by Dr Alex Fibishenko
With the advancements made in dental medicine and oral surgery, dental implants have become not only an increasingly viable option, but a preferred solution for patients seeking a more permanent and aesthetically pleasing alternative to loose dentures. However, there are situations where conventional dental implants simply will not work, such as cases with advanced jawbone atrophy caused by long-term denture wearing or from severe infections in the past, cancer or even the common gum disease that can also destroy the jawbone over time.
In such cases, the jawbone is either not strong enough, or there is not enough of it, to house the implants. In situations as such, longer fixtures known as “zygomatic implants”, or “Zygomas”, may be used instead of the conventional standard fixtures. These longer implants anchor to the underside of the cheekbone, rather than deficient upper jaw, and provide the required support for a fixed bridge in highly bone-compromised situations.
The Zygoma technique is not new, and while excellent results have been achieved with this method, traditional zygomatic implants have been associated with a moderate incidence of complications such as sinusitis and oro-antral fistula (a communication between the sinus and oral cavity). To address these concerns, as well as to improve strength, durability, hygiene, aesthetics and comfort, I developed the Zygoma Plus approach at the All On 4 Clinic. It involves performing simultaneous sinus surgery along with bone grafting to reconstruct the jawbone and protect the implant from the sinus space, which helps to overcome the issues caused by the anatomical limitations. Not only does this reduce the risks and improve the safety of the procedure, but it also facilitates better positioning of the implants for a more optimal result, as well as improved comfort and longevity. Unsurprisingly, the response to Zygoma Plus in the dental community, from those who have seen this performed or the results, has been overwhelming. Below is a couple of the relevant questions that I’ve received in correspondence from a certain colleague:
Do you expect that Zygoma Plus will become the gold standard for zygomatic implants in the future?
and,
How long should the patient avoid flying after this procedure?
As I previously mentioned, the response to this newer technique has been very positive, including at my showcases around the world – and I certainly will never go back to the conventional technique. So why isn’t this approach already the new standard? The answer lies not at all in pros and cons of the technique itself, but rather the way we think as clinicians, and the things we don’t know that we don’t know. I have not had the opportunity to publish this technique as yet, thus only the clinicians who have been to my lectures have been exposed to it. Also, this is a very advanced technique and requires not only advanced skills that are not taught at university, but extensive experience with dental implants as well as with sinus surgery and bone grafting. A focus in the field of oral implantology is a pre-requisite, and since there is no such thing as “dental implants specialists”, typically only those rare clinicians with practices exclusive to dental implants and dento-facial surgery, who perform these procedures routinely in their everyday practices, would be be the ideal breed, albeit still somewhat rare.
Is Zygoma Plus the GOLD STADARD of the Future? If this sounds amazing, why isn’t it already?
In the traditional model, for Zygoma treatment, dentists would refer the patient to an Oral and Maxillo-Facial Surgeon (OMFS), as some may have received some basic training with the Zygoma technique. At the very least they would be seen in the dental community as having the requisite surgical skills and experience to perform advanced surgeries, such as Zygoma and bone grafting. However the fact of the matter is that, although OMFS’s are highly trained specialists in oral and maxillofacial surgery, they are relied upon in the industry for treatments such as cancer resections, orthognathic surgeries to correct skeletal jaw deficiencies, repairs of clefts and dealing with oral surgical complications. For most OMFS’s, dental implants is not a focus. Not in their training, nor in practice. More limiting still, when it comes to considerations of aesthetics, comfort or hygiene, is their limited exposure to the restorative process and practical needs of the patient and dentist. This is not a lack of thoroughness by any means; rather, it is simply a reflection of their other highly important and needed roles in the dental community. Since there is no speciality dedicated to the field of oral implantology, a restorative dentist with a patient who could benefit from Zygomatic Implants might often refer to an OMFS for treatment, being the closest match personally known to him/her with the requisite surgical skills.
But here lies the catch-22: due to the perceived complexity of a zygomatic implants treatment, the restorative clinician is unlikely to get involved in the planning process or weigh in on long term considerations. This is extremely unfortunate, since it is that same restorative dentist who would later be the first to deal with any issues that arise with speech, hygiene, comfort and breakages; all this is aside aside to the above-mentioned surgical risks. It should come as no surprise then that many of the first to show interest in adopting the new technique have been those with experience with the traditional Zygoma techniques, and who got a taste of the restorative and practical issues resulting from the surgical inadequacies, not to be confused with inadequacies of the surgeons themselves, but rather those inherent to the old technique.
OMFS’s or surgical clinicians, who also perform restorative phase, or who work in practices that consist of a close and functional team of both the surgeons and restorative clinicians, is an ideal scenario in order for them to appreciate the complex cross-disciplinary concepts. I firmly believe that as more feedback and multi-centre results become available, and the dialogue between restorative and surgical clinicians on the topic increases, many more OMFS’s will adopt the superior Zygoma Plus technique.
And what about FLYING after surgery?
This should be less of a set time period and based more on real-world results. The consideration here is whether normal, healthy drainage of the sinuses has returned. Post-surgery, facial swelling and inflammation of the schneiderian membrane in the sinus interrupts normal drainage. Even after this inflammation goes down, one must consider the possibility of blood clots and presence of excess mucous which can cause physical obstructions leading to infection. Common wisdom states that the likelihood of infections is highest for three weeks after surgery – and as such one should never fly within that time. If flying is not necessary, waiting 7 to 10 weeks out of an abundance of caution is encouraged. I’ve found the following regimine to greatly improve the return of normal sinus drainage:
- Dexamethasone + Cefazolin + Metronidazole administered during the operation
- Augmentin Duo Forte 875/125 q12d (or Clindamycin) one day prior to surgery and taken for continuously for two weeks
- Decongestants (Pseudoephedrine during the day, antihistamines at night, nasal spray when required) post operatively
- NSAID’s (eg. Anaprox 550mg) for 3 days following the operation
Zygoma Plus has quickly become the standard at every All On 4 Clinic throughout Australia, and I look forward to the technique becoming the industry standard, in order to provide more patients with safer treatments and better outcomes.
