Zygoma Implant-Supported Midfacial Prosthetic Rehabilitation: a 4-Year Follow-Up Study And, Therefore, Social Integration

Constantin Alexander Zygoma implant-supported midfacial Landes prosthetic rehabilitation: a 4-year follow-up study including assessment of quality of life

Authors’ affiliation: Key words: maxillary defect, maxillectomy, midfacial rehabilitation, prosthetic cantilever, Constantin Alexander Landes, Maxillofacial and zygoma implant, Zygomaticus fixture Plastic Facial Surgery, The J.-W. Goethe University Medical Centre, Frankfurt, Germany Abstract Correspondence to: Dr Dr Constantin Alexander Landes Objective: Successful prosthetic rehabilitation is crucial for quality of life in cases of large Klinik fu¨ r Kiefer und plastische Gesichtschirurgie maxillary defects when surgical reconstruction is not advisable because of general health or Johann-Wolfgang Goethe Universita¨t patient refusal. For this purpose, the extended indications for Zygomaticuss fixtures in Frankfurt Theodor-Stern-Kai 7 different defect types were evaluated. 60596 Patients and methods: Twelve patients received 28 zygoma implants and 23 dental Frankfurt am Main Germany implants (if a segment of alveolar process was available) and were followed-up 14–53 Tel.: þ 49-69-6301-5879 months. Zygoma implants were positioned classically in the maxillary molar region and to Fax: þ 49-69-6301-5644 e-mail: [email protected] reduce leverage, a premolar and a canine position was developed. The quality of life was assessed by a validated questionnaire after complete rehabilitation. Results: Cumulative zygoma implant survival was 82%. Three losses occurred because of persistent infection and gradual loosening. Lost implants were immediately replaced in adjacent bone. Insufficient implant length within soft tissue reconstructions was prone to chronic infection by pocketing and recurrent overgrowth of granulating tissue. Longer implants were free of soft tissue inhibition, yet prone to overloading and high leverage in cases when no anterior alveolar process and dental implants were present. Zygoma implant success was therefore 71%, including the new premolar and canine Zygomatikusfixture- position. Periotests values increased from 0 to þ 7 to the fourth year, peri-implant bleeding and plaque index were decreasing from 56% to 0% and 33% to 0%, respectively, and good general quality of life with the priorities on chewing and activity was noted. Conclusion: Zygoma implants can reliably anchor the midfacial maxillary prostheses and enable a quality of life comparable with autologous maxillary reconstruction. They can be replaced immediately if local infection or loosening should occur. A premolar and canine position reduce leverage when no anterior alveolar process is present. The patient can alternatively be provided with dental implants.

Date: Patients with severe maxillary defects have myocutaneous or osteo-myocutaneous tis- Accepted 25 April 2004 major difficulties to re-establish their mas- sue transfer is an alternative (Swartz et al. To cite this article: tication, speaking, soft tissue projection 1996; Rogers et al. 2003). However, some Landes CA. Zygoma implant-supported midfacial prosthetic rehabilitation: a 4-year follow-up study and, therefore, social integration. When patients prefer to avoid secondary morbid- including assessment of quality of life. the options of local bone augmentation ity from reconstructive procedures, and Clin. Oral Impl. Res. 16, 2005; 313–325 doi: 10.1111/j.1600-0501.2005.01096.x and elevation of the sinus floor do not others are limited by their general health supply sufficient bone for safe dental im- condition. These individuals benefit from Copyright r Blackwell Munksgaard 2005 plant positioning (Triplett & Schow 1996), an oronasal obturator prosthesis. However,

