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Zygoma Implant Reconstruction of Acquired Maxillary Bony Defects

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Zygoma Implant Reconstruction of Acquired Maxillary Bony Defects Zygoma Implant Reconstruction of Acquired Maxillary Bony Defects Luis G. Vega, DDSa,b,*, William Gielincki, DDSc, Rui P. Fernandes, DMD, MDd,e KEYWORDS Zygoma implants Maxillary defect Maxillectomy KEY POINTS Zygoma implant reconstruction of acquired maxillary defect is a safe, predictable and cost- effective treatment modality. The complexity of zygoma implant reconstruction of these defects calls for a prosthetically driven treatment plan in which a team approach between the surgeon and the restorative dentist is para- mount for treatment success. The number, position, angulation, and length of the zygoma implants is going to depend on the size of the defect, residual bone, soft tissue coverage, and more important on the biomechanics of the prosthetic restoration. Closure of the oroantral/oronasal communication with placement of zygoma implants after or during closure facilitates the prosthetic reconstruction. The reconstruction of acquired maxillary bony structures, patient medical condition, and overall defects after pathologic ablation, infectious de- prognosis. Moreover, most of these techniques bridement, avulsive trauma, or previously failed have the common denominator of long treatment reconstructions is among the most challenging time frames, multiple surgical procedures, donor areas in oral and maxillofacial reconstruction. The site morbidity, high cost, and so forth. Maxillary main goal of these reconstructive efforts is to main- obturators, with or without dental implant support, tain or improve the patient’s quality of life by trying have been historically a great prosthetic option for to restore the lost form and function. Multiple clas- selected patients.7 Alternatively, microvascular sifications, techniques and algorithms have tried to tissue transfers in combination with dental implants simplify the approach to these defects but the best have become a popular way to restore these reconstruction method remains controversial.1–6 defects (Fig. 1).8,9 Traditionally, these defects have been recon- Using the zygoma bone as anchorage, Bra˚ ne- structed according to their size, residual anatomic mark, developed the zygomatic implant as a Oral and Maxillofacial Residency Program, Health Science Center at Jacksonville, University of Florida, 653-1 West 8th Street, Jacksonville, FL 32209, USA; b Department of Oral and Maxillofacial Surgery, Health Science Center at Jacksonville, University of Florida, 653-1 West 8th Street, Jacksonville, FL 32209, USA; c Private Practice, Jacksonville Center for Prosthodontics and Implant Dentistry, 6855 Belfort Oaks Place, Jacksonville, FL 32216, USA; d Department of Oral and Maxillofacial Surgery, College of Medicine, University of Florida 653-1 West Eight Street, LRC 2nd Floor, Jacksonville, FL 32209, USA; e Department of Surgery, Division of Surgical Oncology, College of Medicine, University of Florida, 653-1 West Eight Street, LRC 2nd Floor, Jackson- ville, FL 32209, USA * Corresponding author. Department of Oral and Maxillofacial Surgery, Health Science Center at Jacksonville, University of Florida, 653-1 West 8th Street, Jacksonville, FL 32209. E-mail address: [email protected] Oral Maxillofacial Surg Clin N Am 25 (2013) 223–239 http://dx.doi.org/10.1016/j.coms.2013.02.007 1042-3699/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved. oralmaxsurgery.theclinics.com 224 Vega et al Fig. 1. Acquired right maxillary defect after myxoma resection reconstructed with a fibula free flap. (A) Postop- erative three-dimensional computed tomographic reconstruction showing a right maxillary reconstruction with fibula free flap. (B) Intraoperative view of the placement of 4 dental implants. (C) Postoperative panoramic radiograph after implant placement. (D) Implants ready to be restored. (E) Fixed-hybrid prosthesis in place. a solution to the lack of maxillary bony support for 5.4 mm). From a qualitative view, Nkenke and prosthetic rehabilitation.10 Although they have colleagues19 indicated that the zygoma bone had become increasingly popular for the treatment of poor trabecular bone density but a strong cortex. severely atrophic maxilla, several investigators This finding led them to suggest that primary have reported their use as a simple, predictable, stability of the zygoma fixture could be achieved and cost-effective solution to the reconstruction if it is inserted in zygomatic cortical bone. Further- of acquired maxillary bony defects (Box 1).11–17 more in a microcomputed tomography study, Kato The focus of this article is to review the surgical and colleagues21 found that the trabecular bone at and prosthetic nuances to successfully recon- the end of the zygomatic fixture