What are long implants?
Volume of
Zygoma bone:
2 x 2 x 2 cm
Overview
• Indications
• Techniques for long implants
• Clinical examples
Indications for long implants
• Terminal bone atrophy
• Failures of previous reconstructive procedures
• Defects (congenital, acquired, posttraumatic)
Long implants = end of the line in treatment modalities
What is terminal bone atrophy?
• Classification of bone atrophy
• How do we diagnose terminal bone
atrophy?
• Overview af treatment modalities with
advancing atrophy
The Misch Classification of bone resorption
A B B-w C-w C-h D
↓ Width ↓ Height
From: Dental Implant Prosthetic, Carl Misch
Misch classification
• Relates degree of bone atrophy to time
elapsed since extractions
• Allows a comparison of comparable cases
in the literature
• Resorption can be „modulated‟ by a
number of factors resulting in accelerated
resorption
What is terminal bone atrophy?
• Classification of bone atrophy
• How do we diagnose terminal bone
atrophy?
• Overview af treatment modalities with
advancing atrophy
Measuring = knowing: the bone table
H: 13.81 mm
W: 7.27 mm
Example : Bone table
Bone Table
• Principle:
– For each implant location
– Measure height and width
– Take into account eventual alveolectomy
– Compare measured values against minimum
required bone volume
– E.g. Height 10 mm; Width 6 mm
16 15 14 13 12 11
21 22 23 24 25 26
Bone table for the Upper Jaw
16 15 14 13 12 11 21 22 23 24 25 26
Hgt - 3.1 2.0 3.1 3.3 3.6 5.7 5.2 5.9 4.8 3.4 1.7
Th - 2.0 1.8 3.4 3.5 3.6 4.3 4.3 4.9 3.76 3.1 1.9
What is terminal bone atrophy?
• Classification of bone atrophy
• How do we diagnose terminal bone
atrophy?
• Overview af treatment modalities with
advancing atrophy
Typical treatment strategies with
increasing bone atrophy
Div A Div B Div C Div D
A B B-w C-w C-h D
Standard implants
All-on-4
Sinus lift
Short
Zygoma
Standard implants
Standard implants
Tilted implants
Tilted implants
Sinus lifting
Sinus lifting
Short implants
Short implants
Standard + Long implants
2RP-4 RP 2Z
Standard + Long implants
19/06/2010: Preïmplantaat
Quad zygoma
Quad zygoma
Overview
• Indications
• Techniques for long implants
• Clinical examples
Techniques for long implants
• Intrasinusal (Brånemark)
• Stella
• Extramaxillary
• Quad zygoma
• Pterygoid implants
• Skullbase implants
Intrasinusal zygoma
Techniques for long implants
• Intrasinusal (Bränemark)
• Stella
• Extramaxillary
• Quad zygoma
• Pterygoid implants
• Skullbase implants
Anterior slot technique
Techniques for long implants
• Intrasinusal (Bränemark)
• Stella
• Extramaxillary
• Quad zygoma
• Pterygoid implants
• Skullbase implants
Extramaxillary
Techniques for long implants
• Intrasinusal (Bränemark)
• Stella
• Extramaxillary
• Quad zygoma
• Pterygoid implants
• Skullbase implants
Quad zygoma
Techniques for long implants
• Intrasinusal (Bränemark)
• Stella
• Extramaxillary
• Quad zygoma
• Pterygoid implants
• Skullbase implants
Pterygoid / Sphenoid
Techniques for long implants
• Intrasinusal (Bränemark)
• Stella
• Extramaxillary
• Quad zygoma
• Pterygoid implants
• Skullbase implants
Skull base
To guide or not to guide?
• Mental navigation
• Drill guide surgery
• Navigation technique
Mental Navigation
• Surgery is simulated on 3D software
• Performed freehand by the surgeon using
surgical skill and 3D knowledge of the
surgeon
To guide or not to guide?
