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Fixed rehabilitation of patient with aggressive periodontitis using zygoma implants

Gunaseelan Rajan, Mirza Rustum Baig1, John Nesan, Jayaram Subramanian

Rajan Dental Institute, ABSTRACT Chennai, India, 1Department of , University of Treatment of patients with aggressive periodontitis has always been a challenge to the clinician. Malaya, KL, Malaysia Both young and old are known to be affected by this progressive destructive condition of the supporting dental structures. Although dental implants have been offered as a viable treatment alternative for such patients, additional procedures (like ) and delayed protocols Received : 07-04-09 have limited their usage. This case report describes the treatment of a young patient with Review completed : 11-09-09 aggressive periodontitis using a graftless implant solution. Zygoma implants in conjunction Accepted : 20-10-09 with conventional implants were used with immediate loading. PubMed ID : *** DOI: 10.4103/0970-9290.62801 Key words: Aggressive periodontitis, maxillary edentulism, zygoma implant

Aggressive periodontitis is a rapidly progressive destructive upper and lower anterior teeth and generalized mobility condition of the supporting dental tissues[1] leading to of remaining teeth [Figure 1]. The patient requested for tooth mobility and subsequent premature loss of teeth. comprehensive treatment with replacement of missing Treatment option for this condition often includes total teeth. There was generalized bleeding on probing and extraction and rehabilitation with removable or implant- mobility of all teeth on clinical examination. OPG and CT based fixed prosthesis. For treatment, scans of the maxilla and mandible revealed severe maxillary the posterior maxilla is found defi cient in bone due to and mandibular bone loss, especially in the posterior region extensive . In addition, poor bone [Figure 2]. quality and proximity to the sinus are challenges to implant installation. Traditionally, bone grafting has been The patient was presented with various treatment options: advocated to enable implant placement, thereby causing • Total extraction of teeth and replacement with delay and involving multiple surgical procedures. In recent conventional removable acrylic maxillary and times, zygomatic implants have developed as an alternative mandibular complete dentures to conventional grafting procedures for the rehabilitation • Total extraction of teeth, onlay bone grafting and of the edentulous maxilla with severe bone resorption. subsequent implant placement, six to nine months High success rates have been reported with these implants later, with immediate or conventional loading protocol with predictable long-term results.[2,3] These implants, based on the initial stability of implants in conjunction with conventional root form implants, • Total extraction, zygoma implants in conjunction with present a defi nitive option for replacement of natural regular implants and immediate loading with implant teeth with restoration of function, form and esthetics with retained fi xed prosthesis, if good primary stability one surgical procedure and provision for immediate achieved. loading.[4,5] Due to various considerations, the patient opted and This article describes the role of zygomatic implants in the was planned for option C, i.e. complete extraction and dental rehabilitation of a young patient with aggressive immediate placement of zygoma implants, with two regular periodontitis. implants in the anterior maxilla and four regular implants in the mandible with maxillary and mandibular implant- CASE REPORT retained fi xed prostheses. A 24-year-old male presented with complaints of missing Under general anesthesia, 24 maxillary and mandibular teeth along with an impacted right mandibular third molar Address for correspondence: Dr. Mirza Rustum Baig, were removed. Local anesthesia (2% Lignocaine with E-mail: [email protected], [email protected] 1:200,000 adrenaline) was infi ltrated in the upper buccal

125 Indian J Dent Res, 21(1), 2010 Zygomatic implant-based dental rehabilitation Rajan, et al.

Figure 1: Anterior view of the remaining teeth pre-treatment Figure 2: Panoramic view of the maxillae and mandible pre-treatment

