Year : 2010 | Volume
: 21 | Issue : 1 | Page : 125--128
Fixed rehabilitation of patient with aggressive periodontitis using zygoma implants
Gunaseelan Rajan1, Mirza Rustum Baig2, John Nesan1, Jayaram Subramanian1,
1 Rajan Dental Institute, Chennai, India
2 Department of Prosthodontics, University of Malaya, KL, Malaysia
Mirza Rustum Baig
Department of Prosthodontics, University of Malaya, KL, Malaysia
Treatment of patients with aggressive periodontitis has always been a challenge to the clinician. Both young and old are known to be affected by this progressive destructive condition of the supporting dental structures. Although dental implants have been offered as a viable treatment alternative for such patients, additional procedures (like bone grafting) and delayed protocols have limited their usage. This case report describes the treatment of a young patient with aggressive periodontitis using a graftless implant solution. Zygoma implants in conjunction with conventional implants were used with immediate loading.
|How to cite this article:|
Rajan G, Baig MR, Nesan J, Subramanian J. Fixed rehabilitation of patient with aggressive periodontitis using zygoma implants.Indian J Dent Res 2010;21:125-128
|How to cite this URL:|
Rajan G, Baig MR, Nesan J, Subramanian J. Fixed rehabilitation of patient with aggressive periodontitis using zygoma implants. Indian J Dent Res [serial online] 2010 [cited 2021 Feb 27 ];21:125-128
Available from: https://www.ijdr.in/text.asp?2010/21/1/125/62801
Aggressive periodontitis is a rapidly progressive destructive condition of the supporting dental tissues  leading to tooth mobility and subsequent premature loss of teeth. Treatment option for this condition often includes total extraction and rehabilitation with removable or implant-based fixed prosthesis. For dental implant treatment, the posterior maxilla is found deficient in bone due to extensive periodontal disease. In addition, poor bone quality and proximity to the sinus are challenges to implant installation. Traditionally, bone grafting has been advocated to enable implant placement, thereby causing delay and involving multiple surgical procedures. In recent times, zygomatic implants have developed as an alternative to conventional grafting procedures for the rehabilitation of the edentulous maxilla with severe bone resorption. High success rates have been reported with these implants with predictable long-term results. , These implants, in conjunction with conventional root form implants, present a definitive option for replacement of natural teeth with restoration of function, form and esthetics with one surgical procedure and provision for immediate loading. ,
This article describes the role of zygomatic implants in the dental rehabilitation of a young patient with aggressive periodontitis.
A 24-year-old male presented with complaints of missing upper and lower anterior teeth and generalized mobility of remaining teeth [Figure 1]. The patient requested for comprehensive treatment with replacement of missing teeth. There was generalized bleeding on probing and mobility of all teeth on clinical examination. OPG and CT scans of the maxilla and mandible revealed severe maxillary and mandibular bone loss, especially in the posterior region [Figure 2].
The patient was presented with various treatment options:
Total extraction of teeth and replacement with conventional removable acrylic maxillary and mandibular complete denturesTotal extraction of teeth, onlay bone grafting and subsequent implant placement, six to nine months later, with immediate or conventional loading protocol based on the initial stability of implantsTotal extraction, zygoma implants in conjunction with regular implants and immediate loading with implant retained fixed prosthesis, if good primary stability achieved.
Due to various considerations, the patient opted and was planned for option C, i.e. complete extraction and immediate placement of zygoma implants, with two regular implants in the anterior maxilla and four regular implants in the mandible with maxillary and mandibular implant-retained fixed prostheses.
Under general anesthesia, 24 maxillary and mandibular teeth along with an impacted right mandibular third molar were removed. Local anesthesia (2% Lignocaine with 1:200,000 adrenaline) was infiltrated in the upper buccal vestibule to aid haemostasis. Buccal vestibular incisions were placed in relation to right and left premolar-molar region and the mucoperiosteal flaps were raised to expose up to the superior border of the zygomatic bone. Care was taken to protect the infraorbital nerves and vessels.