313 Landes . Zygoma implant-supported midfacial prosthetic rehabilitation in cases of extensive palatomaxillary resec- senting with a complex defect with con- The implantation was performed under tion, these obturators tend to be unstable, comitant loss of the alveolar process general anaesthesia and 1 g of Cephalexine and residual anchoring teeth are frequently because of long-time edentulousness and (Rocephins, Roche, Basel, Switzerland) overloaded and may be consecutively lost. atrophy. A local osteoplasty was considered intraoperatively and 250 mg of oral Cefur- Furthermore, little frictional or capillary hazardous for postoperative bone exposure oxim (Elobacts, Cascan, Bad Oldeslone, retention is available when the patient is and resorption because of local scars after Germany) postoperatively twice for 5 days edentulous and oronasal communication multiple palatal reconstructive surgery. A were given. Resorbable stitches were used. present (Keller et al. 1987; Sakuraba et al. free combined bone-soft tissue flap with The insertion was readily performed accor- 2003). A dental-implant-retained obturator microvascular anastomosis was considered ding to the technique given by Reichert frequently sustains high cantilever forces on overtreatment. Patient no. 3 had a max- et al. (1999) and Parel et al. (2001). The the anterior implants because of lack of illary osteosarcoma and refused free flap zygoma implant required a vestibular dorsal support, resulting in attachment loss reconstruction out of concern for masking a Le-Fort I incision from the canine to the and finally implant loss (Parel et al. 2001). tumor recurrence. The patient initially had molar area and local mucoperiosteal mobi- Prosthetic rehabilitation in total alveolar a 2/3 maxillectomy after the ablation of the lization. Thus, intraoral access to the zygo- atrophy employing single bilateral Zygoma- recurrence this defect became a 3/4 max- matic buttress area was directly created ticusfixturess (Bra˚nemark-System, Nobel- illectomy. Patient no. 4 had a hemimax- after a partial maxillary resection. Alterna- Biocare Norden AB, Gothenburg, Sweden) illectomy of a palatal squamous cell tively, when an intact maxillary sinus was supporting the molar region and anterior carcinoma with cardiopulmonary disease present, a suitable window in the anterior dental implants in residual canine alveolar at 72 years, precluding major reconstruc- wall was created. After the anterolateral process are clinically established with tion. Patient no. 5 had palatal adenoid- sinus mucosa had been mobilized, piloting accruing follow-up (Reichert et al. 1999; cystic carcinoma ablated 4.5 years ago and implant placement were carried out Bedrossian & Stumpel 2001; Bedrossian with hemimaxillectomy and successful re- under direct visualization of the receptor et al. 2002; Malevez et al. 2004). This habilitation by a tooth retained obturator. site from the sinus opening. Transcuta- study evaluates zygoma implants alone The retaining teeth had been lost because neous palpation of the exit area ensured and in combination with dental implants of local cantilever overloading from absent that the peripheral cortex was punctured. as prosthetic anchors for better social re- dorsal prosthesis support. A new obturator When the diameter of the drill-hole was integration of patients suffering from max- retention without major surgery was re- correct, the tip of the inserted fixture could illary defects. Particular attention was quested by the patient and major recon- be palpated transcutaneously piercing the given to extended zygoma implant indica- structive surgery was contraindicated. cortex by 1 or 2 mm. The patient’s indivi- tions in 450% maxillectomies to reduce Patient 6 had a recurrent malignant mixed dual number of zygoma implants and den- leverage. Zygoma implant success and sur- salivary carcinoma and cardiopulmonary tal implants, implant length, position, vival, as well as the quality of life, were disease at 77 years of age. The tumor diameter, brand and abutment type can be evaluated. recurred during follow-up, resulting in a seen in Table 2. Complications and dura- total maxillectomy. Patients no. 7–9 and tion of follow-up are shown in Table 3. All 11 with hemimaxillectomy after palatal implants were allowed to heal for 6 months Patients and methods and maxillary sinus squamous cell carcin- and were loaded in succession. After the oma ablation had cardiopulmonary disease. healing period, the abutment procedure Twelve patients received 28 zygoma im- Case no. 10 with an ameloblastoma (3/4 followed under local anaesthesia, in three plants (Zygomaticusfixtures,Bra˚nemark- maxillectomy) is a diagnosed anxiety dis- cases combined with a peri-implant soft- System, Nobel-Biocare Norden AB). order and no. 12 a depressive disorder tissue reduction. All patients were seen at Twenty-three additional dental implants making elaborate reconstructive operations monthly to 6-month intervals depending were inserted when a partial alveolar pro- a high-risk intervention. on their primary affliction. The mean Perio- cess (i.e. a residual alveolar segment) was Implants were inserted intraoperatively tests-values (Gulden-Medizin technik, present. Average age at implantation was up to 59 months postoperatively, an aver- Beusheim, Germany) (Lukas & Schulte 59 years (24–79 years), and 10 females and age of 16 months later. For example, pa- 1990), peri-implant bleeding indices (PBIs) two males were included, see Table 1. The tient no. 6 received implants at the time of and plaque indices (PIs), (Loë 1967) were me- first patient suffered from total absence of tumor resection when frozen margins were asured after implant loading at 6 months, the maxillary alveolar process when all tumor free. Patients no. 1 and 2 were not and every 6 months. Probing depths could teeth had been extracted at 20 years of included in the calculation of the time not be measured when zygoma implants age because of amelogenesis imperfecta. interval to the primary operation, as these had bulky local flaps and hypertrophic Earlier osteoplasty and a Le Fort I osteo- were more than 20 years previously. Six sinus mucosa at their point of mucosal pene- tomy resulted in complete bone-transplant patients received preoperative chemother- tration. Follow-up radiographs 12 months resorption making dental implant place- apy and five patients were postoperative- after insertion or 6 months after loading ment apart from the left canine region ly irradiated. When irradiation was and every following year were scrutinized impossible. The second patient had had performed, the implants were inserted for peri-implant radiolucencies. Dental to- cleft lip, alveolar process and palate, a on average after an 18-month disease-free mograms gave inferior information and severely scarred hard and soft palate pre- interval. therefore in preoperative, postoperative

314 | Clin. Oral Impl. Res. 16, 2005 / 313–325 Table 1. The benchmark patient data, diagnoses, preoperative chemotherapy, amount of resection and postoperative irradiation Patient Age at primary Diagnoses Defect size or extent of Chemotherapy Radiation Indication for zygoma Time gap to no. operation tumor ablation (Gy) implants vs. operative implantation (years) maxillary reconstruction (months) 1 20 Amelogenesis imperfecta, Total absence of Maxillary Osteoplasty failure 460 long-time full prosthesis alveolus 2 15 Bilateral cleft lip and palate, Large median defect, 40% Severe muco-periosteal 460 long-time full prosthesis of the hard palate and scarring, high risk for alveolus, severe scarring osteoplasty resorption 3 19 Maxillary and orbital 2/3 maxillectomy Carboplatin-etoposidphosphate 45 Concealment of recidive 59 osteosarcoma T4N0M0 by free flap 4 71 Maxillary squamous cell Hemimaxillectomy, soft tissue 61.5 Higher age, cardiopulmonary 6 carcinoma T4N1M0 palatal reconstruction disease 5 58 Palatal adenoid cystic Hemimaxillectomy Limited tooth loss because of 54 carcinoma, T4N0M0 overloading after 4.5 years tooth-borne obturator rehabilitation 6 77 Recurrent maxillary mixed Total maxillectomy Higher age, cardiopulmonary 0 salivary carcinoma T4N0M0 disease 7 57 Maxillary squamous cell Hemimaxillectomy Preoperative cisplatin 51.3 Cardiopulmonary disease 10 carcinoma T4N1M0 embolization 8 60 Maxillary squamous cell Hemimaxillectomy, soft Cisplatin embolization 58 Cardiopulmonary disease 9 carcinoma T4N0M0 tissue palatal reconstruction preoperatively, four cycles with local flap of Doxetacel postoperatively rehabilitation prosthetic midfacial implant-supported Zygoma . Landes 9 77 Maxillary squamous cell Hemimaxillectomy, soft tissue Preoperative cisplatin Higher age, cardiopulmonary 6 carcinoma, T4N0M0 palatal reconstruction embolization disease with local flap 10 46 Large maxillary 3/4 maxillextomy Late primary interview, general 14 ameloblastoma anxiety disorder 11 52 Maxillary squamous cell Hemimaxillectomy Preoperative cisplatin 51.3 Cardiopulmonary disease 11 1 | 315 carcinoma T4N1M0 embolization 3 19 Maxillary osteosarcoma 3/4 maxillectomy, palatal soft 45 Concealment of recidive by 15 recurrence T4N0M0 tissue reconstruction with free flap ln rlIp.Res. Impl. Oral Clin. local flap 6 79 Malignant mixed salivary Total maxillectomy Higher age, cardiopulmonary disease, 0 tumor recurrence T2N0M0 multiple possibly concealed tumor recurrences 12 60 Maxillary squamous cell Hemimaxillectomy, soft tissue Preoperative Depressive disorder 3 carcinoma T4N0M0 palatal reconstruction with cisplatin-embolization local flap 16

