Protocol zygoma implant Luc Vrielinck Department Maxillofacial Surgery Ziekenhuis Oost-Limburg, Genk
Menu • Preoperative • Surgery • Prosthetics
Menu • Preoperative • Surgery • Prosthetics
Menu • Preoperative – Pre-surgical treatment planning – General pre-surgical examination – Preoperative radiographic examination
• Surgery • • • •
Recommended equipment and machinery Implant installation Suturing Implant removal
• Prosthetics • Abutment connection • Prosthetic steps • Rigid bar splinting
• Final conclusions
Menu • Preoperative – Pre-surgical treatment planning – General pre-surgical examination – Pre-operative radiographic examination
Menu • Preoperative – Pre-surgical treatment planning – General pre-surgical examination – Pre-operative radiographic examination
Pre-surgical treatment planning • Indications for zygoma implants: – Edentulous or partial edentulous in the dorsal zone – Resorption of the lateral parts of the maxilla
Pre-surgical treatment planning
Zone 3:Molars
Zone 2: Bicuspids
Zone 1: Premaxilla
Pre-surgical prosthetic considerations: – An effective team-approach is necessary in preparing the treatment plan with input from prosthodontist dental technician and surgeon
Pre-surgical prosthetic considerations • From the prosthetic side: • • • • •
Facial profile and contours Parafunctional habits Horizontal and vertical jaw relationships Occlusal relationships Status of the opposing dentition
Pre-surgical prosthetic considerations • Surgical aspects: position and angulation of the implants – Tooth position must be decided preoperatively starting from the removable denture – The most simple drill guide available= clear acrylic replica with palatal aspects grinded away
Pre-surgical prosthetic considerations
Pre-surgical prosthetic considerations • Biomechanical aspects: – Bending moments: • Because of length of the implant (30 ↔52.5 mm) • Reduced amount of bone on the crest • Thus splinting of the implants is mandatory
Pre-surgical prosthetic considerations – Number of implants: • • • •
Depending on the prothetic outcome E.g. fixed bridge: 4 standard + 2 zygoma E.g. dorsal atrophy: 2 standard + 2 zygoma E.g. Total atrophy: 4 zygoma + Overdenture
Pre-surgical prosthetic considerations 4RP + 2Z
March 2000
Pre-surgical prosthetic considerations 2RP + 2Z
Pre-surgical prosthetic considerations 2RP + 2Z
Pre-surgical prosthetic considerations Quad zygoma
Pre-surgical prosthetic considerations Quad zygoma
Pre-surgical prosthetic considerations
Quad zygoma: 2Z + 2pterygoid
Pre-surgical prosthetic considerations
Quad zygoma: 2Z + 2pterygoid
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Pre-surgical prosthetic considerations • Cross-arch stabilization in overdenture
Pre-surgical prosthetic considerations • Cross arch stabilization in fixed bridge work
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Decrease the buccal lever arm
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Decreased cantilevers (MD and AP)
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Balanced occlusion • Balanced occlusion (e.g. electronic measurement using T-scan)
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Decreased cuspal inclination
Pre-surgical prosthetic considerations • How to reduce bending moments? – Cross-arch stabilisation – Decreased buccal lever arms – Decreased cantilevers (MD and AP) – Balanced occlusion (e.g. T-scan) – Decreased cuspal inclination
Pre-surgical prosthetic considerations • Prosthetic design – Incorporate sufficient rigidity and precision in the restoration – Decrease bending moments – Balance functional, esthetic, phonetic and hygienic requirements
• If not rigid: deformation of the prosthesis can cause deflection of the implants, crestal bone loss and implant loss and provoke screw loosening
Pre-surgical prosthetic considerations • Zygoma implant pierces the oral mucosa in the premolar region, slightly palatal • The orientation of the implant is very important since it will dictate the position of the prosthetic screw.
