Rehabilitating a severely atrophic maxilla presents one of the most complex challenges in implant dentistry. Traditional implant placement is often compromised due to insufficient bone volume, especially in the posterior maxilla.
In such cases, the strategic use of pterygoid and zygomatic implants, combined with conventional anterior and molar implants, offers a predictable and minimally invasive solution. This blog outlines a step-by-step protocol for guided placement of zygomatic and pterygoid implants using bone-supported guides and periosteal pin registration.
Understanding the Hybrid Approach
The hybrid approach integrates flapless guided pterygoid implants, conventional anterior implants, and then bone supported zygomatic implants.
This method ensures optimal stability, reduced surgical trauma, and immediate functional loading when planned meticulously. The key lies in precise guide stabilization and sequential osteotomy using bone-supported templates.
Step-by-Step Protocol for Guided Zygo-Pterygoid Implant Planning
Step 1: Flapless Pterygoid Implant Placement
Begin with flapless placement of pterygoid implants using a pre-designed surgical guide. The guide should be fabricated based on CBCT and intraoral scans, ensuring accurate trajectory into the pterygoid process. This step avoids unnecessary flap elevation and preserves soft tissue integrity.
Step 2: Periosteal Pin Registration
Once the pterygoid implants are placed, use periosteal pins to register the guide. These pins anchor the guide to the maxillary bone, providing a stable reference for subsequent steps. This registration is critical for maintaining positional accuracy throughout the surgery.
Step 3: Flapless Anterior Implant Placement
With the guide stabilized using periosteal pins, proceed to place anterior implants flaplessly. These implants serve as additional anchors and contribute to the overall stability of the prosthesis. The flapless approach minimizes bleeding and accelerates healing.
Step 4: Flap Elevation
After anterior implants are placed, elevate a full-thickness flap to expose the lateral maxillary wall and zygomatic buttress. This exposure is necessary for the zygomatic osteotomy and guide adaptation. Careful flap elevation ensures visibility without compromising vascularity.
Step 5: Placement of Zygoma Guide 2 and Initial Osteotomy
Position zygoma guide 2 over the exposed bone and stabilize it using the same periosteal pin registration. Begin the osteotomy using a round bur to mark the entry point and initiate the path toward the zygomatic bone. This guide ensures the correct angulation and depth.
Step 6: Placement of Zygoma Guide 1 and Bone Reduction
Replace guide 2 with zygoma guide 1 and use a diamond bur to reduce the lateral maxillary bone. This step creates a smooth path for the zygomatic implant and prevents deflection during drilling. Bone reduction is essential for passive guide seating and accurate osteotomy.
Step 7: Reposition Zygoma Guide 2 and Complete Osteotomy
Reposition zygoma guide 2 and continue the osteotomy using sequential drills. The guide maintains the trajectory into the zygomatic bone, ensuring bicortical engagement and primary stability. Complete the osteotomy and place the zygomatic implant with torque control.
Clinical Pearls for Success
- Always pre-plan the guide design with 3D software integrating CBCT and intraoral scans
- Use long implants for pterygoid placement to engage the pterygoid plate and posterior maxilla
- Ensure flap elevation is minimal and strategic to preserve vascular supply
- Maintain strict asepsis during periosteal pin placement to avoid contamination
- Verify guide seating at each step to prevent cumulative errors
Conclusion
Guided placement of zygomatic and pterygoid implants, when combined with conventional molar and anterior implants, offers a robust solution for rehabilitating the severely atrophic maxilla.
This protocol minimizes surgical trauma, enhances accuracy, and supports immediate loading. With careful planning and execution, clinicians can restore function and esthetics even in the most challenging cases.
With over a decade of experience in dentistry, I specialize in diagnosing a wide range of oral diseases and have developed a deep passion for dental imaging. My interest in CBCT reporting and digital implantology led me to become a pioneer in the concept of diagnostic 3D modelling. Throughout my career, I have supported and educated numerous dentists in mastering CBCT interpretation, virtual implant planning, and the latest advancements in 3D printing for dental applications. Read more about me on the “about me” page.
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