05/313–325 / 2005 , The time gap between operation or irradiation to the implant insertion is listed. Note that patients 3 and 6 are listed twice as they had two procedures of zygoma implant insertion. 1 | 316 implant-supported mid Zygoma . Landes Table 2. The dental status, surgery data and prosthetic treatment Patient Age at Dental No. of Implantation Zygoma Local anatomy, number, location and brand Prosthetic treatment ln rlIp.Res. Impl. Oral Clin. no. implantation status zygoma site implant of the additional dental maxillary implants after 6 months (years) implants length (mm) healing period 1 47 Edentulous 2 16, 26 45, 45 Bilateral single zygomafixture, one 1 One Branemark 10 4mm Three individual gold dental implant at 23 residual bone fixture regio 23 telescopes and transplant, mandible edentulous overdenture 2 68 Edentulous 2 16, 26 45, 45 Bilateral single zygomafixture, 0 Two individual gold

16 no alveolus present, mandible telescopes and

05/313–325 / 2005 , edentulous overdenture 3 24 Partially 2 16, 15 35, 30 Dentate residual alveolus 0 Two magnetic dentate at 23–27, mandible completely telescopes and partial

dentate denture with braces prosthetic facial to retaining teeth 4 72 Edentulous 2 16, 26 35, 35 No alveolus present, dental implant 1 One median Branemark Three individual gold insertion only medial, including nasal 10 4 mm fixture telescopes and spine, mandible edentulous overdenture 5 62 Partially 1 26 45 Teeth 24, 25 were lost because of 2 Two Branemark MKIV Three individual gold rehabilitation dentate overloading and dorsal cantilever forces, 4 13 mm fixtures at telescopes and residual maxilla and mandible dentate regio 24, 25 overdenture 6 77 Edentulous 2 16, 26 45, 45 No alveolus after total maxillectomy 0 Two individual gold (apart from the orbital floor), mandible telescopes and edentulous overdenture 7 58 Edentulous 1 16 30 Severe alveolar atrophy dental implant 1 One median Branemark Two ready-made insertion only possible including the 10 4 mm fixture ball abutments and nasal spine, mandible edentulous overdenture 8 61 Edentulous 1 26 35 Sufficient anterior alveolar 5 Five ITI SLA solid screws Six ready-made ball bone for additional dental implant 12 4.1 mm regio abutments and placement, mandible edentulous 15, 13, 11, 21, 23 overdenture 9 77 Partially 2 15, 16 30, 35 Anterior dentate patient, with 2 Two ITI SLA solid screws Golden individual dentate edentulous alveolus anterior to the regio 11, 13 bar-abutment and zygoma implants, mandible edentulous overdenture 10 47 Edentulous 2 25, 26 30, 35 Contralateral edetulous alveolus, 4 Four ITI SLA solid screws Four individual gold mandible edentulous regio 12, 13, 14, 15 telescopes and overdenture 11 53 Partially 2 15, 16 30, 35 Contralateral edetulous alveolus, 4 Four ITI SLA solid screws regio Six individual gold dentate residual maxillary incisors 11, 21, 23, 25 telescopes and mandible edentulous overdenture 3 27 Partially 4 16, 15, 13, 23 35, 40, 35, 40 Residual alveolus at teeth 24–27, 1 One Branemark MKIV 15 mm Golden individual dentate mandible completely dentate fixture regio 26 between bar-abutment and residual teeth partial denture, single crown suprastructure to implant at 26 6 79 Edentulous 3 15, 25, 26 40, 40, 45 No alveolus after total 0 Four individual gold maxillectomy (apart from orbital telescopes and floor), mandible edentulous overdenture 12 60 Edentulous 2 16, 26 35, 35 Edentulous anterior alveolus 2 Two ITI SLA solid screws Two individual parallel present, mandible edentulous, regio 13, 23 barclips and overdenture four interforaminal ITI-implants

