least four cortical portions is recom-

mended (i.e. the alveolar process at the

molar region and the cortex of the zygo-

Fig. 3. (a) Patient no. 3, aged 24 years, with re-

current maxillary and orbital osteosarcoma after

exenteration, 2/3 maxillectomy and soft-tissue

reconstruction with local flaps. Two zygoma

implants had been furnished with magnetic tele-

scopes. In the second year of loading both devel-

oped chronic infection, were buried in granulation

tissue and finally lost. (b) The infected and loo-

sened implants were removed, an anterior recur-

rence was resected and two parallel longer implants

were repositioned to support the molar and premo-

lar region as can be seen on the Water’s projec-

tion. One additional anterior angulated zygoma

implant was positioned to rest in the zygomatic

body on each side and support the canine region

after 3/4-maxillectomy. (c, d) A bar-clip abutment

yielded sufficient stabilization a dental implant at

regio 26 was not needed for retention and there-

fore, treated with a single crown. (e, f) Complete rehabilitation with reconstructed eyelids and eye

epithesis.



Tab

le5.

Co

mp

ari

son

of

zyg

om

aim

pla

nt

an

do

btu

rato

rre

hab

ilit

ate

din

div

idu

als

fro

mth

isst

ud

yto

two

case

seri

es

rep

ort

ed

by

Ro

gers

et

al.

(2003)

zyg

om

aim

pla

nts

an

do

btu

rato

rp

rost

hesi

s-n¼

8

Free

deep

circ

um

flex

ilia

cart

ery

flap

reco

nst

ruct

ion

,n¼

20

Free

fib

ula

reco

nst

ruct

ion

,n¼

16

Ob

tura

tor

pro

sth

esi

sw

ith

-o

ut

imp

lan

tre

ten

tio

n,

n¼

28

Free

flap

maxi

llary

reco

nst

ruct

ion

,n¼

18

Zyg

om

aim

-p

lan

tsan

do

btu

rato

rp

rost

hesi

s,n¼

8

Free

deep

cir-

cum

flex

ilia

cart

ery

flap

reco

nst

ruct

ion

,n¼

20

Free

fib

ula

reco

nst

ruct

ion

,n¼

16

Ob

tura

tor

pro

sth

esi

sw

ith

ou

tim

-p

lan

tre

ten

tio

n,

n¼

28

Free

flap

maxi

llary

reco

nst

ruct

ion

,n¼

18

Mean

(%)

%B

est

sco

rePain

78

75

67

90

88

50

45

46

60

72

Ap

peara

nce

63

60

65

63

76

05

810

28

Act

ivit

y78

66

65

73

71

13

10

15

30

28

Recr

eati

on

81

73

71

80

75

25

20

23

30

33

Swall

ow

ing

91

79

52

91

88

88

60

870

67

Ch

ew

ing

69

55

31

60

58

38

25

820

28

Speech

89

75

74

79

76

63

35

21

30

33

Sho

uld

er

79

83

79

91

95

63

67

69

70

83

Tast

e94

76

45

75

55

14

Sali

va76

69

64

79

39

36

Mo

od

72

78

77

13

45

29

An

xiety

69

78

75

13

53

36

Ave

rag

e78

72

64

78

78

43

38

26

40

47

Ro

gers

et

al.

(2003)

AC

om

pa-

riso

no

fth

elo

ng

-term

mo

rbid

ity

foll

ow

ing

deep

circ

um

flex

ilia

can

dfi

bu

lafr

ee

flap

sfo

rre

con

stru

ctio

nfo

llo

win

gh

ead

an

dn

eck

can

cer.

Pla

stic

an

dre

con

stru

ctiv

esu

rgery

112:

1517–1

525.

Ro

gers

et

al.

(2003)

Healt

h-

rela

ted

qu

ali

tyo

fli

feaft

er

maxi

llect

om

y:a

com

pari

son

betw

een

pro

sth

eti

co

btu

rati

on

an

dfr

ee

flap

.Jo

urn

al

of

Ora

lan

dM

axi

llo

faci

al

Surg

ery

61:

174–1

81.

Ro

gers

et

al.

(2003)

Aco

mp

ar-

iso

no

fth

elo

ng

-term

mo

rbid

ity

foll

ow

ing

deep

circ

um

flex

ilia

can

dfi

bu

lafr

ee

flap

sfo

rre

con

stru

ctio

nfo

llo

win

gh

ead

an

dn

eck

can

cer.

