zero maxilla zygomatic impant subperiosteal implant

Zero maxilla

2. BDS,MSc,PhD,MOMS RCPS Glass,MOS RCS Ed,FDS
RCS ED
Senior Consultant Maillofacial surgeon
Professor of OMFS MUST university
Examiner in the RCS Ed
Council Member in RCS Ed
Prof Lotfy Killany

3. BDS,MSc,MFDS RCS Ed, MOMS RCPS Glasd,
FFD RCSI,FDS RCPS GLasg,FDS RCS Ed
FFD GDent London
Senior Consultant OMFS
Head of OMFS Agamy Hospital
IMAXFAX center
Mr.Islam Kassem

4. •There is no conflict of interest in this lecture
•I have no monetary benefit from this lecture.
•No implied sponsorship by any company to the
speaker
•all photographed patients were treated by the
speaker and consented for photographing and
public publishing

8. Details please

9. E-log book
M implant Diploma

10. [email protected]
Diagnosis first
2006

11. WHAT IS GRAFT ?
A viable tissue that after removal from
a donor site is implanted with in a
recipient tissue is then restored
repaired & regenerated.

12. WHAT IS GRAFTING ?
Procedure used to replace /
restore missing bone or gum
tissue.

13. WHAT ARE BONE GRAFTS?
Bone grafts are the materials used for
replacement or augmentation of the
bone.
Food and Drug Administration (FDA)
regulates bone grafting materials

14. OSTEOINDUCTION
•  A chemical process by which molecules
contained in the graft(bmp)convert the
neighbouring cells into osteoblasts which
in turn form bone.
•  Process by which graft material is
capable of promoting
- osteogenesis

- cementogenesis - new PDL
(Urist & McLean)

15. A graft, a biomaterial or a
substance is osteo inductive when
implanted in a non osseous
environment called as an ectopic site,
bone formation occurs.

16. OSTEOGENESIS
represents all the steps & processes leading to bone
formation. This term has been used by some authors to
define bone grafts capable of forming bone through
osteoblastic cells contained in the transplanted graft
OR
the process of bone formation, which begins with either
osteoblasts in the patient's natural bone or from surviving
cells in the bone graft that is placed.

17. OSTEOCONDUCTION
• A physical effect by which the matrix of
the graft forms a scafold that favours
outside cells to penetrate the graft and
form new bone.
• The Graft material acts as a passive
matrix like a trellis or scaffolding for new
bone to cover over itself. 

( Urist & colleagues ) 

•

18. OSTEOSTIMULATION - “The
stimulation of osteoblast proliferation
and differentiation as evidenced
during in vitro osteoblast cell culture
studies by increased DNA content and
elevated osteocalcin and
alkalinephosphatase levels”
FDA 2005

19. INDICATIONS FOR GRAFTS
 Deep Intraosseous Defects 

Tooth Retention 

Support for Critical Teeth 

Bone Defects Associated With Aggressive
Periodontitis 

Esthetics (Shallow Intraosseous Defects) 

Furcation Defects 


20. technology can help?

22. Bone substitutes
Xenogeneic grafts (xenografts)
Bovine-derived hydroxyapatite
Coralline calcium carbonate Alloplastic grafts
(alloplasts)
Polymers Bioceramics
- Tricalcium phosphate
- Hydroxyapatite Bioactive glasses

23. IDEAL CHARACTERISTIC OF BONE
GRAFT
• Nontoxic
• Nonantigenic
• Resistant to infection
• No root resorption or ankylosis
• Strong and resilient
• Easily adaptable
• Readily and sufficiently available
• Minimal surgical procedure 

Stimulates new attachment 


24. AUTOGRAFTS
•  first bone replacement grafts reported for
periodontal applications
•  ‘‘Gold Standard’’ for bone grafting procedures
• Rich source of bone & marrow cells
•  osteogenic potential 

•

25. Go Digital Equal
more safety
www.mrread.ca

26. •Vitamin deficiency
in adolescent ,
review article ,
•Europtian J of
pediatric 2014
Kassem et at 

•

27. Dental Council of The Royal College of Surgeons of
Edinburgh, United Kingdom (2023-2028)

28. (Full Story)

29. (Full Story)

32. Zero Maxilla 

In this classification, the maxilla is divided into four different zones:-
Zone 1: Anterior region (from canine to canine)
Zone 2: Premolar region
Zone 3: Molar region
Zone 4: Zygoma
Bedrossian classification




33. ➢1- When bone is present in three
zones 1,2 and 3
Conventional axial implant should be
performed
Surgical Approaches:- 


34. ➢2- When bone is present only in zone1
and 2 tilted implants
should be used( All on x) dental implant
Surgical Approaches:- 


35. ➢3- When bone is present only in zone1
Two conventional implants in the anterior maxilla
and one zygoma implant on each side should be used
Surgical Approaches:- 