Adequate precaution was taken to avoid injuries to the floor of the orbit. A 5 x 5 mm window was created on the lateral wall of the maxillary sinus close to the infrazygomatic crest. The sinus mucosa was elevated off the superior-lateral part of the roof of maxillary sinus. On the right side, a two cm releasing incision was placed palatally close to the extraction socket in relation to the maxillary first molar-second premolar region. On the left side, a small stab incision (2-3 mm) was placed palatally close to the extraction socket in relation to the second maxillary premolar region. A long round bur in a straight surgical hand piece was used to make an entry through the palatal alveolar bone and reach the floor of the maxillary sinus. Direct visualization was done through the sinus window. The zygomatic bone implant bed was prepared using standard implant drilling protocol for zygoma implants. Using the straight depth indicator, the desired length of the zygoma implant to be used was measured. Verification of the depth of the prepared site was done with the help of the angled depth indicator. This ensured that the selected implant length could be fully seated without apical bone interference. Once verified, two Branemark Zygoma TiUnite implants (52.5 mm) were placed bilaterally. An insertion torque of more than 35 Ncm was achieved for both the zygoma implants. Two regular Nobel Biocare Replace Select dental implants were also placed in the maxillary anterior region. The primary stability for these implants was greater than 35 Ncm.
In the mandible, four Nobel Biocare Replace Select dental implants were placed. The primary stability for these implants was greater than 35 Ncm for all except one, where only 25 Ncm was achieved. Healing abutments were placed on all implants [Figure 3]. Wound closure was done with 3-0 vicryl sutures. Primary impressions were made for fabrication of custom trays for final impressions.
Postoperatively, the patient's recovery was uneventful. There was minimal edema on the surgical site. On the third postoperative day, final impressions were recorded and, subsequently, by the end of the first week, the interim maxillary and mandibular acrylic screw-retained implant prostheses were torqued to the implants at 10 Ncm torque. The patient was reviewed and placed on follow-up maintenance. Six months postoperatively, clinical examination was done and the stability of the implants checked manually and by resonance frequency analysis test (Osstell, Integration Diagnostics AB, Goteborg, Sweden). The patient had no symptoms of pain or tenderness and the surrounding gingival tissues showed satisfactory healing.
The definitive metal-acrylic resin screw-retained maxillary and mandibular prostheses were then fabricated and issued [Figure 4]. The abutments were also finally torqued to 35 Ncm and the screw-access holes filled with gutta percha and composite [Figure 5]. The patient was then given oral hygiene instructions and placed on a follow-up maintenance protocol.
Zygoma implant is an alternative to bone augmentation or maxillary sinus grafting in patients with atrophic posterior maxillae needing implant fixed rehabilitation. , In 1993, Aparicio et al.  mentioned the possibility of implant placement in the zygomatic bone. In 1997, Weischer et al.  cited the use of the zygomatic bone as a support structure in the rehabilitation of patients subjected to maxillectomies. Since then, zygoma implants have developed as an effective treatment modality for severe maxillary bone loss. Branemark et al.  recorded a survival rate of 94.2% with 52 Zygoma; implants in 28 patients with a follow-up period of 5-10 years. Malevez et al.  published a retrospective study with a follow-up duration of 6-48 months post-prosthetic loading, evaluating the survival rate of 103 zygomatic implants placed in 55 edentulous, severely resorbed maxillae with a 100% zygomatic implant survival rate, with a single complication prior to prosthetic loading (severe sinus infection successfully treated with antibiotics). Bedrossian et al.  reported 100% survival in a series of 44 zygomatic implants in 22 patients, with a 91.25% survival rate for the 80 standard implants placed in the anterior maxillae. The observation period was 34 months. There have been reports of speech alterations and difficulty in maintaining oral hygiene, largely as a result of the palatine emergence of the platform of the zygomatic implant. Boyes-Varley et al.  placed 30 zygomatic implants in 18 patients, modifying the angulation of the implant head 558, to position emergence at alveolar crest level. According to the authors, this angulation of the implant head affords a cantilever reduction of over 20%, which in addition to improving the space required for tongue movement allows the patient better access for adequate maintenance of the dental prosthesis.
The use of the zygomatic implants lessened the need for extensive bone grafting, shortened hospital stay, and reduced postoperative morbidity and pain.  Zygomatic implants are an effective treatment alternative for the management of patients with aggressive periodontitis and atrophic maxillae. It is important to note that this procedure is not without complications, and requires thorough knowledge of the technique and surgical skill.
Zygoma implants offer a viable treatment alternative for complete maxillary edentulism in patients with a history of aggressive periodontitis. The use of these implants provides the patient with a graftless solution, with no necessity for extensive onlay grafting or sinus grafting procedures. The one-stage procedure is also established with this technique, whereby the implants can be splinted and cross arch stabilized with regular implants to achieve immediate loading. There is no doubt that a single case report cannot lead to definitive conclusions; hopefully more studies will be published in the future to corroborate or challenge this report. Similar findings may further help eliminate controversies regarding dental implant therapy in aggressive periodontitis patients.
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