Patients 3 and 6 required zygoma implant replacement because of chronic inflammation in conjunction with overload and consecutive loosening. Table 3. Data from the follow-up including complications and losses, periodontal parameters and scores at the quality of life questionnaire ads.Zgm mln-upre ifca rshtcrehabilitation prosthetic midfacial implant-supported Zygoma . Landes 1 | 317 ln rlIp.Res. Impl. Oral Clin. 16 05/313–325 / 2005 , Landes . Zygoma implant-supported midfacial prosthetic rehabilitation and follow-up, the occipitomental Water’s point average percentage and percentile of anteriorly on each side and supported the projection was preferred. The dental im- maximum life quality (i.e. minimum canine region. This should once more re- plants were, however, judged based on pathology after completed prosthetic reha- duce leverage on the zygoma implants and dental tomograms. bilitation) were evaluated. consecutive overloading from anterior bi- Weber two-point discrimination deter- ting and mastication, as addressed in patient mined the accuracy of skin sensitive discri- no. 6 (Fig. 2). Insufficient zygoma implant mination; that is, the distance between two Results length within flap reconstructions was points that must be spanned before subjects prone to recurrent local infection by pock- report feeling two distinct sensations. Static With a follow-up of 14–53 months the eting and overgrowth of granulating tissue or moving assessment measures the adapt- Kaplan–Meier cumulative 4-year zygoma (i.e. patients no. 3 and 10). In the last case ing fiber-receptor system. When this test implant survival/in situ rate was 82% (see two implants for the above reason could was bilaterally equal in those dermal seg- Tables 3 and 4, Fig. 1). Assuming intra- not become integrated in the prosthetic ments innervated by the infraorbital and individual dependence, 83% of patients rehabilitation. Although these implants zygomaticofacial nerve, a positive result had no zygoma implant loss (Chuang et al. were osseointegrated and they survived, was noted (Dellon 1978). When there was 2001). The rate of chronic zygoma implant they could not be counted as successes. bilateral maxillary resection, the supraorbi- infection was 11% and all were lost during Longer implants were free of soft tissue tal segment was examined and the area of follow-up. One loaded implant loss within inhibition yet prone to overloading by lesser sensitivity in comparison noted as the first year probably was because of local high leverage as seen in Fig. 2. PI, PBI at negative. Likewise negative results were overloading (patient no. 6) (see Fig. 2). It the end of the follow-up can be seen in recorded when it was known the nerve was explanted, two zygomafixtures were Table 3 decreasing from 56% to 0% and had been intra-operatively cut. immediately inserted anterior and dorsal to 33% to 0%, which may be attributed to The Kaplan–Meier analysis was made for the original implant slot. At the right repeated personal hygiene instruction and implant success after the following criteria: zygoma, a parallel zygomafixture was posi- better compliance once local scarring had clinical mobility 0–1, no peri-implant tioned anterior to support the premolar set and the prostheses were incorporated radiolucency, no prevalent peri-implant region. Seven identical ‘pairs’ of parallel into the patient’s body concept. No im- infection with purulent secretion, no pain, zygomafixtures were inserted in six pa- plant had infection or purulent secretion at discomfort or dysaesthesia related to the tients in an identical fashion to reduce the the end of the follow-up. implant placement (adapted after Buser prosthetic leverage and support the pre- All implants were clinically stable, and et al. 1990). Survival referred simply to molar region. The patient with two implant the latest Periotests values can be seen in whether the implant was in situ or not. losses in the second year (no. 3) had Table 3 increasing from average 0 to 7 in After the completion of the prosthetic re- chronic infection around two zygomafix- the fourth year. No peri-implant radio- habilitation, 6 months after implant inser- tures that were buried in granulation tissue lucencies were noted on Water projections tion all patients were asked to fill out a (Fig. 3). After replacement by a right-sided at the end of follow-up. Because of over- University of Washington Quality-of-Life pair of parallel zygoma implants, one addi- projection of the cranial base peri-implant scale questionnaire (UW-QOL, Weymuller tional third zygoma implant was positioned bone loss could not be evaluated. et al. 2001; Rogers et al. 2002). The UW- QOL is a validated 12-item questionnaire, completed by the patient and emphasizing 100.00% critical issues of oral, head and neck tu- 90.00% mors and their treatment, i.e. pain, appearance, activity, recreation, swallowing, 80.00% chewing, speech, shoulder mobility, taste, 70.00% saliva, mood and anxiety. Version 4 in- 60.00% cludes the psychological dimension of 50.00% quality of life (Rogers et al. 2002, 2003). % An importance rating on an individual 40.00% basis, two health-related quality-of-life questions and one general quality-of-life 30.00% question are included. The domains are 20.00% scored from no symptoms (i.e. pain) to 10.00% severe symptoms in four or five grades, the corresponding values are 100, 75, 50, 0.00% 25 and 0 or 100, 67, 33 and 0, respectively. 1324 These can be applied in individual long- itudinal follow-up and the composite UW- Implant survival (in white) and success (in black) was assessed for a 4 year follow-up QOL score is obtained by averaging the domain scores. In this study, the time- Fig. 1. Kaplan-Meier analysis of implant survival and success.

318 | Clin. Oral Impl. Res. 16, 2005 / 313–325 Landes . Zygoma implant-supported midfacial prosthetic rehabilitation

The zygomaticofacial nerve sensitivity was intact in all cases except patient no. 3 who had it resected at tumor removal. The infraorbital nerve was never severed during zygoma implant insertion, however, ﬁve of 12 patients had primary nerve resection when tumor ablation was performed (see Table 3). No patient reported foreign-body sensation, dysaesthesia coming from the implants or pain on implant percussion. Therefore, a zygoma implant success rate of 71% was reached when the three losses and two zygoma implants that could % Optimal value not be loaded were subtracted (Fig. 1).

ty in general. The general life quality was good, most Assuming intraindividual dependence 75% of patients had immediately successful treatment (Chuang et al. 2001). As abutments gold or magnetic telescopes were used in nine prostheses. Three prostheses had individual bar-clips and two ready-made ball abutments. Two patients, because of implant removal and tumor recurrence ablation, required a second prosthesis. Only the first prosthesis in patient no. 3 braced the remaining teeth, all other Excellent Mean (%) 7628225 1269475 78.1 13 cases did not. After recurrence, the bar-clip was sufficient for retention. The UW-QOL questionnaire was returned in eight cases after prosthetic treatment (80%), two cases were not oral tumor 358963 Much better or cancer patients (nos. 1 and 2) and, therefore, the questionnaire did not apply to them (presented in Tables 3 and 4). Half of the patients did not register any pain, the Better/ good other half only had accidental to moderate pain. One case reported painkiller taking at intervals because of scarring, impaired swallowing, xerostomia and mucositis 1 6 1 Better 67 0 moderate after irradiation (no. 11). The majority of cases noted little changes in their outward appearance, however, two complained of major changes in conjunction with exenteration (Fig. 3, no. 3) or severe local radio- Worse Identical/ dermatitis of the cheek and malar complex (no. 11). All patients noted none to min- imal limitation in activities. Three patients 1 2 1 2 2 Identical 54 0 PainMuch Appearanceworse Activity Recreation Swallowing Chewing Speech Shoulder Tastereported Saliva Mood 100% Anxiety and five medium chewing capacity. Speech without limitation was noted by 63% of the patients, the remain- der reported minor difficulties but were heard speaking on the telephone. Taste in all cases was 75–100% present. Most patients reported adequate saliva, but two had quality of life in the last 7 days of life compared with the pretherapeutic situation xerostomia. Except in one young osteo- Symptom 0% 25% 30% 50% 70% 75% 100% Mean (%) % Best score

