Can you keep pace with today’s evolving workflow?

23 January 2024

A look at the use of zygomatic implants.

Zygomatic implant placement, often seen as a complex procedure for dental professionals, has evolved into a reliable solution for patients with an atrophic maxilla.

First introduced in 1998 by Per Ingvar Brånemark, who is often referred to as ‘the father of dental implantology’, the treatment process has significantly improved over time, leading to higher success rates and fewer complications. Today, it is established as a predictable implant rehabilitation option in moderate to severely atrophic maxillary cases. According to recent studies, long-term survival rates have risen from 86 per cent a decade ago to approximately 96.1 per cent success after five years. The success of zygomatic implants (ZIs) is expected to continue increasing with the introduction of the Zaga-Straumann ZI, developed by Carlos Aparicio, founder of the Zaga Centres.

The Zaga philosophy emphasises anatomically guided ZI placement to preserve the integrity of the maxillary structures, including the maxillary sinus, whilst taking into account each patient’s unique maxillofacial anatomy. The combined use of the Zaga concept and the new ZagaStraumann implant designs has been shown to result in less traumatic osteotomy, improved implant stability, better bone-to-implant contact, and enhanced bone sealing around the implant neck. Moreover, the rate of late complications, such as oral–sinus communication or soft tissue recession, has significantly decreased compared to the original technique. The advent of 3D digital technology has also played a crucial role in the improved success of ZIs. Today’s standard ZI procedure is markedly different from the first one performed over 25 years ago.

Into three dimensions

The planning stages of ZI placement are just as critical as the surgical procedure itself. Today, 3D planning based on cone beam computed tomography (CBCT) is at the forefront of implant surgery. When used to inform a guided approach, it has been shown to increase surgical accuracy and precision compared to free-hand surgical techniques of the past. With CBCT scans, clinicians can develop tailored treatment plans for each patient, taking into consideration the unique variations in facial structures, especially following atrophy in the maxilla.

A ZI approach is distinctive in its own regard. By basing the implant in the namesake bone, clinicians enter new territories of facial surgery that open up the potential for unfavourable results. Whilst failure has been minimised, complications such as maxillary sinusitis may still arise at the hands of an inexperienced clinician or ill-informed treatment plan – when present alongside other issues, there may be a reduced chance of implant survival and/or a decreased quality of life.

One preferable approach to avoid rhinosinusitis complications is an extra-maxillary placement technique. This can help to avoid perforations of the sinus, which would produce the opportunity for infection. Accurately placed outcomes not only rely upon pre-operative 3D imaging, but digital planning and guiding software could be of use, too.

As part of the digital revolution in dentistry, computer-guided implant procedures look to establish themselves as a new normal in many workflows. This includes using a bones-supported guide, born out of digital preparation and 3D printing, which minimises the differentials of a planned and positioned implant.

Ensuring minimal deviation between a planned approach and the final outcome is essential. If the entry position or angle were to differ even minutely from the prospective design, a clinician could see a greater emphasised divergence at the apex. This issue is exacerbated in zygomatic procedures, given the inherent length of the implant fixtures. The use of computer- and software-guided surgical approaches could, therefore, minimise the risk of intrusion into anatomical structures such as the maxillary sinus. In turn, this minimises the development of sinusitis and more closely replicates treatment plans.

Knowledge is power

Digital workflows do not make ZI placement any easier for the uninitiated, and the procedure must only be completed by those with the appropriate clinical training. Similarly to how treatment outcomes are only successful in the hands of a skilled clinician, 3D imaging from CBCT scanners and digital planning techniques are only beneficial when applied correctly. Dental professionals should seek out education on the latest workflows and applications to ensure their patients with atrophic maxillae receive the highest quality of care. The training should be provided by experienced and trusted professionals who have seen how workflows have developed and understand how to achieve optimal outcomes in modern dentistry.

Clinicians can begin their ZI journey with the hands-on course from Ucer Education based at Zaga Centre Manchester, which offers a comprehensive programme led by the specialist oral surgeon, Cemal Ucer. With 25 years of teaching, research, and clinical experience in implantology, the former ADI president ensures delegates understand the complete zygomatic workflow to implement the care into their practice. There is immense coverage on using modern CBCT imaging and 3D digital planning in the unique workflow to help delegates plan effectively for their treatments.

Approaches to ZIs will only develop with time, but clinicians must embrace the capabilities of digital technology to improve treatment outcomes. With greater imaging and planning workflows, there is the opportunity to create safer and more successful solutions for those in need.