• Mental navigation
• Drill guide surgery
• Navigation technique
Drill guide
• Types:
– SurgiGuide™ (Materialise)
– NobelGuide™ (NobelBiocare)
• Sometimes give a false impression of
safety
• Blind surgery if performed flapless
Surgery performed with a drill Guide
Postoperative imaging
Here we have an obvious problem !Apparent correct position of
both implants
Preoperative and postoperative matching
Frontal view Occlusal view
Distal displacement of the tip of the right
Zygomatic implant
Orange= planned position; Yellow = placed position
Top view Left lateral view
Orange= planned position; Yellow = placed position
Cranial displacement of the tip of the left
implant with pterygoid anchorage
>15 mm
>10 mm
To guide or not to guide?
• Mental navigation
• Drill guide surgery
• Navigation technique
Navigation technique
• Is more interactive than drill guide surgery
• Peroperative finding sometimes
≠radiological findings
• Seems to be the most flexible approach
To Guide or not to Guide?
• Usefulness of a conventional drill guide in
zygoma implants seems rather limited due
to very large exit points deviations
• Navigation technique seems to be very
promising
• Mental navigation depends on the
surgeons skills and ability to visualise in
3D
Overview
• Indications
• Techniques for long implants
• Clinical examples
Techniques for long implants
• Intrasinusal (Bränemark)
• Stella
• Extramaxillary
• Quad zygoma
• Zygoma and pterygoid
• Skullbase implants
Techniques
Intrasinusal
4 standard implants frontal, 2 zygoma dorsal
Intrasinusal
4 standard implants frontal, 2 zygoma dorsal
Simplant SurgiGuide™ Safe System™ prototype (2001)
Intrasinusal
4 standard implants frontal, 2 zygoma dorsal
Simplant SurgiGuide™ Safe System™ prototype (2001)
Intrasinusal
4 standard implants frontal, 2 zygoma dorsal
Simplant SurgiGuide™ Safe System™ prototype (2001)
Intrasinusal
Intrasinusal
Stella
Stella
Stella
Typical position for a “Stella”
Extramaxillary
Extramaxillary
Buccal coverage with a Titanium mesh
Pterygoid implant
Extramaxillary Zygoma implant
Extramaxillary
Extramaxillary
Extramaxillary
Quad Zygoma
Div D Div D Div D
Quad Zygoma
16 13 11 21 23 26
Hgt 6.00 10.08 7.78 8.53 9.79 -
Th 1.82 3.77 5.37 2.52 2.81 -
Quad Zygoma
Quad Zygoma
Quad Zygoma
Bone supported zygoma drill guide
Quad Zygoma
4x Extra maxillary Zygoma implants
Quad Zygoma
Coverage with Isotis™
Quad Zygoma
Postoperative view
Quad Zygoma
Pterygoid implants
Pterygoid implants
Pterygoid implants
Pterygoid implants
Pterygoid implants
Pterygoid implants
Pterygoid implants
Pterygoid implants
Skull base implants
1997
Skull base implants
1999
Skull base implants
2000
Finally all implants get lost …
Skull base implants
Skull base implants
12/09/2005: Follow up
Skull base implants
12/09/2005: Follow up
Skull base implants
12/09/2005: Follow up
Skull base implants
12/09/2005: Follow up
Skull base implants
18/05/2010: Follow up 8 jaar
Skull base implants
18/05/2010: Follow up 8 jaar
Skull base implants
18/05/2010: Follow up 8 jaar
Skull base implants
18/05/2010: Follow up 8 jaar
Look at the extreme vertical height of the prosthesis
Skull base implants
Where to find additional information?
• Zygoma Course 10 and 11/12 in Brussels
• www.linkedIn.com
Two day Zygoma course in
Brussels on 10 and 11/12/2010
Where to find additional information?
• www.linkedIn.com Zygoma implant group
Conclusion
• Long implants can offer a solution for
totally „hopeless‟ cases
• The technique requires advanced surgical
skills and top notch prosthetic therapy
• The preoperative and postoperative
trajectory must be closely monitored in
order to evaluate the long term results of
this technique