. The University of Washington Quality-of-Life (UW-QOL) in head and neck cancer questionnaire scores sarcoma case with exenteration (Fig. 3, 45 Recreation 6 Swallowing7 Chewing8 Speech 9 Shoulder Taste 1 2 5 1 7 3 5 92 69 79 88 38 63 1Pain23 Appearance Activity 1 2 1 2 4 78 50 patient 6 no. 3), all reported 63 good emotional 0 15 Health-related 16 General quality of life 5 3 Good 73 0 14 Health-related quality 1011 Saliva12 Mood Anxiety13 Priorities 1 1 2 1 1 1 3 3 6 1 6 3 6 1 1 2 76 72 69 1 79 13 13 1 2 Item no. Results of eight of ten patients who returned their answered UW-QOL questionnaire. Patients were most concerned with chewing, recreation and activi patients experienced identical health-related quality of life compared with the pretherapeutic situation.

Table 4 stability and little anxiety. The patient

319 | Clin. Oral Impl. Res. 16, 2005 / 313–325 Landes . Zygoma implant-supported midfacial prosthetic rehabilitation

priorities in judging successful rehabilitation were in descending order: chewing, activity, recreational activity and speech, emotional stability, and pain. Appearance, swallowing, shoulder mobility and xerostomia were noted by one patient to be major concern (no. 11). Half of the patients reported better health-related quality of life than before treatment onset. The other reported worsening of their general health. However, the general quality-of-life average was reported to be much better.

Discussion

The use of the zygomatic bone as implant site in conjunction with ablative tumor surgery has been previously described (Parel et al. 1986; Vuillemin et al. 1990; Jensen et al. 1992; Izzo et al. 1994; Rou- manas et al. 1994; Evans et al. 1996; Weischer et al. 1997; Reichert et al. 1999). Autologous bone grafting, myocutaneous or osteo-myocutaneous tissue transfer implies major surgery. Considerable donor site morbidity may occur although satisfactory success rates have been well- documented (Breine & Bra˚nemark 1980; Isaksson 1994; Hu¨ rzeler et al. 1996; Swartz et al. 1996; Lekholm et al. 1999; Rogers et al. 2003). For zygomafixtures, survival rates of 65% to 75% were reported when they were inserted after ablative tumor surgery (Weingart et al. 1992), and a similar 71% zygoma implant success was found in the present study in 4-year follow-up. Only multi-centre studies pro- vide cases in adequate numbers for a defect- specific success analysis. The value of a homogenous collective for clinical use is limited as most centres face variant defect severity in few patients. Large maxillary cleft-palate defects are a sequel of no better up-to-date treatment today for elderly patients. Extended maxillary resections are individually different for each patient. Dif- ferent treatment regimens and safety margins are used for different malignomas at different centers. Detailed analysis of mul- Fig. 2. (a, b) Patient no. 6, aged 77 years, suffered from recurrent malignant maxillary salivary gland carcinoma and cardiopulmonary disease precluded operative maxillary reconstruction. At first one zygoma implant on tiple cases, with examination of the tech- each side provided obturator retention by telescopes. The left loaded zygoma implant was lost within the first nical possibilities using zygomafixtures year probably because of overload and leverage. Before the left implant definitely failed, a local infection with broadens the indication range. Similar to extraoral fistulation occurred. (c, d) Furthermore, a local recurrent tumor was resected and the left fixture was Malevez et al. (2004), the intimacy of bone explanted. Three new implants were immediately positioned as can be seen on the Water’s projection. Two to implant contact and marginal bone loss implants were positioned on the left, anterior and posterior to the original implant site. A second implant was positioned anterior in the right zygoma to support the premolar region as well. (e, f) The telescoped fixtures were difficult to evaluate. Water’s projec- piercing the bulky mucosa, an absent alveolar process and the complete rehabilitation can be seen. tion seemed reliable for judging peri-im-

320 | Clin. Oral Impl. Res. 16, 2005 / 313–325 Landes . Zygoma implant-supported midfacial prosthetic rehabilitation