is thicker and struct acquired maxillary bony defects with wider than in other regions of the zygoma bone. zygoma implants. These investigators suggested that after osseoin- tegration, this thickening significantly assists the THE BASICS support of the zygoma fixture. Zygoma Bone Zygoma Implant and Biomechanics Several studies have described the anatomic characteristics of the zygoma bone with the Worldwide, several manufactures have designed purpose of implant placement.10,18–21 These and commercialized zygomatic implants. The prin- studies showed that mean dimensions of zygo- cipal differences between them can be observed matic bone range from 14.1 to 25.4 mm in the an- in Table 1. However, even in the presence of these teroposterior (AP) length and 7.6 to 9.5 mm in differences, their main characteristic is being mediolateral (ML) thickness. In addition, when a long implant (30–62.5 mm) that obtains its main the length of the zygoma bone is measured along anchorage from the zygoma bone in presence or the potential implant axis, the measurements absence of maxillary alveolar bone. Several range from 14 to 16.5 mm. Clinically, Balshi and biomechanical three-dimensional finite elemental colleagues22 found similar results. Their study of analyses have corroborated this distinctive bone-to-implant contact (BIC), in 77 patients with feature.23–25 Ujigawa and colleagues23 compared 173 zygoma implants showed that the mean BIC functional stress distribution of zygoma implants was 15.3 mm (4.9–32.9 mm). This finding repre- with and without connected dental implants sup- sented an average of 35.9% (12.2%–67.3%) of porting a superstructure in a severely atrophic the implant that came into contact with the maxilla. These investigators found in the con- zygoma bone. A statistically significant difference nected implant model that the stress was mostly was encountered between the BIC in males concentrated in the zygoma bone and the middle (16.5 mm Æ 6 mm) and females (14.7 mm Æ of the implant. In contrast, the stress in the single Zygoma Implant Reconstruction 225 Box 1 should not be less than 15 mm. From a clinical Zygoma implant reconstruction of acquired perspective, these findings correlate with the maxillary bony defects: indications, average BIC from the study of Balshi and contraindications, advantages, and colleagues22 described earlier. disadvantages Using different configurations in the number and position of implants, Miyamoto and colleagues24 Indications studied the biomechanics of an implant-retained Benign pathologic ablation (ameloblastoma, prosthesis in hemimaxillectomy defects. Their myxoma) results revealed that on the affected side, 2 Malignant pathologic ablation (squamous cell zygoma implants instead of 1 allow for better carcinoma, mucoepidermoid carcinoma) stress distribution to the zygoma bone and the Infectious debridements (mucormycosis) implant-abutment joint. In addition, in the unaf- fected side, the stress generated in the residual Avulsive trauma (gunshot wounds) maxillary alveolus after the placement of 2 or 3 Failed reconstructions regular dental implants did not have a negative effect on their potential osseointegration. Using 1 Contraindications zygoma implant in a unilateral maxillary defect, Medically compromised patient Korkmaz and colleagues25 studied 4 different Adequate maxillary alveolar bone for dental implant configurations to support a bar-retained implants obturator. These investigators concluded that an Acute sinusitis increase in the number of dental implants on the unaffected side did not decrease the maximum Severe trismus (relative contraindication) stress affecting the bone surrounding the Radiation treatment (relative contraindication) implants. On the other hand, a marked decrease Advantages of the stress affecting the model was found when the dental implants on the unaffected side were Avoids bone grafting and its morbidity substituted by a zygomatic fixture. Shorter treatment time frames Potential immediate function PREOPERATIVE EVALUATION Potential cost reduction Multiple entities can be responsible for the crea- Disadvantages tion of maxillary bony defects such as benign or Technique sensitive malignant pathologic ablation (eg, ameloblastoma, myxoma, squamous cell carcinoma, mucoepider- Needs general anesthesia moid carcinoma), infection debridement (eg, mu- Failures are more difficult to treat cormycosis, actinomycosis), and avulsive trauma (eg, gunshot wound). The primary diagnosis, surgical management, and postoperative care of implant model concentrated in zygoma bone, these conditions are not discussed because they middle of the implant, maxillary alveolar bone are out of the scope of this review. However, and implant-abutment joint. These findings because of the intricate nature of these causes, it showed that a better distribution of forces
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