Preoperative workup

The patient must have satisfactory health to undergo deep sedation or general anesthesia. The patient also must have sufficient anterior bone for the placement of two to four anterior implants to stabilize the restoration. Preoperative radiographs should reveal a healthy maxillary sinus without polyps or other significant pathologic conditions. Axial and reconstructed computed tomography (CT) scans should indicate 8 to 12 mm of bone in the zygomas, as well as appropriate morphologic bone structure to allow placement of the zygomaticus implants within the confines of the lateral aspect of the maxilla. A consultation with the restorative dentist should confirm that immediate fabrication of a temporary cross-arch bar will be possible at the time of exposure, ensuring the stabilization of the maxillary implants.

Surgical procedure

As mentioned, the patient may have either general anesthesia or deep sedation for this surgery. The incision is made and released to allow the subperiosteal reflection to extend over the superior aspect of the zygoma (Figure 5-2). The incision can be made in the vestibule, directly over the alveolar crest, or slightly palatal to the crest. This author prefers the incision to be slightly palatal to the crest. The incision extends from the second molar region to the midline with a vertical release in the midline of the maxilla. One side of the maxilla is operated on first; the contralateral dissection then is performed.

After the incision has been made, a full-thickness mucoperiosteal flap is elevated. Occasionally, a posterior release incision is necessary. The subperiosteal reflection is performed to expose bilaterally the following:

After exposure of the lateral aspect of the maxillary bone, the palatal mucosa is elevated from the first molar to the incisive canal region for placement of the implants. An instrument is aligned from the palate to the zygoma to approximate the planned path of the zygomaticus implant. This path enables the surgeon to locate the proposed implant site and perform the sinus membrane elevation (Figure 5-3).

This author uses a round bur to prepare the site for the maxillary sinus membrane elevation. A rectangular piece of bone, approximately 8 × 20 mm, is carefully removed while the integrity of the underlying sinus membrane is maintained. The sinus membrane is elevated from the inner aspect of the maxillary sinus to allow direct visualization of the entry of the zygomaticus drills, place the implant into the zygoma, and prevent membrane entrapment between the implant and bone (Figures 5-4 and 5-5).

After the membrane has been elevated, the long round bur is used. The drill is angled to place the entry point in the maxilla within the crest of the alveolus, often palatal to the crest (Figure 5-6). The drill should enter the maxillary sinus and engage the inner aspect of the zygoma. The drill should be completely within the confines of the lateral wall of the maxilla. The round bur is used to create a purchase point for the next drill.

The next drill is 2.9 mm in diameter, matching the diameter of the previously used round bur. This drill is taken through the palatal site, traversing the maxillary sinus, to prepare the implant site from the inner aspect of the zygoma; it passes through the lateral aspect of the zygoma superiorly. The orbital rim must be avoided.

The next drill is a transition drill, which has a guide to enter the 2.9-mm-diameter hole in the palate and zygoma (Figure 5-7). This drill opens the hole to the final size in the zygoma. This transition drill is not intended to complete the implant site. The next drill is the 3.5-mm-diameter twist drill, which is taken through the superior aspect of the zygoma. If the palatal bone is thick, the 4.0-mm twist drill can be used to complete the palatal site. If the maxillary alveolar bone is thin, the 3.5-mm drill is used, and the 3.5-mm drill is used in the zygoma.

At this point in the procedure, the surgeon is ready to place the zygomaticus implant. However, the necessary length of the implant must be confirmed before an implant is removed from its container. The measuring instrument, which has the implant’s length etched by sequential lines, is placed into the site, entering the palatal hole and exiting the zygoma site. The length of the implant is determined by identifying the line of corresponding length at the palatal site (Figure 5-8).

The appropriate-length implant is chosen and placed onto the sterile field. The glass container is opened, and the implant is carefully removed with its sheath. The two wings of the sheath are expanded and removed, exposing the cover screw on the implant. The cover screw is removed and placed onto a sterile tray. The implant is mounted on the delivering handpiece adapter and is placed into the palatal site. As the implant enters the dense zygoma bone, the torque of the drill most likely will be exceeded. The handpiece adapter is removed, and the manual turning instrument is used to complete placement of the implant. The angle of the driving mount screw should be inferiorly oriented. The driving mount is removed, and the external hex of the implant is visible. The cover screw is placed to cover the external hex. The same procedure is performed on the contralateral side of the maxilla (Figures 5-9 to 5-13). After the two zygomaticus implants have been placed, two to four anterior implants are placed. The wound is irrigated thoroughly and closed. Nonresorbable sutures are recommended.

Six months is recommended for integration. At the time of exposure, temporary gingival abutments are placed. It is critical for the success of these implants that they be connected rigidly to the anterior implants within a few days of exposure because they probably will integrate only in the dense zygoma bone, not in the thin palatal bone. Therefore, making an index of the implants at exposure facilitates the fabrication of a temporary rigid bar. At exposure, the palatal tissue may need to be thinned.