Menu • Preoperative – Pre-surgical treatment planning – General pre-surgical examination – Pre-operative radiographic examination
General pre-surgical considerations • Fit for treatment under local or general anaesthesia • Patient must be: – Free of sinus pathology – No pathology in bones of soft tissue – All other dental treatment completed
Menu • Preoperative – Pre-surgical treatment planning – General pre-surgical examination – Pre-operative radiographic examination
Pre-operative radiographic examination • Investigation to examine frontal maxillary bone cfr. Standard implant placement – Orthopantomogram, intraoral lateral ceph…
Pre-operative radiographic examination • Investigation of the zygomatic bone and maxillary sinus, purpose: – exclude sinus pathology – evaluation of zygomatic bone (variable) – evaluate infratemporal fossa – evaluate buccal concavity anterior wall maxillary sinus
Pre-operative radiographic examination • Technique of choice is CT scan or cone-beam scan: – Crossectionals – 3D reconstruction – Treatment simulation – (Surgical Guide)
Menu • Preoperative • Surgery • Prosthetics
Surgery • • • • •
Recommended equipment and machinery Implant installation Suturing Implant removal Depth measurement system
Surgery • • • • •
Recommended equipment and machinery Implant installation Suturing Implant removal Depth measurement system
Surgery • Recommended equipment and machinery • Implant drill motor e.g. Osseoset or other • Zygoma hand-piece 20:1 - Drilling speed: 2000rpm - Implant installation: 45 Ncm or by hand - Maximum Torque: 50Ncm
Surgery
Surgery • • • • •
Recommended equipment and machinery Implant installation Suturing Implant removal Depth measurement system
Implant installation • See live surgery • Separate detailed presentation
Surgery • • • • •
Recommended equipment and machinery Implant installation Suturing Implant removal Depth measurement system
Suturing • Submucosal sutures (resorbable) • Use simple and matress non resorbable suture material • Provide a liquid tight closure of the wound
Implant removal • Characteristics of a failed implant: – Dull sound on tapping – Mobile & painfull – Usually associated with buccoantral communication – Reactive sinusitis
Implant removal • Secure the implant mount on top of the implant • Rotate counterclock wise • Close buccoantral communication • If the implant is fractured (1 case in the world) leave integrated part in zygomatic bone and remove alveolar part
Menu • Preoperative • Surgery • Prosthetics
Prosthetics • Abutment connection • Rigid bar splinting
Prosthetics • Abutment connection • Prosthetic steps • Rigid bar splinting
Healing abutment connection • Same procedure as with standard implants • Zygoma abutments available in two lengths: 3 mm and 5 mm • Verify correct fitting with radiograph 5 mm 3 mm
Prosthetics • Abutment connection • Prosthetic steps • Rigid bar splinting
Prosthetic steps • • • • • • • • • • •
Impression Adjustment and relining of removable prosthesis Master cast Registration of jaw relations No primary Tooth set-up in wax occlusal Try-in of preliminary tooth set-up contacts on Framework fabrication distal cantilever ! Try-in of framework Processing and delivery Post-insertion visit Recall schedule
Prosthetics • Abutment connection • Prosthetic steps • Rigid bar splinting
Rigid bar splinting • Since there is limited amount of alveolar bone bending forces can be induced • Therefore the implants should be splinted. • This should be done immediately after stage II surgery (abutment connection)
Procedure of immediate splinting for a bar • • • • •
Second stage surgery , place impression copings Place rubberdam to cover sutures Abutment and impression copings perforate Take an impression Pour a plaster cast and attach gold copings to implant replicas • Adjust a gold bar and solder to the gold copings • Attach rigid bar to the abutments intraorally and fixate with gold screws • Adjust and reline the prosthesis
Procedure for immedate splinting using old prosthesis
Final remarks • Survival and succesratio of implants, connecting screws and prosthetic work can be affected by: – lack of passive fit of the restoration – inadequate prosthesis design – trauma to the oral region – all types of biomechanical overload
Final remarks • General: the zygoma implant can withstand functional load if rigidly connected to two or more osseointegrated implants • It is said that 1 zygoma bears the loading capacity of 2 standard implants