Pla

stic

an

dre

con

stru

ctiv

esu

rgery

112:

1517–1

525.

Ro

gers

et

al.

(2003)

Healt

h-r

ela

ted

qu

ali

tyo

fli

feaft

er

maxi

llect

om

y:a

com

pari

son

betw

een

pro

sth

eti

co

btu

rati

on

an

dfr

ee

flap

.Jo

urn

al

of

Ora

lan

dM

axi

llo

faci

al

Surg

ery

61:1

74–1

81.

%o

fp

ati

en

tssc

ori

ng

go

od

or

bett

er

(all

/th

ose

wh

osc

ore

dg

oo

do

rb

ett

er)

Healt

h-r

ela

ted

qu

alit

yo

flif

ein

the

last

7d

ays

88

(7/8

)74

(14/1

9)

50

(7/1

4)

Gen

era

lq

uali

tyo

fli

fe100

(8/8

)68

(13/1

9)

50

(7/1

4)

Th

efi

rst

com

pare

sm

axi

llo

faci

al

free

bo

ne

reco

nst

ruct

ion

fro

mth

eil

iac

crest

(fre

ed

eep

circ

um

flex

ilia

cart

ery

flap

)w

ith

free

fib

ula

.Th

ese

con

d,

tho

ug

hu

sin

gU

niv

ers

ity

of

Wash

ing

ton

Qu

ali

ty-o

f-Li

fe

(UW

-QO

L)ve

rsio

n1

wit

hli

mit

ed

com

pati

bil

ity

com

pare

so

btu

rato

rre

hab

ilit

ate

dm

axi

llect

om

yp

ati

en

tsvs

.fr

ee-fl

ap

reco

nst

ruct

ion

.Th

ele

ftco

lum

nare

the

mean

sco

res,

the

rig

ht

dark

shad

ed

gre

yth

eb

est

sco

rep

erc

en

tag

es.

Belo

ware

the

ave

rag

esc

ore

sfo

rb

lun

tco

mp

ari

son

.H

ealt

hre

late

dan

dg

en

era

lq

uali

tyo

fli

fesc

ore

sw

ere

no

tim

ple

men

ted

inU

W-Q

OL

vers

ion

1as

em

plo

yed

by

the

seco

nd

stu

dy.



matic bone). The inherent angle of 451

proved adequate and was readily connected

to abutments in all cases (Uchida et al.

2001). Schramm et al. (2000) in patients

and Steenberghe et al. (2003) in cadavers

use Computer and CT-assisted navigation

for an exact placement below 1 mm and 31,

which was not imperative in this series.

Navigation is adequate when navigation-

supported tumor ablation is performed

and the equipment is ready to use. In the

present study, the bone volume was suffi-

cient and the placement was not difficult.

Navigation by itself remains expensive and

prolongs the operation time but can sup-

port exact placement and optimum bone

utilization. Navigation-supported zygoma

implant positioning across the temporal

fossa could (Jensen et al. 1992) include

two more cortical fractions from the zygo-

matic arch. Although parallel zygoma im-

plant positioning was achieved manually,

inserting a third zygoma implant may be

facilitated through navigation not to jeopar-

dise the orbital floor. All zygoma implants

were stable even when inserted in only two

zygomatic cortical portions.

All patients gained good oronasal sealing,

speech and feeding, as well as midfacial and

upper lip projection according to their own

perception. To further measure individual

perception of rehabilitation, quality-of-life

assessment is mandatory. Multiple vari-

ables have to be considered in ‘successful’

rehabilitation. A constant struggle by a

patient overstrained in manual dexterity

to incorporate and remove an obturator

prosthesis or a prosthesis that yields no

chewing or speech cannot be called a suc-

cess. Preoperative, 6 and 12 months post-

operative ratings by patients with head and

neck cancer rated in a study similar to this

included, in descending order: speech,

chewing, swallowing, activity and appear-

ance (Rogers et al. 2002, 2003). A compar-

ison of zygoma implant rehabilitated

individuals’ UW-QOL scores to maxillofa-

cial cancer patients reconstructed with iliac

bone (deep circumflex iliac artery flap

(DCIA)) and free fibula bone is shown in

Table 5. A second study of maxillectomy

patients either reconstructed by obturator

or a free flap is added (Rogers et al. 2002,

2003). The zygoma implant-borne prosthe-

sis case series scored highest in activities

and recreation, swallowing, chewing,

speech, taste and saliva quality. Simple

obturator cases had the least pain and

equally good swallowing while free flap

maxillary reconstruction scored best for

appearance. Mood and anxiety were better

in DCIA and fibula reconstructed indivi-

duals. Health-related quality of life in the

last 7 days was superior for the zygoma

implant rehabilitated followed by DCIA.