failure could be determined: overloading leverage in extensive maxillectomy, overgrowth of local soft tissues restricting the abutment connection, recurrent infection triggered by the above factors and tumor recurrence. The latter did not force zygoma implant removal in this series as recurrences did not occur at implant sites. The follow-up did not show implant fatigue fractures as hypothesized (Reichert et al. 1999) because of the long arm of lever. Reichert et al. (1999) and this study used zygoma implants in cases when patients refused the morbidity of bone transplanta- tion from the iliac crest or fibula and when the general condition did not permit major reconstruction. The authors report five indications for zygoma implants: tumor ablation maxillectomy, osteoplasty failure, osteoplasty avoidance, local stress relief after osteoplasty and an alternative to sinus-lifting or sinuslift failure. Implant positioning in the alveolar crest or slightly palatinal could not be maintained in bigger maxillary defects. The implant head should then rest close to the residual bone to reduce leverage. However, it should not be submerged in soft tissue to reduce the risk of a local infection. Lastly soft tissue Fig. 3. (a) Patient no. 3, aged 24 years, with re- thickness over the residual bone should be current maxillary and orbital osteosarcoma after exenteration, 2/3 maxillectomy and soft-tissue kept to a minimum. Soft-tissue flaps create reconstruction with local flaps. Two zygoma deep peri-implant pockets that are prone to implants had been furnished with magnetic tele- infection. scopes. In the second year of loading both devel- Microporous implant surfaces compared oped chronic infection, were buried in granulation with machined surfaces have higher re- tissue and finally lost. (b) The infected and loo- sened implants were removed, an anterior recur- moval torques after osseointegration and rence was resected and two parallel longer implants the data documents a superior osseointe- were repositioned to support the molar and premo- gration (Buser et al. 1991; Cochran et al. lar region as can be seen on the Water’s projec- 1996). Therefore, SLA dental implants tion. One additional anterior angulated zygoma were used in patients no. 8–12. Micropor- implant was positioned to rest in the zygomatic body on each side and support the canine region ous surface in zygoma implants should be after 3/4-maxillectomy. (c, d) A bar-clip abutment prospectively considered. Wide opening of yielded sufficient stabilization a dental implant at the mouth with tongue protusion required regio 26 was not needed for retention and there- for zygoma implant insertion causes an fore, treated with a single crown. (e, f) Complete rehabilitation with reconstructed eyelids and eye increased risk of intraoperative contamina- epithesis. tion. The vicinity to sinus mucosa and moving gingiva at the implant-shaft are unfavourable (see Fig. 2d) with open-lying plant radiolucency when compared with concept is supported by the fact that zy- thread convolutions. A feasible compro- CT and dental tomograms. goma implants are overloaded when posi- mise may be a microporous surface re- In this study 17% of patients faced zy- tioned in the molar region in the absence of stricted to the zygoma implant tip. goma implant losses. However, uneventful an anterior maxilla. Parallel anterior zy- Nkenke et al. (2003) evaluated the zygo- and successful replacement was possible. goma implants enabled a trapezoid pros- matic bone diameter and report highly Parel et al. (2001) reported that zygoma thesis support. Moreover, anteroposterior trabecular bone quality. Employment of implant-borne dorsal defect prosthesis sup- zygomafixtures created support in the can- at least four cortical portions is recom- port decreased the leverage on the remain- ine region as called for by Reichert et al. mended (i.e. the alveolar process at the ing teeth and anterior dental implants. This (1999). Four factors of zygoma implant molar region and the cortex of the zygo-

321 | Clin. Oral Impl. Res. 16, 2005 / 313–325 2 | 322 implant-supported mid Zygoma . Landes ln rlIp.Res. Impl. Oral Clin.

Table 5. Comparison of zygoma implant and obturator rehabilitated individuals from this study to two case series reported by Rogers et al. (2003) zygoma Free deep Free fibula Obturator Free flap Zygoma im- Free deep cir- Free fibula Obturator Free flap implants and circumflex reconstruction, prosthesis with- maxillary plants and cumflex iliac reconstruction, prosthesis maxillary 16 ¼ ¼ 05/313–325 / 2005 , obturator iliac artery flap n 16 out implant reconstruction, obturator artery flap n 16 without im- reconstruction, prosthesis- reconstruction, retention, n ¼ 18 prosthesis, reconstruction, plant retention, n ¼ 18 n ¼ 8 n ¼ 20 n ¼ 28 n ¼ 8 n ¼ 20 n ¼ 28

Mean (%) % Best score prosthetic facial Pain 78 75 67 90 88 50 45 46 60 72 Appearance 63 60 65 63 76 0 5 8 10 28 Activity 78 66 65 73 71 13 10 15 30 28 Recreation 81 73 71 80 75 25 20 23 30 33

Swallowing 91 79 52 91 88 88 60 8 70 67 rehabilitation Chewing 69 55 31 60 58 38 25 8 20 28 Speech 89 75 74 79 76 63 35 21 30 33 Shoulder 79 83 79 91 95 63 67 69 70 83 Taste 94 76 45 75 55 14 Saliva 76 69 64 79 39 36 Mood 72 78 77 13 45 29 Anxiety 69 78 75 13 53 36 Average78726478784338264047 Rogers et al. (2003) A Compa- Rogers et al. (2003) Health- Rogers et al. (2003) A compar- Rogers et al. (2003) Health-related rison of the long-term morbidity related quality of life after ison of the long-term morbidity quality of life after following deep circumflex iliac maxillectomy: a comparison following deep circumflex iliac maxillectomy: a comparison and fibula free flaps for between prosthetic obturation and fibula free flaps for between prosthetic obturation reconstruction following head and free flap. Journal of Oral reconstruction following head and free flap. Journal of Oral and neck cancer. Plastic and and Maxillofacial Surgery 61: and neck cancer. Plastic and and Maxillofacial Surgery reconstructive surgery 112: 174–181. reconstructive surgery 112: 61:174–181. 1517–1525. 1517–1525. % of patients scoring good or better (all/those who scored good or better) Health-related 88 (7/8) 74 (14/19) 50 (7/14) quality of life in the last 7 days General quality 100 (8/8) 68 (13/19) 50 (7/14) of life

