The entire surgery was performed under local anesthesia without IV sedation. The implants were placed free-hand.
There were no bone augmentation procedures with autografts, allografts nor biomaterials but the soft tissues were managed with attention.
In the maxilla, a flap was carefully raised to get a good visual access to the crest and to the zygomatic arch. A crestal incision was made on the palatal side from the top of the residual ridge to provide a large amount of keratinized gingiva around the emergence of the implants at a later surgical stage. This approach allows for a soft tissue peri-implant protection essential for the long-term survival of the implant.
Special care was taken to stay away from the palatal artery in the posterior area.
Retractors were positioned to protect the soft tissue from drilling and to ensure the preparation of the zygomatic implant beds under visual control.
As the surgery was performed under local anesthesia, the flap was not raised over the entire jaw but in one sector firstly (left maxillary in this case) followed by the second sector (right maxillary).
For each half maxillary jaw, two vertical releasing incisions were made in the retro-tuberosity area and in the distal side of the nasal spine.
A corticotomy of the anterolateral wall of the maxillary sinus was performed with a diamond ball drill and allowed for a direct visualization of the corner of the maxillary sinus roof and a clear view on the path and the tip of the drills.
In the left side of the maxilla, the crestal bone could not support conventional implants due to the severely horizontal and vertical resorbed ridge. Therefore, a slot was made with a special Straumann drill at the second premolar site, and one Straumann® Zygomatic Implant ZAGA™ Flat (47,5mm) was placed in order to get the implant neck submerged into the bone crest.
At the lateral incisive site, the bone was partially present and one Straumann® Zygomatic Implant ZAGA™ Round (40mm) was inserted. The tapered design provided a good grip in the zygomatic bone (Fig.3). Afterwards, two Straumann® Zygomatic Screw-retained Abutments 3,5mm were screwed at 35N/cm and the flap was closed.
In the right side of maxilla, two Straumann® Zygomatic Implant ZAGA™ Round were placed keeping a knife-edge ridge in vestibular protection. The coronal threads and micro-threads stabilized the implant in this residual crestal bone and the implants were anchored through the zygomatic bone with the tapered apical portion. An Straumann® Zygomatic Implant ZAGA™ Round 45mm was placed in the lateral incisor site, while a Straumann® Zygomatic Implant ZAGA™ Round 40mm in the first premolar site. Finally,
two Straumann® Zygomatic Screw-retained Abutments 3,5mm were screwed at 35N/cm. (Fig. 4, 5, 6 and 7).
For both sides, a pedicled buccal fat pad was used for the closure of the open sinus wall creating a protective layer between the implants and the mucosa to prevent an erosion of the mucosa. Suturing was performed using resorbable 5.0 monofilament (Monofast 5.0).
In the mandible, a crestal incision preserving the keratinized gingiva was attentively performed and the alveolar ridge prepared to place 4 Straumann® Mini Implant 12mm between the two mental foramina (Fig. 8) achieving initial primary stability.
Immediately after surgery completion, impression caps were snapped onto the mandibular Straumann® Mini Implant, and the removal prosthesis itself was used as an impression tray.
For the maxilla abutment-level open tray impression posts were screwed on and a total impression was taken using the perforated impression tray and vinyl polysiloxane material (Honigum Mono DMG).
The dental laboratory completed the final work and six hours after surgery the temporary bridge was screwed onto the Straumann® Zygomatic Implant and their zygomatic SRA.
The removable prosthesis with the Optiloc® yellow retention inserts (medium retention force) was placed on the Straumann mini-implants.
All implants were loaded immediately on the same day (Fig. 9 and 10).
The post-op medication was as follows:
- Amoxicillin/clavulanic acid 1 gr twice a day starting 24 hours before surgery for 8 days
- Pain medication: Ibuprofen 400mg & Paracetamol 1g alternately in case of pain
- Rinofluimucil Nasal Spray (decongestant), 2 spray in each nostril 3 times per day for 5 days.
- Mouth rinse & Chlorhexidine gel, 3 times a day for 5 days
- 2 ice packs (local application)
The patient was recommended to follow a soft diet during the first 4 months following the surgery.