The general quality of life in all cases was

good or better for zygoma implant rehabil-

itated, followed by DCIA and still 50% of

the fibula-rehabilitated patients. ANOVA

with a¼0.5 significance level revealed

significant differences for the score

averages: Po0.01 at F¼ 3.2. Therefore,

the outcome differences cannot be attri-

buted to chance. Reports using obturator

prostheses find better outcomes in small

defects when sufficient speech, chewing

and swallowing abilities are maintained

(Kornblith et al. 1996). Free graft recon-

struction was established partly to solve

the disadvantages of the obturator: nasal

leakage, cleaning, frequent prosthetic cor-

rections (Brown 1996; Cordeiro & Santa-

maria 2000) by itself or in combination

with an obturator (Sakuraba et al. 2003).

Large maxillary and orbitomaxillary defects

are difficult to fit with acceptable pros-

theses and impaired vision complicates

prosthesis handling. Various methods

have been described for large defect closure

(Pollice & Frodel 1998; Truitt et al. 1999;

Baumann & Ewers 2000) and the experi-

ences were cataloged as algorithms (Brown

et al. 2000; Cordeiro & Santamaria 2000).

To the DCIA flap (Brown 1996) came the

rectus abdominis and radial flap (Cordeiro

& Santamaria 2000), fibula (Futran &

Haller 1999) and subscapular artery flaps

(Uglesic et al. 2000). Dental implants can

be inserted into revascularized bone. How-

ever in many cases, resorption is high and

unless prefabricated transplants are used

(Breine & Branemark 1980). The best

choice remains obturation or free tissue

transfer (Rogers et al. 2003). Donor site

and overall morbidity has been variably

reported and the patient adapts to the pre-

valent reconstruction. If the patient’s

general health and consent permit, pre-

fabricated free transplants should be con-

sidered first. Zygoma implants can be

reliably used even in total maxillectomy.

However severe defects involving the orbi-

tonasal complex should remain a primary

indication for reconstructive surgery.

Resume

La rehabilitation prothetique reussie est cruciale

pour la qualite de vie dans les cas de lesions max-

illaires etendues quand la reconstruction chirurgicale

n’est pas envisageable du a des problemes generaux

ou a un refus du patient. Pour cette raison, les

indications etendues des implants Zygomaticuss

dans differents types de lesions ont ete evaluees.

Douze patients ont recu 28 implants zygoma et 23

implants dentaires (si un segment du rebord alveo-

laire etait disponible) et ont ete suivis entre 14 et 53

mois. Les implants zygoma ont ete positionnes

classiquement dans la region molaire maxillaire et

pour reduire la force de levier une position premo-

laire et une canine ont ete choisies. La qualite de vie

a ete evaluee par un questionnaire a la fin du

traitement. La survie cumulatif de l’implant zygoma

etait de 82%. Trois pertes ont ete constatees dues a

une infection persistante et une perte progressive.

Les implants perdus ont ete immediatement re-

places dans l’os adjacent. Une longueur implantaire

insuffisante a l’interieur des reconstructions de tis-

sus mous favorisait une infection chronique par

poches grandissantes et une reapparition de tissus

granuleux envahissants. Les implants plus longs

n’avaient pas d’inhibition des tissus mous mais

etaient sensibles a une charge trop importante et a

une force de levier trop elevee dans les cas ou aucun

rebord alveolaire anterieur et donc des implants

dentaires n’etaient presents. Le succes de l’implant

zygoma etait de 71%, incluant le nouveau zygoma-

ticus position implantaire aux niveaux premolaire et

canin. Des valeurs Periotests augmentaient de 0 a

þ7 apres quatre annees, le saignement paroımplan-

taire et l’indice de plaque diminuaient de 56 a 0% et

de 33 a 0%, et une bonne de qualite de vie avec des

priorites telles que la mastication et l’activite ont ete

notees. Les implants zygoma peuvent donc de man-

iere certaine ancrer des protheses maxillaires mi-

faciales et permettre une qualite de vie comparable

aux reconstructions maxillaires autogenes. Ils peu-

vent etre remplaces immediatement si une infection

locale ou une perte de stabilite survenait. Une

position premolaire et canine reduit l’effet de levier

quand il n’y a pas de rebord alveolaire anterieur

present. Ce patient peut eventuellement aussi rece-

voir des implants classiques.

