Dentistry Review 2 (2022) 100054

Contents lists available at ScienceDirect

Dentistry Review
journal homepage: www.elsevier.com/locate/dentre

“Decision making with zygomatic and pterygoid dental implants in the

severely atrophic maxilla: A narrative review"
Alexandre Amir Aalam a, Alina Krivitsky a, Gregori M. Kurtzman b,∗
a
Clinical Associate Professor, Herman Ostrow School of Dentistry of USC and Private Practice, Los Angeles, CA, United States
b
Private practice, 3801 International Drive, Suite 102, Silver Spring, MD 20906, United States

a r t i c l e i n f o a b s t r a c t

Keywords: The severely atrophic maxilla can present with some challenges during treatment planning with communication
Atrophic maxilla between those performing the surgical and prosthetic aspects of the treatment as well as communication with
Zygomatic implants the patient as to what is being suggested for treatment. This article will review the decision making process
Pterygoid implants
to simplify the communication and understanding of treating the severely atrophic maxilla and based on the
Treatment planning
Bedrossian classification gives a guideline for the surgical approach to be adapted based on the patient residual
anatomy.

Introduction of standard endosteal implants [4]. Zygomatic implants are useful in

treating and managing the severely atrophic maxilla [5].
Significant alveolar resorption is a frequent occurrence with patients Clinical evaluation utilizing panoramic and/or CBCT radiographs of
who have been in a full arch removable maxillary prosthesis which can the patient is performed to determine what the volume of bone is present
hamper implant placement. Lack of osseous stimulation by either teeth in the areas of missing teeth to allow treatment planning options to treat
or implants within the bone results in negative volumetric changes. This the patient with an implant based approach. The evaluation needs to
is complicated in the posterior maxilla by sinus enlargement. Follow- include determining the appropriate incisal edge position, need for lip
ing periodontal bone loss or tooth extraction, a cascade of inevitable support and the appropriate vertical dimension of occlusion.
bone remodeling of the alveolar ridge occurs. The ensuing bone remod- Physiological bone remodeling can be associated with genetically
eling occurs in a three-dimensional manner with loss to both height and low maxillary bone density and is observed at a faster more profound
width of the residual ridge. The result is inadequate bone for implant rate then in the mandible. This may be accelerated by traumatic induced
placement without augmentation procedures. When a significant level resorption (ex: long term denture wear) leading to the bone available in
of bone resorption has occurred in the maxilla, only a limited number the anterior and posterior areas without augmentation to allow place-
of surgical options are available. Those may include tilted implants to ment of implants. Potential available bone sites are identified using the
avoid the pneumatized sinuses with a resulting prosthesis with premolar Bedrossian classification of the maxilla to identify zones that implants
occlusion or significant osseous grafting in those deficient areas to per- may be placed into [6,7] (Fig. 1). The Bedrossian classification gives a
mit implant placement in those areas lacking sufficient bone to house guideline for the surgical approach to be adapted. This is done by re-
implants. Augmentation procedures add to the treatment time and the viewing the patient’s panoramic radiograph. The maxilla is divided into
cost of the total treatment to achieve implant placement and restoration different zones; Zone I – Between canine to canine, Zone II – bicuspids,
to return the patient to function. Non-grafting solutions to these clini- Zone III – molars and Zone IV – zygoma. The presence or absence of
cally challenging situations has been presented which include tilted im- bone in these zones determines the surgical approach to be adapted.
plants, zygomatic implants and pterygoid implants to utilize what bone A severely atrophic maxilla would be defined as an arch or quadrant
volume is present [1]. Zygomatic implants have been in successful use that has undergone significant osseous resorption, often combined with
to allow osseous grafting of the maxillary sinus and deficient ridge to enlargement of the maxillary sinus that yields insufficient ridge height
be avoided and still permit implant placement in distant available bone and/or width to allow implant placement without osseous grafting to
[2,3]. Although zygomatic implants are more complex to place and re- create volume. One of the methods for decision making in the atrophic
quire a higher surgical skill level, their survival rates are similar to those maxilla is to follow the Bedrossian classification, a radiographic classi-

∗
Corresponding author.
E-mail address: [email protected] (G.M. Kurtzman).

https://doi.org/10.1016/j.dentre.2022.100054
Received 25 April 2022; Received in revised form 22 May 2022; Accepted 24 June 2022
2772-5596/© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
A.A. Aalam, A. Krivitsky and G.M. Kurtzman Dentistry Review 2 (2022) 100054

Fig. 3. A-P spread with placement of a zygomatic implant bilaterally at the 1st
Fig. 1. The Bedrossian zone classification of the maxilla. (Zone I = premaxilla, molar position and standard implants in zones I and II.
Zone II= premolars, Zone III= molars and Zone IV=zygomatic process).