The first compares maxillofacial free bone reconstruction from the iliac crest (free deep circumflex iliac artery flap) with free fibula. The second, though using University of Washington Quality-of-Life (UW-QOL) version 1 with limited compatibility compares obturator rehabilitated maxillectomy patients vs. free-flap reconstruction. The left column are the mean scores, the right dark shaded grey the best score percentages. Below are the average scores for blunt comparison. Health related and general quality of life scores were not implemented in UW-QOL version 1 as employed by the second study. Landes . Zygoma implant-supported midfacial prosthetic rehabilitation maticbone).Theinherentangleof451 obturator cases had the least pain and Re´sume´ proved adequate and was readily connected equally good swallowing while free flap to abutments in all cases (Uchida et al. maxillary reconstruction scored best for La re´habilitation prothe´tique reússie est cruciale 2001). Schramm et al. (2000) in patients appearance. Mood and anxiety were better pour la qualite´ de vie dans les cas de le´sions maxillaires e´tendues quand la reconstruction chirurgicale and Steenberghe et al. (2003) in cadavers in DCIA and fibula reconstructed indivi- n’est pas envisageable duˆ a` des proble`mes geńe´raux use Computer and CT-assisted navigation duals. Health-related quality of life in the ou a` un refus du patient. Pour cette raison, les for an exact placement below 1 mm and 31, last 7 days was superior for the zygoma indications e´tendues des implants Zygomaticuss which was not imperative in this series. implant rehabilitated followed by DCIA. dans diffe´rents types de le´sions ont e´te´ e´valueés. Navigation is adequate when navigation- The general quality of life in all cases was Douze patients ont reçu 28 implants zygoma et 23 implants dentaires (si un segment du rebord alveó- supported tumor ablation is performed good or better for zygoma implant rehabil- laire e´tait disponible) et ont e´te´ suivis entre 14 et 53 and the equipment is ready to use. In the itated, followed by DCIA and still 50% of mois. Les implants zygoma ont e´te´ positionne´s present study, the bone volume was suffi- the fibula-rehabilitated patients. ANOVA classiquement dans la re´gion molaire maxillaire et cient and the placement was not difficult. with a ¼ 0.5 significance level revealed pour re´duire la force de levier une position pre´mo- Navigation by itself remains expensive and significant differences for the score laire et une canine ont e´te´ choisies. La qualite´ de vie ae´te´ e´valueé par un questionnaire a` la fin du prolongs the operation time but can sup- averages: P 0.01 at F ¼ 3.2. Therefore, o traitement. La survie cumulatif de l’implant zygoma port exact placement and optimum bone the outcome differences cannot be attri- e´tait de 82%. Trois pertes ont e´te´ constateés duˆ es a` utilization. Navigation-supported zygoma buted to chance. Reports using obturator une infection persistante et une perte progressive. implant positioning across the temporal prostheses find better outcomes in small Lesimplantsperdusonte´te´ imme´diatement re- fossa could (Jensen et al. 1992) include defects when sufficient speech, chewing place´s dans l’os adjacent. Une longueur implantaire insuffisante a` l’inte´rieur des reconstructions de tis- two more cortical fractions from the zygo- and swallowing abilities are maintained sus mous favorisait une infection chronique par matic arch. Although parallel zygoma im- (Kornblith et al. 1996). Free graft recon- poches grandissantes et une reápparition de tissus plant positioning was achieved manually, struction was established partly to solve granuleux envahissants. Les implants plus longs inserting a third zygoma implant may be the disadvantages of the obturator: nasal n’avaient pas d’inhibition des tissus mous mais facilitated through navigation not to jeopar- leakage, cleaning, frequent prosthetic cor- e´taient sensibles a` une charge trop importante et a` uneforcedeleviertrope´leveé dans les cas ou` aucun dise the orbital floor. All zygoma implants rections (Brown 1996; Cordeiro & Santa- rebord alveólaire ante´rieuretdoncdesimplants were stable even when inserted in only two maria 2000) by itself or in combination dentaires n’e´taient pre´sents. Le succe`s de l’implant zygomatic cortical portions. with an obturator (Sakuraba et al. 2003). zygoma e´tait de 71%, incluant le nouveau zygoma- All patients gained good oronasal sealing, Large maxillary and orbitomaxillary defects ticus position implantaire aux niveaux pre´molaire et s speech and feeding, as well as midfacial and are difficult to fit with acceptable pros- canin. Des valeurs Periotest augmentaient de 0 a` þ 7apre`s quatre anneés, le saignement paroı¨mplan- upper lip projection according to their own theses and impaired vision complicates taire et l’indice de plaque diminuaient de 56 a` 0% et perception. To further measure individual prosthesis handling. Various methods de 33 a` 0%, et une bonne de qualite´ de vie avec des perception of rehabilitation, quality-of-life have been described for large defect closure priorite´s telles que la mastication et l’activite´ ont e´te´ assessment is mandatory. Multiple vari- (Pollice & Frodel 1998; Truitt et al. 1999; noteés. Les implants zygoma peuvent donc de man- ables have to be considered in ‘successful’ Baumann & Ewers 2000) and the experi- ie`re certaine ancrer des prothe`ses maxillaires mi- faciales et permettre une qualite´ de vie comparable rehabilitation. A constant struggle by a ences were cataloged as algorithms (Brown aux reconstructions maxillaires autoge`nes. Ils peu- patient overstrained in manual dexterity et al. 2000; Cordeiro & Santamaria 2000). vent eˆtre remplace´s imme´diatement si une infection to incorporate and remove an obturator To the DCIA flap (Brown 1996) came the locale ou une perte de stabilite´ survenait. Une prosthesis or a prosthesis that yields no rectus abdominis and radial flap (Cordeiro position pre´molaire et canine re´duit l’effet de levier chewing or speech cannot be called a suc- & Santamaria 2000), fibula (Futran & quand il n’y a pas de rebord alveólaire ante´rieur pre´sent. Ce patient peut e´ventuellement aussi rece- cess. Preoperative, 6 and 12 months post- Haller 1999) and subscapular artery flaps voir des implants classiques. operative ratings by patients with head and (Uglesic et al. 2000). Dental implants can neck cancer rated in a study similar to this be inserted into revascularized bone. How- included, in descending order: speech, ever in many cases, resorption is high and Zusammenfassung chewing, swallowing, activity and appear- unless prefabricated transplants are used Ziel: Bei grossen Oberkieferdefekten ist die erfol- ance (Rogers et al. 2002, 2003). A compar- (Breine & Bra˚nemark 1980). The best greiche prothetische Rekonstruktion fu¨ reinegute ison of zygoma implant rehabilitated choice remains obturation or free tissue Lebensqualita¨t entscheidend. Dies ist besonders individuals’ UW-QOL scores to maxillofa- transfer (Rogers et al. 2003). Donor site dann wichtig, wenn ein schlechter Allgemeinzu- cial cancer patients reconstructed with iliac and overall morbidity has been variably stand des Patienten die Behandlung verunmo¨glicht, bone (deep circumflex iliac artery flap reported and the patient adapts to the pre- oder er die chirurgische Rekonstruktion verweigert. Fu¨ rsolcheFa¨lle erweiterte man den Indikationsber- (DCIA)) and free fibula bone is shown in valent reconstruction. If the patient’s s eich der Zygomaticus -Implantate und untersuchte Table 5. A second study of maxillectomy general health and consent permit, pre- sie bei verschiedenen Defekttypen. patients either reconstructed by obturator fabricated free transplants should be con- Patienten und Methoden: Zwo¨lf Patienten erhielten or a free flap is added (Rogers et al. 2002, sidered first. Zygoma implants can be 28 Jochbeinimplantate und 23 Zahnimplantate (so- 2003). The zygoma implant-borne prosthe- reliably used even in total maxillectomy. fern noch ein Segment vom Alveolarfortsatzes vorhanden war) und wurden wa¨hrend 14 bis 53 sis case series scored highest in activities However severe defects involving the orbi- Monaten nachuntersucht. Die Jochbeinimplantate and recreation, swallowing, chewing, tonasal complex should remain a primary setzte man in der klassischen Region der Oberkie- speech, taste and saliva quality. Simple indication for reconstructive surgery. fermolaren. Um die Hebelkraft zu reduzieren,