Zusammenfassung

Ziel: Bei grossen Oberkieferdefekten ist die erfol-

greiche prothetische Rekonstruktion fur eine gute

Lebensqualitat entscheidend. Dies ist besonders

dann wichtig, wenn ein schlechter Allgemeinzu-

stand des Patienten die Behandlung verunmoglicht,

oder er die chirurgische Rekonstruktion verweigert.

Fur solche Falle erweiterte man den Indikationsber-

eich der Zygomaticuss-Implantate und untersuchte

sie bei verschiedenen Defekttypen.

Patienten und Methoden: Zwolf Patienten erhielten

28 Jochbeinimplantate und 23 Zahnimplantate (so-

fern noch ein Segment vom Alveolarfortsatzes

vorhanden war) und wurden wahrend 14 bis 53

Monaten nachuntersucht. Die Jochbeinimplantate

setzte man in der klassischen Region der Oberkie-

fermolaren. Um die Hebelkraft zu reduzieren,



suchte man auch eine Abstutzung in der Eckzahn-

und Pramolarenregion. Zur Beurteilung der Lebens-

qualitat unterbreitete man dem Patienten nach Ab-

schluss der Rehabilitation einen vorbereiteten

Fragebogen.

Resultate: Die kumulative uberlebensrate der Joch-

beinimplantate betrug 82%. Man verzeichnete drei

Implantatverluste auf Grund einer persistierenden

Infektion und einer schrittweisen Lockerung. Die

verlorengegangenen Implantate konnten im benach-

barten Knochen gleich wieder ersetzt werden. War

das Implantat ungenugend lang, so neigte das wie-

deraufgebaute Weichgewebe darum zu chronischen

Infekten mit Taschenbildung und es kam wiederholt

zu einem uberschiessenden Wachstum von Gra-

nulationsgewebe. Langere Implantate zeigten diese

Probleme nicht, neigten dafur aber zu uberlastungen

und waren grossen Hebelkraften unterworfen, wenn

im anterioren Bereich der Alveolarfortsatz oder un-

terstutzende Zahnimplantate fehlten. Die Erfolgs-

rate des Zygoma-Implantates betrug daher 71%.

Darin eingeschlossen waren die neuen Lokalisatio-

nen der Zygomaticus-Implantate im Pramolaren-

und Eckzahnbereich. Die Periotests-Werte nahmen

bis zum vierten Jahr von 0 auf þ 7 zu, die Blutung

um die Implantate und der Plaqueindex nahmen ab

von 56% auf 0% und 33% auf 0%. Ebenso konnte

man eine gute Lebensqualitat bezuglich Kaukomfort

und sonstiger Aktivitaten verzeichnen.

Zusammenfassung: Zygoma-Implantate konnen

Oberkieferprothesen in zuverlassiger Art im Mittel-

gesicht verankern und so zu einer Lebensqualitat

verhelfen, die einer autologen Oberkieferrekon-

struktion vergleichbar ist. Sie konnen immediat

ersetzt werden, wenn lokale Infekte auftreten, oder

sie sich losen sollten. Eine Positionierung in der

Pramolaren- oder Eckzahnregion vermindert die

Hebelwirkung, wenn der Alveolarkamm im ante-

rioren Bereich fehlt. Als Alternative stehen dem

Patienten die Zahnimplantate zur Verfugung.

Resumen

Objetivo: La rehabilitacion protesica exitosa es cru-

cial para la calidad de vida en los casos de defectos

maxilares extensos en los que la reconstruccion

quirurgica no es aconsejable debido a salud general

o rechazo del paciente. Para este proposito, se eva-

luaron las indicaciones extendidas para las fijaciones

Zygomaticuss en diferentes tipos de defectos.

Pacientes y Metodos: Doce pacientes recibieron 28

implantes zigomaticos y 23 implantes dentales (si

un segmento del proceso alveolar se encontraba

disponible) y se siguieron de 14 a 53 meses. Los

implantes zigomaticos se posicionaron clasicamente

en la region molar y para reducir la palanca se

desarrollo una posicion premolar o canina. Se valoro

la calidad de vida por medio de un cuestionario

validado tras la completa rehabilitacion.