36. ➢4- When there is no bone present in three
zones 1,2 or 3 Quad zygoma implants
or subperiosteal implants should be considered
Surgical Approaches:- 


37. Zygomatic Implants 


38. ➢What are zygoma implants?
➢When are zygoma implants
indicated?
➢What are the contraindications for
zygoma implants?
➢What anatomical considerations are
there for zygoma implant placement?
Objectives


39. ➢What are the different surgical techniques
for zygoma implant placement?
➢What is included in zygoma implant kits?
➢What are the steps of surgical procedure
for zygoma implants
Objectives


40. ➢Zygoma implants are extra-
alveolar implants that has an
anchorage from the zygomatic
bone.
What are zygoma implants?






41. 1- Severe atrophy of
maxillary bone that
precludes placement of
conventional dental implants
When are zygoma implants indicated?




42. 2- rehabilitation of defects resulting from
trauma or tumor resection, where patients had
lost extensive sections of the maxilla and palate
When are zygoma implants indicated?



3- Failure of of conventional dental
implants and or bone grafting

43. Zygomatic bone length (14 to 25.5mm)
Zygoma thickness (7.5 to 9.5mm).
Upon placement of a zygoma implant, Slightly more than
one-third of the implant (14–16.5 mm) comes into direct
contact with the zygoma’s solid, sturdy outer cortex
Zygoma Anatomy


44. Zygomatic implant length (30 to 60 mm)
Zygoma thickness (4to 5 mm).
Zygoma Implant Design


45. 1.Maxillary alveolar bone can support traditional implants
2.Medically compromised patients
3.Pathology involving the zygomatic bone
4.A history of intravenous (IV) bisphosphonate use
5.A history of head and neck irradiation with dosages greater than 70 Gy
6.Maxillary sinus pathology OR a history of sinusitis
CONTRAINDICATIONS


46. A Intrasinus Technique
1- Brånemark Intrasinus Technique
2- Sinus Slot Stella and Warner Technique
B Extrasinus Zygoma Implants Malo
C The Zygoma Anatomy-guided Approach (ZAGA) Technique (Aparicio)
Surgical Techniques

47. The Zygoma Anatomy-guided Approach (ZAGA) Technique (Aparicio)
The rationale for the ZAGA method is to provide individualized treatment for a
patient based on his/her unique anatomical presentation

48. The ZAGA classification system
➢ZAGA type 0: intrasinus path
➢In this type, the lateral wall of the maxillary sinus is flat, and the implant takes an intrasinus path.
➢The implant head is usually purely in crestal bone.
➢No window is made. Like in the original Brånemark intrasinus protocol, the implant passes
through the sinus..
➢The implant contacts the bone at the crest, zygoma, and sometimes the lateral wall of the sinus.
THE ZYGOMA ANATOMY-GUIDED APPROACH
(ZAGA) TECHNIQUE

49. The ZAGA classification system
➢ZAGA type 1: extra-intrasinus path
➢In this type, the anterior maxillary wall is slightly concave, and the implant takes an extra-intrasinus path.
➢Osteotomy is slightly through the wall.
➢Although the implant can be seen through the wall, most of the implant body takes an intrasinus path.
➢The head of the implant is on the crest.
➢The implant contacts the bone at the crest, zygoma, and lateral wall of the sinus.
THE ZYGOMA ANATOMY-GUIDED APPROACH
(ZAGA) TECHNIQUE

50. The ZAGA classification system
➢ZAGA type 2: extra-intrasinus path•
➢In this type, the anterior maxillary wall is concave, and the implant takes an extra-intrasinus path.
➢Osteotomy is slightly through the wall.
➢Although the implant can be seen through the wall, most of the implant body has an extrasinus path.
➢The head of the implant is on the crest.
➢The implant contacts the bone at the crest, lateral wall of the sinus, and zygoma.
THE ZYGOMA ANATOMY-GUIDED APPROACH
(ZAGA) TECHNIQUE

51. The ZAGA classification system
➢ZAGA type 3: extrasinus path
➢In this type, the anterior maxillary wall is very concave, and the implant takes an extrasinus path.
➢Osteotomy starts from the palatal aspect of the crest, keeping the head on the alveolar crest
➢The implant then passes buccally to the concave part of the wall of the sinus and penetrates the
zygoma.
➢The implant contacts the coronal alveolar bone and the apical part of the zygoma.
THE ZYGOMA ANATOMY-GUIDED APPROACH
(ZAGA) TECHNIQUE

52. THE ZYGOMA ANATOMY-GUIDED APPROACH
(ZAGA) TECHNIQUE

53. i.Anesthesia
ii.Incision and flap design
iii.Drilling into the zygomatic bone
iv.Creating the path of the implant body
v.Placement of the implant
The Surgical Procedure

54. The Surgical Procedure
i.Anesthesia
❖General Anesthesia
❖Local Anesthesia with Oral/IV Sedation.
The intraoral blocks include the following:
Block of posterior superior alveolar nerve
Block of infraorbital nerve
Block of greater palatine nerve
Extraoral infiltrations over the zygoma

56. The Surgical Procedure
ii. Incision and flap design
❖A midcrestal full-thickness
incision is made on the crest of the
ridge from the midline to the first
molar region..
❖Two vertical releasing incisions
made for better visibility and to
prevent flap tearing, the first one in
the midline and another posteriorly.