Figure 3: Panoramic view of the maxillae and mandible post-implant Figure 4: Anterior view of the prosthesis post-treatment placement Adequate precaution was taken to avoid injuries to the fl oor of the orbit. A 5 5 mm window was created on the lateral wall of the maxillary sinus close to the infrazygomatic crest. The sinus mucosa was elevated off the superior-lateral part of the roof of maxillary sinus. On the right side, a two cm releasing incision was placed palatally close to the extraction socket in relation to the maxillary first molar-second premolar region. On the left side, a small stab incision (2-3 mm) was placed palatally close to the extraction socket in relation to the second maxillary premolar region. A long round bur in a straight surgical hand piece was used to make an entry through the palatal alveolar bone and reach the fl oor of the maxillary sinus. Direct visualization was done through the sinus window. The zygomatic bone implant bed was prepared using standard implant drilling Figure 5: Occlusal view of the maxillary arch post-treatment protocol for zygoma implants. Using the straight depth indicator, the desired length of the zygoma implant to be vestibule to aid haemostasis. Buccal vestibular incisions used was measured. Verifi cation of the depth of the prepared were placed in relation to right and left premolar-molar site was done with the help of the angled depth indicator. region and the mucoperiosteal fl aps were raised to expose This ensured that the selected implant length could be fully up to the superior border of the zygomatic bone. Care was seated without apical bone interference. Once verifi ed, two taken to protect the infraorbital nerves and vessels. Branemark Zygoma TiUnite implants (52.5 mm) were placed

Indian J Dent Res, 21(1), 2010 126 Zygomatic implant-based dental rehabilitation Rajan, et al. bilaterally. An insertion torque of more than 35 Ncm was treated with antibiotics). Bedrossian et al.[10] reported 100% achieved for both the zygoma implants. Two regular Nobel survival in a series of 44 zygomatic implants in 22 patients, Biocare Replace Select dental implants were also placed in with a 91.25% survival rate for the 80 standard implants the maxillary anterior region. The primary stability for these placed in the anterior maxillae. The observation period was implants was greater than 35 Ncm. 34 months. There have been reports of speech alterations and diffi culty in maintaining , largely as a result In the mandible, four Nobel Biocare Replace Select dental of the palatine emergence of the platform of the zygomatic implants were placed. The primary stability for these implant. Boyes-Varley et al.[11] placed 30 zygomatic implants in implants was greater than 35 Ncm for all except one, where 18 patients, modifying the angulation of the implant head 55, only 25 Ncm was achieved. Healing abutments were placed to position emergence at alveolar crest level. According to the on all implants [Figure 3]. Wound closure was done with authors, this angulation of the implant head affords a cantilever 3-0 vicryl sutures. Primary impressions were made for reduction of over 20%, which in addition to improving the fabrication of custom trays for fi nal impressions. space required for tongue movement allows the patient better access for adequate maintenance of the dental prosthesis. Postoperatively, the patient’s recovery was uneventful. There was minimal edema on the surgical site. On the The use of the zygomatic implants lessened the need for third postoperative day, fi nal impressions were recorded extensive bone grafting, shortened hospital stay, and reduced [11] and, subsequently, by the end of the first week, the postoperative morbidity and pain. Zygomatic implants are interim maxillary and mandibular acrylic screw-retained an effective treatment alternative for the management of implant prostheses were torqued to the implants at patients with aggressive periodontitis and atrophic maxillae. 10 Ncm torque. The patient was reviewed and placed on It is important to note that this procedure is not without follow-up maintenance. Six months postoperatively, clinical complications, and requires thorough knowledge of the examination was done and the stability of the implants technique and surgical skill. checked manually and by resonance frequency analysis test (Osstell, Integration Diagnostics AB, Goteborg, Sweden). CONCLUSION The patient had no symptoms of pain or tenderness and the surrounding gingival tissues showed satisfactory healing. Zygoma implants offer a viable treatment alternative for complete maxillary edentulism in patients with a history of The defi nitive metal-acrylic resin screw-retained maxillary aggressive periodontitis. The use of these implants provides and mandibular prostheses were then fabricated and issued the patient with a graftless solution, with no necessity for [Figure 4]. The abutments were also fi nally torqued to extensive onlay grafting or sinus grafting procedures. The 35 Ncm and the screw-access holes fi lled with gutta percha one-stage procedure is also established with this technique, and composite [Figure 5]. The patient was then given oral whereby the implants can be splinted and cross arch stabilized hygiene instructions and placed on a follow-up maintenance with regular implants to achieve immediate loading. There protocol. is no doubt that a single case report cannot lead to defi nitive conclusions; hopefully more studies will be published in the future to corroborate or challenge this report. Similar DISCUSSION fi ndings may further help eliminate controversies regarding dental implant therapy in aggressive periodontitis patients. Zygoma implant is an alternative to bone augmentation or maxillary sinus grafting in patients with atrophic posterior maxillae needing implant fi xed rehabilitation.[3,6] In 1993, REFERENCES [7] Aparicio et al. mentioned the possibility of implant 1. Hoffmann O, Beaumont C, Zafiropoulos GG. Combined periodontal [8] placement in the zygomatic bone. In 1997, Weischer et al. and implant treatment of a case of aggressive periodontitis. J Oral cited the use of the zygomatic bone as a support structure in Implantol 2007;33:288-92. the rehabilitation of patients subjected to maxillectomies. 2. Malevez C, Abarca M, Durdu F, Daelemans P. Clinical outcome of 103 consecutive zygomatic implants: 6-48 months follow-up study. Clin Since then, zygoma implants have developed as an effective Oral Implants Res 2004;15:18-22. treatment modality for severe maxillary bone loss. Branemark 3. Pi Urgell J, Revilla Gutiérrez V, Gay Escoda CG. Rehabilitation of atrophic et al.[9] recorded a survival rate of 94.2% with 52 Zygoma® maxilla: A review of 101 zygomatic implants. Med Oral Patol Oral Cir implants in 28 patients with a follow-up period of 5-10 years. Bucal 2008;13: E363-70. [2] 4. Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, et al. Malevez et al. published a retrospective study with a Immediate/Early loading of zygomatic implants: Clinical experiences follow-up duration of 6-48 months post-prosthetic loading, after 2 to 5 years of follow-up. Clin Implant Dent Relat Res 2008 Dec 3. evaluating the survival rate of 103 zygomatic implants placed In press. in 55 edentulous, severely resorbed maxillae with a 100% 5. Mozzati M, Monfrin SB, Pedretti G, Schierano G, Bassi F. Immediate loading of maxillary fixed prostheses retained by zygomatic and zygomatic implant survival rate, with a single complication conventional implants: 24-month preliminary data for a series of clinical prior to prosthetic loading (severe sinus infection successfully case reports. Int J Oral Maxillofac Implants 2008;23:308-14.