323 | Clin. Oral Impl. Res. 16, 2005 / 313–325 Landes . Zygoma implant-supported midfacial prosthetic rehabilitation suchtemanaucheineAbstu¨ tzung in der Eckzahn- maxilares extensos en los que la reconstruccioń und Pra¨molarenregion. Zur Beurteilung der Lebens- quiru´rgica no es aconsejable debido a salud general qualita¨t unterbreitete man dem Patienten nach Ab- o rechazo del paciente. Para este propo´sito, se eva- schluss der Rehabilitation einen vorbereiteten luaron las indicaciones extendidas para las fijaciones Fragebogen. Zygomaticuss en diferentes tipos de defectos. Resultate: Die kumulative u¨ berlebensrate der Joch- Pacientes y Me´todos: Doce pacientes recibieron 28 beinimplantate betrug 82%. Man verzeichnete drei implantes zigoma´ticos y 23 implantes dentales (si Implantatverluste auf Grund einer persistierenden un segmento del proceso alveolar se encontraba Infektion und einer schrittweisen Lockerung. Die disponible) y se siguieron de 14 a 53 meses. Los verlorengegangenen Implantate konnten im benach- implantes zigoma´ticos se posicionaron cla´sicamente barten Knochen gleich wieder ersetzt werden. War en la regioń molar y para reducir la palanca se das Implantat ungenu¨ gend lang, so neigte das wie- desarrollo´ una posicioń premolar o canina. Se valoro´ deraufgebaute Weichgewebe darum zu chronischen la calidad de vida por medio de un cuestionario Infekten mit Taschenbildung und es kam wiederholt validado tras la completa rehabilitacioń. zu einem u¨ berschiessenden Wachstum von Gra- Resultados: La supervivencias acumulada del im- nulationsgewebe. La¨ngere Implantate zeigten diese plante zigoma´tico fue del 82%. Hubo tres pe´rdidas Probleme nicht, neigten dafu¨ raberzuu¨ berlastungen debido a infeccioń persistente y aflojamiento gra- und waren grossen Hebelkra¨ften unterworfen, wenn dual. Los implantes perdidos fueron inmediatamente im anterioren Bereich der Alveolarfortsatz oder un- reemplazados en el hueso adyacente. Una longitud terstu¨ tzende Zahnimplantate fehlten. Die Erfolgs- insuficiente del implante dentro del tejido blando rate des Zygoma-Implantates betrug daher 71%. tendio´ a infecciones crońicas por formacioń de bolsas Darin eingeschlossen waren die neuen Lokalisatio- y sobrecrecimiento recurrente de tejido de granula- nen der Zygomaticus-Implantate im Pra¨molaren- cioń. Unos implantes mas largos se liberaron de la und Eckzahnbereich. Die Periotests-Werte nahmen inhibicioń del tejido blando aunque tendieron a bis zum vierten Jahr von 0 auf þ 7zu,dieBlutung sobrecarga y mayor palanca en los casos sin proceso um die Implantate und der Plaqueindex nahmen ab alveolar y sin implantes dentales. Por lo tanto el von 56% auf 0% und 33% auf 0%. Ebenso konnte e´xito de los implantes zigoma´ticos fue del 71%, man eine gute Lebensqualita¨t bezu¨ glich Kaukomfort incluyendo las nuevas posiciones premolares y und sonstiger Aktivita¨ten verzeichnen. caninas de fijaciońzigoma´tica. Los valores de Peri- Zusammenfassung: Zygoma-Implantate ko¨nnen otests se incrementaron de 0 a þ 7al4an˜ o, el Oberkieferprothesen in zuverla¨ssiger Art im Mittel- sangrado periimplantario y el ıńdice de placa dis- gesicht verankern und so zu einer Lebensqualita¨t minuyeron del 56 al 0%, y se noto´ una buena verhelfen, die einer autologen Oberkieferrekon- calidad general de vida con las prioridades de masti- struktion vergleichbar ist. Sie ko¨nnen immediat cacioń y actividad. ersetzt werden, wenn lokale Infekte auftreten, oder Conclusioń: Los implantes zigoma´ticos pueden an- sie sich lo¨sen sollten. Eine Positionierung in der clar fiablemente las pro´tesis mediofaciales maxilares Pra¨molaren- oder Eckzahnregion vermindert die y permitir una calidad de vida comparable a la Hebelwirkung, wenn der Alveolarkamm im ante- reconstruccioń maxilar anto´loga. Se pueden sustituir rioren Bereich fehlt. Als Alternative stehen dem inmediatamente si ocurre una infecciońlocaloun Patienten die Zahnimplantate zur Verfu¨ gung. aflojamiento. Una posicioń premolar o canina reduce la palanca cuando no existe proceso alveolar anterior. El paciente puede ser suministrado alter- Resumen nativamente con implantes dentales.

Objetivo: La rehabilitacio´n prote´sica exitosa es crucial para la calidad de vida en los casos de defectos

References

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