57. The Surgical Procedure
ii. Incision and flap design
he flap must be extended to expose the following
-The alveolar crest
-The posterosuperior part of the zygomatic bone to the
area between the lateral/medial surfaces of the frontal
process and arch of the zygomatic bone, namely the
incisura
-The posterior edge of the maxilla

58. The Surgical Procedure
iii. Drilling
❖The osteotomy into the zygoma
involves four steps:-
1.point A. Identifying the point of
entry at the crest/intraoral
entrance
2.point B. Identifying the point of
entry in the zygoma
3.Joining point A and point B.
4.point C Identifying the exit
point in the zygoma

59. The Surgical Procedure
iii. Drilling
❖The osteotomy into the zygoma involves four steps:-
1.point A. Identifying the point of entry at the crest/
intraoral entrance
If residual bone at the sinus floor level is sufficient
in thickness and width (minimum 3 mm high × 5
mm wide), and the patient has no periodontitis
history, the entry point should be in a position close
to the middle part of the crest with an intra-sinus
starting path of the implant.

60. The Surgical Procedure
iii. Drilling
❖The osteotomy into the zygoma involves four steps:-
1.point A. Identifying the point of entry at the crest/intraoral entrance
If residual bone at the sinus floor level is sufficient in
thickness and width (minimum 3 mmhigh × 5 mm wide), the
entry point should be in a position close to the middle part of
the crest with an intra-sinus starting path of the implant.

62. The Surgical Procedure
iii. Drilling
2- point B. Identifying the point of
entry in the zygoma
the minimum amount of bone that
Must be leave over the implant to
prevent zygomatic bone fracture
during drilling is 3 mm

63. The Surgical Procedure
iii. Drilling
2- point B. Identifying the point of
entry in the zygoma

64. 3- Joining point A and point B (mock
surgery).
The Surgical Procedure
a) Joining point A and
point B (mock surgery).
(b) Creating a tunnel with
a diamond drill.
(c) Tunnel created (mock
surgery).
(d) Tunnel created

65. The Surgical Procedure
b) Placement of the
implant

66. iv- Placement of
the implants
The Surgical Procedure

67. The Surgical Procedure
a) Assembling of multi-unite abutments

68. The Surgical Procedure
a) iv- Placement of the quad zygoma
implants

69. The Surgical Procedure
a) Capping of multi-unite abutments

70. The Surgical Procedure
a) Suturing is done

71. Intra-operative complications
1.Incursions of the implants into the orbit
2.Incursions of the implants into the temporal
fossa
3. Zygomatic bone fractures
COMPLICATIONS

Postoperative complications
1.soft tissue dehiscence
2.oroantral communication.
3.Maxillary sinusitis (78% of intrasinus
technique)

72. Subperiosteal implants are a type of dental
implant used to support prosthetic teeth or
dentures. They are placed under the periosteum,
which is the tissue covering the bone

73. They are generally considered for patients
with severe bone loss or deformity where
other implant types are not feasible

75. It’s an old story
Friction support implant

76. •Surgically driven
•

77. Pre-Surgical Assessment: A comprehensive evaluation,
including imaging (such as CT scans), is performed to
assess bone structure and determine the feasibility of
.the implant
Surgical Planning: The implant is custom-designed
based on the anatomical details obtained from imaging
studies

79. •Workflow
•

80. Minute in planning save hour
In surgery
•

81. Teeth driven

82. Surgical Placement: An incision is made to expose the
bone, and the subperiosteal implant framework is placed
directly onto the bone. The periosteum is then
.repositioned over the implant
Healing Period: The implant is allowed to integrate with
the bone and soft tissue over several months before the
.prosthetic teeth or dentures are attached

83. :Advantages :
- Bone Preservation: Avoids the need for extensive bone
grafting procedures
-Reduced Need for Bone Augmentation: Suitable for
.patients with significant bone resorption

84. :Disadvantages:
Complexity: The procedure is more complex compared to
other types of implants.
Longer Healing Time: The healing period can be longer.
Potential for Complications: Includes risks of infection,
implant failure, and peri-implantitis.

85. Take home massage

Egyptians create the standards,
The world follows

86. •Islam Kassem
•[email protected]
•00201559900333
•Slide share
•Pub med
•Researchgate