127 Indian J Dent Res, 21(1), 2010 Zygomatic implant-based dental rehabilitation Rajan, et al.

6. Nakai H, Okazaki Y, Ueda M. Clinical application of zygomatic implants 10. Bedrossian E, Stumpel L 3rd, Beckely ML, Indresano T. The zygomatic for severely resorbed maxilla: A clinical report. Int J Oral Maxillofac implant: Preliminary data on treatment of severely resorbed maxillae. Implants 2003;18:566-70. A clinical report. Int J Oral Maxillofac Implants 2002;17:861-5. 7. Aparicio C, Branemark P-I, Keller EE, Olive J. Reconstruction of 11. Boyes-Varley JG, Howes DG, Lownie JF, Blackbeard GA. Surgical the premaxilla with autogenous iliac bone in combination with modifications to the Brånemark zygomaticus protocol in the treatment osseointegrated. Int J Oral Maxillofac Implants 1993;8:61-7. of the severely resorbed maxilla: A clinical report. Int J Oral Maxillofac 8. Weischer T, Schettler D, Mohr C. Titanium implants in the zygoma Implants 2003;18:232-7. as retaining elements after hemimaxillectomy. Int J Oral Maxillofac Implants 1997;12:211-4. 9. Brånemark PI, Gröndahl K, Ohrnell LO, Nilsson P, Petruson B, Svensson B, How to cite this article: Rajan G, Baig MR, Nesan J, Subramanian J. Fixed et al. Zygoma fixture in the management of advanced atrophy of the rehabilitation of patient with aggressive periodontitis using zygoma implants. Indian J Dent Res 2010;21:125-8. maxilla: Technique and long-term results. Scand J Plast Reconstr Surg Hand Surg 2004;38:70-85. Source of Support: Nil, Confl ict of Interest: None declared.

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