Resultados: La supervivencias acumulada del im-

plante zigomatico fue del 82%. Hubo tres perdidas

debido a infeccion persistente y aflojamiento gra-

dual. Los implantes perdidos fueron inmediatamente

reemplazados en el hueso adyacente. Una longitud

insuficiente del implante dentro del tejido blando

tendio a infecciones cronicas por formacion de bolsas

y sobrecrecimiento recurrente de tejido de granula-

cion. Unos implantes mas largos se liberaron de la

inhibicion del tejido blando aunque tendieron a

sobrecarga y mayor palanca en los casos sin proceso

alveolar y sin implantes dentales. Por lo tanto el

exito de los implantes zigomaticos fue del 71%,

incluyendo las nuevas posiciones premolares y

caninas de fijacion zigomatica. Los valores de Peri-

otests se incrementaron de 0 a þ7 al 4 ano, el

sangrado periimplantario y el ındice de placa dis-

minuyeron del 56 al 0%, y se noto una buena

calidad general de vida con las prioridades de masti-

cacion y actividad.

Conclusion: Los implantes zigomaticos pueden an-

clar fiablemente las protesis mediofaciales maxilares

y permitir una calidad de vida comparable a la

reconstruccion maxilar antologa. Se pueden sustituir

inmediatamente si ocurre una infeccion local o un

aflojamiento. Una posicion premolar o canina re-

duce la palanca cuando no existe proceso alveolar

anterior. El paciente puede ser suministrado alter-

nativamente con implantes dentales.

References

Baumann, A. & Ewers, R. (2000) Application of the

buccal fat pad in oral reconstruction. Journal of

Oral and Maxillofacial Surgery 58: 392–393.

Bedrossian, E. & Stumpel, L.J. 3rd (2001) Immedi-

ate stabilisation at stage II of zygomatic implants:

rationale and technique. Journal of Prosthetic

Dentistry 86: 10–14.

Bedrossian, E., Stumpel, L. 3rd, Beckely, M. &

Indersano, T. (2002) The zygomatic implant:

preliminary data on treatment of severely resorbed

maxillae. A clinical report. International Journal

of Oral & Maxillofacial Implants 17: 861–865.

Breine, U. & Branemark, P.I. (1980) Reconstruction

of alveolar jaw bone. An experimental and clinical

study of immediate and performed autologous

bone grafts in combination with osseointegrated

implants. Scandinavian Journal of Plastic and

Reconstructive Surgery and Hand Surgery 14:

23–48.

Brown, J.S. (1996) Deep circumflex iliac artery free

flap with internal oblique muscle as a new

method of immediate reconstruction of maxillec-

tomy defect. Head and Neck 18: 412–421.

Brown, J.S., Rogers, S.N., McNally, D.N. & Boyle,

M. (2000) A modified classification of the max-

illectomy defect. Head and Neck 22: 17–26.

Buser, D., Schenk, R.K., Steinemann, S., Fiorellini,

J.P., Fox, C.H. & Stich, H. (1991) Influence of

surface characteristics on bone integration of tita-

nium implants. A histomorphometric study in

miniature pigs. Journal of Biomedical Materials

Research 25: 889–902.

Buser, D., Weber, H.P. & Lang, N.P. (1990) Tissue

integration of non-submerged implants. 1-year

results of a prospective study with 100 ITI hol-

low-cylinder and hollow-screw implants. Clinical

Oral Implants Research 1: 33–40.

Chuang, S.K., Tian, L., Wie, L.J. & Dodson, T.B.

(2001) Kaplan-Meier analysis of dental implant

survival: a strategy for estimating survival with

clustered observations. Journal of Dental Re-

search 80: 2016–2020.

Cochran, D.L., Nummikoski, P.V., Higginbottom,

F.L., Hermann, J.S., Makins, S.R. & Buser, D.

(1996) Evaluation of an endosseous titanium

implant with a sandblasted and acid etched

surface in the canine mandible: radiographic

results. Clinical Oral Implants Research 7:

240–252.

Cordeiro, P.G. & Santamaria, E. (2000) A classifica-

tion system and algorithm for reconstruction of



maxillectomy and midfacial defects. Plastic and

Reconstructive Surgery 105: 2331–2346.

Dellon, A.L. (1978) The moving two-point discrim-

ination test: clinical evaluation of the quickly

adapting fiber/receptor system. Journal of Hand

Surgery 3: 474–481.