fication based on the systematic assessment of the available bone. This

takes into consideration the relationship between the alveolus, nasal
floor and the position and size of maxillary sinus. With the Bedrossian
zone classification when adequate bone is present that can accommo-
date implant placement without augmentation, treatment would follow
these guidelines. Adequate volume of bone in zones I, II and III would
be treated with 4–8 implants placed in an axial (non-angled) direction.
When inadequate bone is present in zone III but is sufficient volume
in zones I and II then the ALL-on-X approach would be followed with
4–6 implants placed axially or angled (tilted) achieve the widest arch
spread for better A-P ratio. A maxilla that has adequate bone only in Fig. 4. A type I maxillary treatment with a cantilever distal to the 1st molar
zones I and IV with insufficient volume in zones II and III treatment position of the zygomatic implant.
would allow placement of 2–4 implants in zone one and a zygomatic
implant bilaterally in zone IV [8]. When bone is also present in zone III,
as well as zones I and IV, pterygoid implants can be placed into zone III
to augment the implants in zones I and IV [9]. Inadequate bone in zones
I and II, without bone augmentation may be treated with dual bilateral
(quad) zygomatic implants. When spread of the zygomatic implants in
each quadrant has the implant platforms with inadequate spread and
sufficient bone is present in zone III, pterygoid implants may be added
to increase the A-P spread to allow restoration of the arch.

Zone based treatment planning

Based on bone availability the severely atrophied maxilla is divided

into three types, 1, 2A and 2B
Fig. 5. Illustration of a type I implant treatment demonstrating the apical posi-
TYPE 1 tion of the zygomatic implant in relation to the orbit blocking potential for future
placement of another zygomatic implant mesial to it should it be required later.
A type 1 maxillary arch presents with a premaxilla (zone II) with a
height of 10 mm or greater and a width of 5 mm or greater (Fig. 2).
This will allow placement of 2–4 regular platforms axial or tilted (de- laterally with its platform at the 1st molar position providing a good
pending on anterior sinus wall proximity) dental implants in the zone I A-P spread and no distal cantilever prosthetically [10] (Fig. 3). Those
with no grafting needed as implant can be placed into native bone and patients with a mandibular 2nd molar or larger arch length, may require
no biological complication are expected (no fenestration, dehiscence) a cantilever distal to the zygomatic implant (Fig. 4). When a cantilever
requiring grafting. Posteriorly, a single zygomatic implant is placed bi- is not required, cleansability is greater for the patient then those cases
with a cantilever present. The disadvantages to this type approach are
the zygoma position at the 1st molar places it in a more vertical ori-
entation with the apical portion of the implant closer to the orbit and
blocking the placement of an anterior zygomatic implant if required in
the future (Fig. 5). The result provides adequate A-P spread to restore a
type 1 resorbed maxillary arch (Fig. 6).

TYPE 2

The type 2 resorbed maxillary arch is divided into subcategory A

and B depending on the degree of resorption. Long-term survival of the
anterior implants may be questionable due to the native anatomical lim-
Fig. 2. Cross-section of the premolar area of the maxilla (zone II) that presentes itations related to the bone quantity and quality availability and thus the
with 10 mm+ height and 5 mm+ width for implant placement. possibility of surgical modification in case of failure should be predicted.

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A.A. Aalam, A. Krivitsky and G.M. Kurtzman Dentistry Review 2 (2022) 100054

Fig. 9. Illustration of implant positions in a type 2A case with anterior implants,

Fig. 6. Panoramic radiograph demonstrating zygomatic implant placement bilateral single zygomatic implants and pterygoid implants.
with traditional implants in the anterior and premolar areas in a type 1 con-
figuration.

TYPE 2A

This type and subcategory present with an atrophic premaxilla (zone

I) with a height of 10 mm and width between 3 and 5 mm (Fig. 7). This
is allows the placement of 2 narrow diameter axial positioned implants,
Vomer or nasalus implants. Bone grafting can be expected at the time of
the implant surgery due to possible fenestration and dehiscence. Posteri-
orly, a single zygomatic implant is placed with its platform positioned in
the 2nd premolar position. Pterygoid implants are placed to allow sup-
port in the molar area without the need for sinus augmentation in the
molar area and improve AP spread while voiding a posterior cantilever Fig. 10. Panoramic radiograph demonstrating zygomatic in a type 2A configu-
(Fig. 8). Should in the future the anterior axial implants fail, a second ration.
zygomatic implant may be placed (Fig. 9). The disadvantage to this ap-
proach is patient hygiene is more difficult to reach around the restored
occlusion with whatever teeth or implants are present in the mandibular
pterygoid implants as their position is at or distal to the natural 2nd mo-
arch (Fig. 10).
lar position. Impression capture during the restorative phase may also
present with some challenges due to the pterygoid implants position.
Position of the pterygoid implants provides maximized A-P spread and TYPE 2B