Evans, J.H., Schweiger, J.W. & Wright, R.F. (1996)

Craniofacial osseointegration of a large midfacial

bone anchored in combination maxillofacial pros-

thesis: a clinical report. Journal of Prosthetic

Dentistry 75: 483–486.

Futran, N.D. & Haller, J.R. (1999) Considerations

for free-flap reconstruction of the hard palate.

Archives of Otolaryngology, Head and Neck

Surgery 125: 665–669.

Hurzeler, M.K., Kirsch, A., Ackermann, K.-L. &

Quinones, C.R. (1996) Reconstruction of the

severely resorbed maxilla with dental implants

in the augmented maxillary sinus: a 5-year clin-

ical investigation. International Journal of Oral &

Maxillofacial Implants 11: 466–475.

Isaksson, S. (1994) Evaluation of three bone grafting

techniques for severely resorbed maxillae in con-

junction with immediate endosseous implants.

International Journal of Oral & Maxillofacial

Implants 9: 679–688.

Izzo, S.R., Berger, J.R., Joseph, A.C. & Lazow, S.K.

(1994) Reconstruction after total maxillectomy

using an implant retained prosthesis: a case report.

International Journal of Oral & Maxillofacial

Implants 9: 593–595.

Jensen, T.O., Brownd, C. & Blacker, J. (1992)

Nasofacial prostheses supported by osseointeg-

rated implants. International Journal of Oral &


Keller, E.E., van Roeckel, N.B., Desjardins, R.P. &

Tolams, D.E. (1987) Prosthetic-surgical recon-

struction of the severely resorbed maxilla with

iliac bone grafting and tissue-integrated pros-

theses. International Journal of Oral & Maxillo-

facial Implants 2: 155–165.

Kornblith, A.B., Zlotolow, I.M., Gooen, J., Huryn,

J.M., Lerner, T., Strong, E.W., Shah, J.P., Spiro,

R.H. & Holland, J.C. (1996) Quality of life of

maxillectomy patients using an obturator prosthe-

sis. Head and Neck 18: 323–334.

Lekholm, U., Wannfors, S., Isaksson, B. & Adiels-

son, B. (1999) Oral implants in combination with

bone grafts. A 3-year retrospective multicenter

study using the Branemark implant system. Inter-

national Journal of Oral and Maxillofacial Sur-

gery 28: 181–187.

Loe, H. (1967) The gingival index, the plaque index

and the retention index system. Journal of Perio-

dontology 38: 610–616.

Lukas, D. & Schulte, W. (1990) Periotest, a dy-

namic procedure for the diagnosis of the human

periodontium. Clinical Physics and Physiological

Measurement 11: 65–75.

Malevez, C., Abarca, W., Durdu, F. & Daelemans,

P. (2004) Clinical outcome of 103 consecutive

zygomatic implants. Clinical Oral Implants Re-

search 15: 18–22.

Nkenke, E., Hahn, M., Lell, M., Wiltfang, J.,

Schulze-Musgau, S., Stech, B., Radespiel-Troger,

S. & Neukam, F.W. (2003) Anatomic site evalua-

tion of the zygomatic bone for dental implant

placement. Clinical Oral Implants Research 14:

72–79.

Parel, S.M., Branemark, P.I., Ohrnell, L.O. &

Svensson, B. (2001) Remote implant anchorage

for the rehabilitation of maxillary defects. The

Journal of Prosthetic Dentistry 86: 377–386.

Parel, S.M., Holt, G.R., Branemark, P.I. & Tjell-

strom, A. (1986) Osseointegration and facial

prosthetics. International Journal of Oral &


Pollice, P.A. & Frodel, J.L. (1998) Secondary recon-

struction of upper midface and orbit after total

maxillectomy. Archives of Otolaryngology, Head

and Neck Surgery 124: 802–808.

Reichert, T.E., Kunkel, M., Wahlmann, U. &

Wagner, W. (1999) Das Zygoma-Implantat – In-

dikationen und erste Erfahrungen. Zeitschrift fur

Zahnarztliche Implantologie 15: 65–70.

Rogers, S.N., Gwanne, S., Lowe, D., Humphris, G.,

Yueh, B. & Weymuller, E.A. (2002) The addition

of mood and anxiety domains to the University of

Washington Quality of Life scale. Head and Neck

24: 521–529.

Rogers, S.N., Laher, S.H., Overend, L. & Lowe, D.