This type and subcategory present with a severely atrophic premax-

illae (zone I) with insufficient height, width and angulation issues to
permit implant placement (Fig. 11). The premaxillary resorption ex-
tends to the nasal floor and thus dental implant without prior grafting
are not indicated. The resorptive presentation due to angulation issues
may not allow implant placement to permit restoration even following
grafting. Bilateral double zygomatic implant placement (referred to as
“quad” zygoma implants) is indicated with implant platform placement
at the canine/lateral positions and 2nd Premolar positions allows sta-
bility of the planned prosthesis but termination of the prosthetics at the
1st molar with a resulting cantilever [11,12] (Figs. 12–14). Quad zygo-
mas have been reported to have comparable success rates as bilateral
Fig. 7. Cross-section of the anterior area of the maxilla (zone I) that presentes single zygomatic implants but offer better implant platform spread in
with 10 mm height and 3–5 mm width for implant placement. those cases that will not permit anterior implant placement [13,14].
Pterygoid implants may be added to improve the AP spread and

Fig. 11. Maxillary anterior area presenting with severe aptrophy preventing
Fig. 8. Platform position in a type 2A implant treatment presents with good implant placement in the anterior due to minimal height, width and angulation
A-P spread and no distal cantilever on the prosthesis. issues to the premaxilla.

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A.A. Aalam, A. Krivitsky and G.M. Kurtzman Dentistry Review 2 (2022) 100054

Fig. 12. Platform positions in a type 2B implant treatment presents with pres-
ence of distal cantilever on the prosthesis.

Fig. 16. Implant placement in a type 2B configuration with bilateral zygomatic

implants and pterygoid implants.

Fig. 13. Implant placement in a type 2B configuration with bilateral zygomatic

implants with distal cantilevers prosthetically. Fig. 17. Panoramic radiograph demonstrating zygomatic in a type 2B configu-
ration with addition of pterygoid implants.

Conclusion

Patients may present either after long periods of maxillary denture

wear or following loss of the dentition related to severe periodontal is-
sues that result in severe atrophy of the maxilla that hamper implant
placement to allow restoration of the arch. Extensive bone grafting may
be performed but those procedures increase the treatment costs. Addi-
tionally, treatment time may be drastically increased precluding some
patients from accepting treatment. Extensive bone grafting would in-
clude sinus augmentation, especially when a lateral window approach
is selected, or when the implant can not be placed simultaneously with
Fig. 14. Panoramic radiograph demonstrating zygomatic in a type 2B configu- the grafting procedure. Recent studies have reported a 98% or greater
ration. long-term success rate for zygomatic implants, so these should be con-
sidered as an alternative to sinus augmentation in the atrophic maxilla
to decrease treatment time and cost allowing the patient to return to
function and have a long-term positive prognosis [15,16].
As we are dealing with a zone 1 edentulism and a severely atrophic
maxilla requiring full arch reconstruction, the bone grafting that would
be considered would be bilateral sinus and anterior ridge augmenta-
tion. This approach will double the healing time prior to providing a
fixed restoration for the patient. Further it was reported a higher com-
plication rate when compared to those when zygomatic implant were
utilized [17]. The decision making presented herein is clinical based on
the radiographic appearance of the patient acquired during treatment
Fig. 15. Platform position in a type 2B implant treatment presents with good
planning. This will help aid the practitioner in discussion with the pa-
A-P spread and no distal cantilever on the prosthesis. tient as to what treatment options are available and also to those only
performing the restorative aspects of treatment in discussion with the
surgeon when formulating the joint treatment plan that will be then
reduce the cantilever depending on the opposing dentition and occlu- discussed with the patient.
sion (Figs. 15–17). As with type 2A, hygiene is more difficult for the As pterygoid implants are placed with emergence at the 2nd or 3rd
patient due to the position of pterygoid implants if they are added and molar (tuberosity region), this can potentially create a hygiene home-
the cantilever if they are not added. Additionally, impression capture care challenge and the patient needs to be given instructions and train-
during the restorative phase may also present with some challenges due ing to maintain homecare. This may involve use of oral irrigators, elec-
to the pterygoid implants position, as well as insertion of the prosthesis tric toothbrushes or other devices to aid them in oral homecare in these
at placement. areas. Design of the prosthesis can also be modified with a reduced por-

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A.A. Aalam, A. Krivitsky and G.M. Kurtzman Dentistry Review 2 (2022) 100054

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[8] Candel-Martí E, Carrillo-García C, Peñarrocha-Oltra D, Peñarrocha-Diago M.
Alexandre Amir Aalam, Alina Krivitsky: Provided clinical infor- Rehabilitation of atrophic posterior maxilla with zygomatic implants: review.
mation and technical details for the paper, reviewed article draft and J Oral Implantol 2011;38(5):653–7 2012 OctEpubFeb 18. PMID: 21332329.
provided editorial input. Gregori M. Kurtzman: Wrote the article draft doi:10.1563/AAID-JOI-D-10-00126.
[9] Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation of the atrophic posterior max-
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j.coms.2018.12.006.
[12] Duan Y, Chandran R, Cherry D. Influence of alveolar bone defects on the
The authors report no conflict of interests or commercial financial stress distribution in quad zygomatic implant-supported maxillary prosthesis.
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