(2002) Importance-rating using the University of

Washington Quality of Life questionnaire in pa-

tients treated by primary surgery for oral and

oro-pharyngeal cancer. Journal of Craniomaxillo-

facial Surgery 30: 125–132.

Rogers, S.N., Lakshmiah, S.R., Narayan, B., Lowe,

D., Brownson, P., Brown, J.S. & Vaughan, E.D.

(2003) A comparison of the long-term morbidity

following deep circumflex iliac and fibula free

flaps for reconstruction following head and neck

cancer. Plastic and Reconstructive Surgery 112:

1517–1525.

Rogers, S.N., Lowe, D., McNally, D., Brown, J.S. &

Vaughan, E.D. (2003) Health-related quality of life

after maxillectomy: a comparison between pros-

thetic obturation and free flap. Journal of Oral

and Maxillofacial Surgery 61: 174–181.

Roumanas, E., Nishimura, R., Beumer, J., Moy, P.,

Weinlander, M. & Lorant, J. (1994) Craniofacial

defects and osseointegrated implants: six-year

follow-up report on the success rates of craniofa-

cial implants at UCLA. International Journal of

Oral & Maxillofacial Implants 9: 579–585.

Sakuraba, W., Kimata, Y., Ota, Y., Uchiyama, K.,

Harii, K. & Ebihara, S. (2003) Simple maxillary

reconstruction using free tissue transfer and pros-

theses. Plastic and Reconstructive Surgery 111:

594–598.

Schramm, A., Gellrich, N.C., Schimming, R. &

Schmelzeisen, R. 2000 [Computer assisted inser-

tion of zygomatic implants (Branemark System)

after extensive tumor surgery]. Mund Kiefer Ge-

sichtschirurgie 4: 292–295.

Swartz, W.M., Banis, J.C., Newton, E.D., Ramasa-

try, S.S., Jones, N.F & Acland, R. (1996) the

osteocutaneous flap for mandibular and maxillary

reconstruction. Plastic and Reconstructive Sur-

gery 77: 530–545.

Van Steenberghe, D., Malevez, C., Cleynenbreugel,

J., Serhal, C.B., Dhoore, E., Schutyser, F., Sue-

tens, P. & Jacobs, R. (2003) Accuracy of drilling

guides for transfer from three-dimensional CT-

based planning to placement of zygoma implants

in human cadavers. Clinical Oral Implants Re-

search 14: 131–136.

Triplett, R.G. & Schow, S.R. (1996) Autologous

bone-grafts and endosseous implants: comple-

mentary techniques. Journal of Oral and Max-

illofacial Surgery 54: 486–494.

Truitt, T.O., Gleich, L.L., Huntress, G.P. & Gluck-

man, J.L. (1999) Surgical management of hard

palate malignancies. Otolaryngology, Head and

Neck Surgery 121: 548–552.

Uchida, Y., Goto, M., Katsuki, T. & Akioshi, T.

(2001) Measurement of the maxilla and zygoma

as an aid in installing zygomatic implants.

Journal of Oral and Maxillofacial Surgery 59:

1193–1198.

Uglesic, V., Virag M, . & Varga, S. (2000) Recon-

struction following radical maxillectomy with

flaps supplied by the subscapular artery. Journal

of Craniomaxillofacial Surgery 28: 153–160.

Vuillemin, T., Raveh, J., Ladrach, K. & Roux, M.

(1990) Reconstruction following hemimaxillec-

tomy. Schweizer Monatsschrift Zahnmedizin

100: 1082–1087.

Weingart, D., Schilli, W. & Strub, J.R. (1992) Pre-

prosthetic surgery and implantology. Schweizer

Monatsschrift Zahnmedizin 102: 1075–1982.

Weischer, T., Schettler, D. & Mohr, C. (1997)

Titanium implants in the zygoma as retaining

elements after hemimaxillectomy. International

Journal of Oral & Maxillofacial Implants 12:

211–214.

Weymuller, E.A., Alsarraf, R., Yueh, B., Deleyannis,

F.W. & Coltrera, M.D. (2001) Analysis of the

performance characteristics of the University of

Washington Quality of Life instrument and its

modification (UW-QOL-R). Archives of Otolar-

yngology, Head and Neck Surgery 127: 489–493.



Zygoma implant-supported midfacial - Constantin Alexander.pdf

Documents

Transcript of Zygoma implant-supported midfacial - Constantin Alexander.pdf